Category Archives: Nutrition

Healthy Obesity?

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From NY Times,  nyti.ms/1diH2d4 –an excerpt:

The idea that there are obese people who are nonetheless healthy may be a myth.

Although some overweight or obese people have normal cholesterol, glucose levels and blood pressure — elements of so-called metabolic health — a new study suggests that obesity by itself increases the risk for heart disease, stroke, diabetes and death.

Researchers analyzed 12 studies that had together followed more than 61,000 adults, most for at least 10 years. About 9 percent of the subjects were obese and metabolically healthy — that is, they had normal LDL, HDL and total cholesterol, along with healthy blood pressure and blood sugar levels. The report was published online last week in Annals of Internal Medicine.

Compared with metabolically healthy people of normal weight, the obese group had a 24 percent increased risk for fatal and nonfatal cardiovascular events like heart attack and stroke, and for death by any cause.

Related blog posts:

Vitamins: often ‘throwing money down the drain’

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From USA Today: Medical journal: ‘Case closed’ against vitamin pills

“it’s time for most consumers to stop wasting money on multivitamins and other supplements, because they have no proven benefits and some possible harms.”

That declaration comes in a strongly worded editorial that accompanies two new studies and an expert panel’s report published Monday in the Annals of Internal Medicine.

“The message is simple: Most supplements do not prevent chronic disease or death, their use is not justified, and they should be avoided,” says the editorial, signed by two researchers from Johns Hopkins University in Baltimore, one British researcher and one of the journal’s senior editors…

The new results from that study will disappoint anyone who hoped a multivitamin might keep them sharp in old age. The study followed male physicians over age 65 for an average of 11 years and found multivitamins had no effect on cognitive decline…

A second, unrelated, new study in Annals found high-dose multivitamins had no effect on the progression of heart disease in heart attack survivors…

there are exceptions. For example, health officials strongly urge women of childbearing age to take folic acid, to prevent birth defects. Some ongoing studies of vitamin D, he says, are justified because some benefits…

most of the 53% of U.S. consumers who use supplements are wasting money, to the tune of $28 billion a year.

Same story from NY Times: http://t.co/kEwrk1mGyQ

Related blog entry:  Live longer -don’t take your vitamins? | gutsandgrowth

Don’t Go Nuts over Nuts

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A recent study (NEJM 2013; 369: 2001-11) showed that nut consumption was associated with a lower mortality rate among more than 115,000 people in two large independent cohorts.  Nut consumption had significant inverse associations with deaths due to cancer, heart disease, and respiratory disease.  Those who ate nuts most frequently (7 or more times per week) had a 20% lower hazard ratio for death. However, the individuals who consumed nuts may have been more likely to have other healthy habits, though this was not identified in the study.

This study is explained more fully in the following video (less than 3 minutes):  nej.md/1aSbuY4 

Have you seen the Duodenal-Jejunal Bypass Liner?

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A recent article (Clin Gastroenterol Hepatol 2013; 11: 1517-20) reports on the effects of the duodenal-jejunal bypass liner (DJBL) on improvement in parameters of nonalcoholic liver disease (NAFLD).  The study enrolled 17 patients who had obesity and type 2 diabetes mellitus.

The following link provides more details on this technique (from a 2009 study) and provides a picture (Figure 2) of the 60 cm sleeve that is placed endoscopically:

Radiographic appearance of endoscopic duodenal … – GI Dynamics

These studies indicate that less invasive approaches may develop as alternatives to bariatric surgery.

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Will Vitamin D Prevent Osteoporosis –Probably Not

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A recent excerpt from the NY Times regarding a study published online in The Lancet.  nyti.ms/1gnT1vz 

In a large review of studies, researchers have found almost no evidence that taking vitamin D supplements has any effect in preventing osteoporosis in middle-aged adults.

The analysis…included 23 randomized trials that measured the effect of vitamin D on bone density at four sites — spine, neck, hip and forearm — and included more than 4,000 generally healthy participants whose average age was 59.

The studies used dosages that varied from 500 units a day to 800 or more, given on varying schedules. In some studies, the subjects were given calcium as well.

Neither the pooled data nor any single study showed a significant increase in bone density across all four sites….The authors write that the widely believed idea that vitamin D promotes bone mineralization is probably incorrect.

“We’re not talking about people who are really vitamin D deficient,” said the lead author, Dr. Ian R. Reid, a professor of medicine at the University of Auckland in New Zealand. “But for healthy people focused on osteoporosis prevention, vitamin D does not make a positive contribution.”

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Sweetened Beverages -A Big Problem for Little Kids

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Many times we may look at a study and think that the results could easily have been anticipated.  Yet, there are many examples when our assumptions are flat-out wrong.

A recent study (Pediatrics 2013; 132: 413-20 -thanks to Jeff Lewis for this reference) helps solidify what we think we already knew, namely that sugar-sweetened beverages (SSB) contribute to weight gain in young children.  This study showed that 2-5 year-olds, followed in the Early Childhood Longitudinal Survey–Birth Cohort (n=9600), who had more frequent SSB consumption had higher BMI z scores by age four (P < .05) than infrequent/nondrinkers of SSB.  This study, for the first time, shows this effect in this younger population.

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Rett Reference

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JPGN 2013; 57: 451-60.  “Assessment and Management of Nutrition and Growth in Rett Syndrome”

  • This references expert recommendations from an international multidisciplinary panel.  “The level of evidence for the statements was low.”
  • “A body mass index of approximately the 25% can be considered a reasonable target in clinical practice.  Gastrostomy is indicated for extremely poor growth, if there is risk of aspiratrion and if feeding times are prolonged.”
  • There was no consensus with regard to fundoplication.  It should be used with “caution in those with significant air swallowing.”

Related previous post:

GI & Nutrition Problems in Rett Syndrome | gutsandgrowth

Nutrition Module

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More notes from this year’s postgraduate course:

Clinical issues in parenteral nutrition, Praveen S. Goday, MBBS, CNSC (page 105)

  • Fish‐oil vs minimizing soybean oil‐based lipid emulsions
  • Catheter‐related bloodstream infections (CRBSI): Ethanol locks “Humans like ethanol and bacterial don’t.”  Meta‐analysis:  In comparison with heparin locks, ETOH locks (various regimens) reduced the following: a) CRBSI‐rate per 1000 catheter days by 7.67 events (81% ↓)  b) catheter replacements by 5.07 (72% ↓), c) 108‐150 catheter days of ETOH lock exposure were necessary to prevent 1 CRBSI, d) Adverse events – rare and included thrombotic events.  Reference: Oliveira et al. Pediatrics 2012;129:318–329

Parenteral Drug Shortages: All PN products except dextrose and water have been in short supply at some point since spring 2010

Imported components from Europe (higher cost)

• Peditrace™ – zinc, copper, manganese, selenium, fluoride, and iodine

• Addamel N™ – zinc, copper, manganese, selenium, fluoride, and iodine, molybdenum, iron, and chromium

Summary / Take‐home points

  • Reduction in soybean oil emulsion or provision of fish oil emulsion results in improvement in cholestasis
  • Ethanol lock therapy decreases CRBSI in children on home PN
  • Significant PN shortages have affected our ability to care for our PN patients; thus need vigilance and good communication between physician, dietitian and pharmacist

Severe Obesity in Your Clinic: The disconnect between the epidemic and the intervention Sarah E. Barlow, MD, MPH (page 125)

What to do for obesity?

  • Behavior modification
  • Pharmacotherapy (and behavior modification)
  1. Orlistat (Xenical, Alli) -Enteric lipase inhibitor, FDA approved starting at age 12 years (OTC $200 per month)
  2. Approved for adults Lorcaserin (Belviq): 5-HT2C agonist
  3. Approved for adults: phentermine and topirimate (Qsymia)
  • Surgery (and behavior modification)
  • Meal replacement (and behavior modification)

Orlistat trial for adolescent obesity:

  • 54 week double-blind RCT
  • 539 subjects: 12 to 16 years of age, BMI 36 ±  4 kg/m2
  • BMI change kg/m2 (mean):  – .55  vs. + 0.31 for control
  • Fecal urgency (%) 20.7 (11.0 in controls)
  • Flatulence (%) 9.1 (4.4 in controls)
  • Fecal incontinence (%) 8.8 (0.6 in controls)
  • Reference: Chanoine et al. JAMA 2005;293:2873

Orlistat meta-analysis among adults :

  • -2.87 kg [95CI -3.21, -2.53] = placebo-subtracted change at 1 year
  • Reference  Rucker D. BMJ 2007;225:1194

Multiple potential medications are being studied

Selection criteria for adolescent bariatric surgery

  • Tanner stage IV or V
  • BMI ≥ 35 kg/m2 with severe
  • Comorbidity or BMI ≥ 40 kg/m2 with comorbidity
  • “Have failed” 6 month of organized attempts at weight loss
  • Committed to pre and post medical and psychological care
  • Supportive family
  • Able to give informed assent
  • Frequent barriers: Distance from center, Insurance, Age, Reluctance
  • Reference: Pratt Obesity 2009;17:901

Complications from Surgery

  • For all procedures: nutritional deficiencies, especially iron, vitamins B12, D, and thiamine
  • For gastric bypass: postprandial hypoglycemia in adults
  • For lap band: need for re-operation for slippage or erosion in adults and small adolescent study.
  • Also pouch dilatation
  • For sleeve gastrectomy: leak or bleeding along suture site

Summary

  1. 4% of children 6 to 19 are severely obese
  2. Severe obesity leads to high levels of cardiovascular disease risk factors, NAFLD, OSA, and pre-diabetes
  3. Behavior modification has modest efficacy, is a partner in all other intensive interventions, but is not readily available behavior modification is underutilized because it is time-intensive and resource-intensive.  It it is necessary even though it is not sufficient.
  4. Orlistat is the only medication currently available for adolescents.

 5 2 1 0

  • 5 servings of fruits and vegetables a day
  • 2 hours or less of screen time
  • 1 hour (60 minutes) or more of physical activity
  • 0 sugar-sweetened beverages

Postgraduate Course Syllabus (posted with permission): PG Syllabus

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) and specific medical interventions should be confirmed by prescribing physician.  Application of the information in a particular situation remains the professional responsibility of the practitioner.

TPN Drug Shortages -A Useful Reference

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A recent article in Today’s Dietician offers advice on drug shortages with TPN.

The following is a link (from a Kipp Ellsworth retweet) and an excerpt: http://t.co/CBKti0mNep

Lipids. Two US manufacturers produce three lipid concentrations  (10%, 20%, and 30%) of IV fat emulsions. The 30% concentration can be used only  in total nutrient admixtures. ICU patients receiving propofol can forgo IV fat  emulsions, since propofol is in a lipid-based emulsion that provides 1.1  kcal/mL, just like the 10% IV fat emulsion.

Since essential fatty acid deficiency doesn’t develop until  after two weeks of lipid-free PN, IV fat emulsions can be safely withheld for  the first two weeks if lipids are in short supply.1 After two weeks of  lipid-free PN, the minimum dose of IV fat emulsions, which is 100 g/week, can  be provided to prevent essential fatty acid deficiency.

IV fat emulsions should be discontinued in patients  tolerating EN and who don’t have malabsorption concerns.

IV Multiple Vitamins               When there’s a shortage of IV multiple vitamins, dietitians  should evaluate all patients for their ability to absorb enteral multiple  vitamin supplements in capsule, tablet, liquid, or chewable forms. For patients  who can’t absorb enteral vitamin supplements, the IV multiple vitamin dose  should be decreased from 10 mL to 5 mL/day to conserve supplies. If IV multiple  vitamins remain in short supply despite conservation efforts, the standard dose  of 10 mL should be given three times per week.2

If supplies have been exhausted, PN must be supplemented  intravenously with individual parenteral vitamins according to the following  ASPEN recommendations: thiamin: 6 mg; folate: 0.6 mg; ascorbic acid: 200 mg;  pyridoxine: 6 mg; and vitamin K: 0.5 to 1 mg/day or 5 to 10 mg/week.2 In  addition, cyanocobalamin (vitamin B12) must be given intramuscularly at least  once per month.2

Trace Elements               Combination trace elements and individual trace element  products offer alternatives to PN products in short supply.

Combination Multiple Trace Element Products               Dietitians have a choice of two different multiple trace  element combination products: MTE4 and MTE5. MTE4 products contain zinc,  copper, chromium, and manganese and come in a standard 3 mL dose or a 1 mL  concentrated dose. MTE5 products contain the same four trace elements with the  addition of selenium in either the standard 3 mL dose or the 1 mL concentrated  dose.

If there’s a shortage of the concentrated products, RDs can  use the standard 3 mL dose of MTE4 and MTE5. When MTE4 products aren’t  available, RDs can substitute the MTE5 products. If MTE5 products aren’t  available, RDs should substitute MTE4 products and add 60 mcg of selenium  individually to achieve the equivalent composition of MTE5.

…If no MTE products are available, individual trace elements  should be added to PN solutions.

Individual Trace Elements               Individual trace elements are used when combination trace  element products are unavailable…

There’s no need to supplement manganese when there are  shortages of multiple trace element products. Whole blood manganese levels  frequently are elevated in long-term PN patients, and manganese contamination  often occurs in other PN products. No alternative IV forms of chromium are  available but, like manganese, there may be some chromium despite the fact it  isn’t intentionally added because of its contamination potential in other PN  products. RDs can evaluate a patient’s ability to absorb chromium as part of  multivitamin and mineral supplementation through the enteral route and monitor  for signs of deficiencies.

Other than the selenium content of MTE5 products, selenium  is available as a single IV trace element product. When MTE5 products and individual  IV selenium products aren’t available, RDs can consider using oral selenium  supplementation.

Copper is available as a single PN trace element in two  forms: IV copper chloride or IV cupric sulfate. If all supplies of IV copper  have been exhausted, a patient should be evaluated for oral copper supplements.

Zinc is available in either IV zinc sulfate or IV zinc  chloride. It’s important to note that if zinc is given enterally in high doses,  RDs should monitor for a copper deficiency, as zinc and copper both compete for  absorption with the same carrier protein when EN is used….

— Mandy L. Corrigan,  MPH, RD, LD, CNSC, is a nutrition support dietitian with Coram Specialty  Infusion Pharmacy.

 Professional  Resources • American Society of Health-System Pharmacists Drug  Shortages Resource Center: www.ashp.org/menu/DrugShortages

• American Society for Parenteral and Enteral Nutrition Drug  Shortages Update: www.nutritioncare.org/Professional_Resources/Drug_Shortages_Update

• FDA Current Drug Shortages Index: www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050792.htm

• FDA Fact Sheet: Drug Products in Shortage in the United  States: www.fda.gov/RegulatoryInformation/Legislation/FederalFoodDrugandCosmeticActFDCAct/ SignificantAmendmentstotheFDCAct/FDASIA/ucm313121.htm

• FDA Frequently Asked Questions About Drug Shortages: www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050796.htm

• Fresenius Kabi Adult Multitrace Element Availability  (product information): www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM355392.pdf

• Fresenius Kabi Pediatric Multitrace Element Availability  (product information): www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM354265.pdf

• Fresenius Kabi Phosphate Injection Availability (product  information): www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM354277.pdf

• National Medication Errors Reporting Program (patients and  clinicians): www.ismp.org/orderforms/reporterrortoISMP.asp

 

For More Information               The following references can serve as viable resources for  dietitians to learn more about parenteral nutrition drug shortages and their  impact on patient safety and patient care:

• Buchman AL, Howard LJ, Guenter P, Nishikawa RA, Compher  CW, Tappenden KA. Micronutrients in parenteral nutrition: too little or too  much? The past, present, and recommendations for the future. Gastroenterology.  2009;137(5 Suppl):S1-S6.

• Corrigan ML, Kirby DF. Impact of a national shortage of  sterile ethanol on a home parenteral nutrition practice: a case series. JPEN  J Parenter Enteral Nutr. 2012;36(4):476-480.

• Holcombe B. Parenteral nutrition product shortages: impact  on safety. JPEN J Parenter Enteral Nutr. 2012;36(2 Suppl):44S-47S.

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) and specific medical management interventions should be confirmed by prescribing physician.  Application of the information in a particular situation remains the professional responsibility of the practitioner.

NASPGHAN Preview

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I had a few free minutes so I decided to take a look at a bunch of upcoming lectures from the 2013 NASPGHAN upcoming meeting.  With electronic media, it is easy to take a quick glance.  Here’s the master link to all of the following talks:

Annual Meeting page.

Some of the power point lectures that I’ve seen so far:

  • Is my PPI dangerous for me? Eric Hassall MBChB, University of British Columbia One point in his slides that I had not seen much about was a hypothesis that PPI use may predispose to the development of eosinophilic esophagitis by allowing food proteins to be more intact ( attributed to Merwat, Spechler. Am J Gastro ’09).  He explains that “acid reflux” is a clever marketing term and has a slide with Madmen actors.  If there is “acid,” one must need acid suppression.
  • My child doesn’t go to school Lynne Walker MD, Vanderbilt University.  Lynne shows an interesting fax from a parent that asks if the problem is physical, how will she help? And, if it is psychological, how can this be remedied?  She outlines a lot of pain theory and indicates that parents need to become health coaches, avoid catastrophizing (?spelling), and encourages mental health evaluation.  Use the parents words ‘I’m going to refer xxx for relaxation and stress management.’
  • My child’s H. pylori will not go away – (the resistant bug) Benjamin Gold MD, Children’s Center for Digestive Healthcare. Ben manages to stuff so much information into his talk.  His talk is like one of those clown cars where more and more people keep coming out.  He has slides with worldwide resistance maps, slides with treatment regimens and algorithms, and the reasons for treatment failure. Perhaps I can convince him to give a live preview.
  • Administrative/executive functioning Richard Colletti MD, Fletcher Allen Healthcare. Offers personal and pragmatic advice for career advancement.  His slides indicate that he started his GI fellowship at age 40.  One of his quotes, “80% of success is showing up” (Woody Allen) is definitely true.  It’s pretty much akin to what I learned about success in medical school.  You need the three As: availability, affability, and ability.  My mentor said the first was what people needed most.
  • The changing face of intestinal transplantation
    Simon Horslen MD, Seattle Children’s Hospital.  Lecture notes that number of intestinal transplants have decreased dramatically, particularly in children. In 2012, only about 100 intestinal transplants were performed whereas it had peaked at nearly 200.  Much of the credit is due to intestinal rehabilitation work and adjustments in parenteral nutrition (eg. lipid minimization, line care).  Two most common reasons for intestinal transplantation at this time are gastroschisis and volvulus.
  •  Gluten sensitivity: Fact or fiction Alessio Fasano MD, MassGeneral Hospital for Children. This blog has covered a lot of the same material, but Alessio’s slides are pretty impressive.  Also, I was not aware that Lady Gaga consumes a gluten-free diet
  • Controversies in parenteral nutrition Christopher Duggan MD, Boston Children’s Hospital.  This lecture provides a timely update on nutrient deficiencies due to component shortages and discusses lipid minimization compared with fish oil-based lipid emulsions.
  • Vitamin D and immunity James Heubi MD, Cincinnati Children’s Hospital and Medical Center.  In the beginning of the slides, Jim provides a very user-friendly definition of an expert and a suitable picture.  He indicates that in 2011 there were 3746 vitamin D publications but inexplicably only chooses to review a tiny fraction.

At the time of this posting, I haven’t had a chance to look through these talks: