Category Archives: Nutrition

What is An Emulsifier and Are They Safe in Our Diets?

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Two recent articles examine emulsifiers and their potential impact on the GI tract and beyond.

Levine et al provide a good overview of the topic of emulsifiers. Key points:

  • Emulsifiers allow “the mixing of water and and water-soluble agents with fats and fat-soluble agents that is they possess both hydrophilic and lipophilic properties”
  • The FDA “has been responsible for approving the use of all direct food additives” (n=~3000) and “for regulatory purposes, [the FDA excluded] some substances that were generally regarded as safe (GRAS) (n=~450)…Precisely how some emulsifiers gained GRAS status is unclear.
  • “Lecithin” is derived from the Greek name for egg yolk (lekithos). “Over the years the use of the term “lecithin” has been taken to include various mixtures of different phospholipids” (not just phosphatidylcholine).
  • Lecithin can provide the substrate “for the production of trimethylamine N-oxide (TMAO)…linked to cardiac events and cardiovascular inflammation.”
  • “The list of emulsifiers that are widely used, but not considered GRAS, most notably include polysorbate 80 (p80), carboxymethylcellulose (CMC) and carrageenan…these emulsifiers have been linked to the disruption of the microbiota and gut mucosal lining…In addition, low-grade inflammation [has been] associated with consumption of emulsifying agents such as CMC and p80” [in mouse models].
  • The International Organization for the Study of Inflammatory Bowel Disease (IOIBD) has recommended that IBD patients “limit consumption of certain commonly encountered synthetic emulsifiers, specifically carboxymethylcellulose (E466/cellulose gum) and polysorbate 80 (E433) [which] are present in many processed foods, such as ice cream. The group also recommends a decrease in foods containing carrageenan”

In the second study by Chassaing et al with 16 healthy adults, the authors studied the effects of CMC in those with an emulsifier-free diet (n=9) or an identical diet enriched with CMC (n=7).

Key findings:

  • Relative to control subjects, CMC consumption modestly increased postprandial abdominal discomfort and perturbed gut microbiota composition in a way that reduced its diversity
  • CMC-fed subjects exhibited changes in the fecal metabolome, particularly reductions in short-chain fatty acids and free amino acids
  • 2 subjects consuming CMC who exhibited increased microbiota encroachment into the normally sterile inner mucus layer, a central feature of gut inflammation, as well as stark alterations in microbiota composition

My take: The dramatic increase in the prevalence of IBD over the past 50 years indicates a strong influence of environment factors, particularly diet. Determining which of these factors are most important will be challenging. These articles indicate that some emulsifiers could be contributing to GI tract inflammation and non-GI tract inflammation as well.

The challenges with identifying dietary factors relate to difficulties with using randomized controlled trials (especially eliminating delicious foods) to assess the impact over a long period of follow-up.

Related blog posts:

Ultraprocessed Food and the Risk of Inflammatory Bowel Disease

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N Narula at al. BMJ 2021; 374: n1554. Open Access: Association of ultra-processed food intake with risk of inflammatory bowel disease: prospective cohort study

Background: “Processed foods often include many non-natural ingredients and additives such as artificial flavours, sugars, stabilisers, emulsifiers, and preservatives. Detergents and emulsifiers that are added to foods might have a detrimental effect on the gut barrier. Carboxymethylcellulose has been shown to increase bacterial adherence to intestinal epithelium and might lead to bacterial overgrowth and infiltration of bacteria into the spaces between intestinal villi. Polysorbate 80, an emulsifier commonly used in processed foods, increases translocation of bacteria such as Escherichia coli across M cells and Peyer’s patches in people with Crohn’s disease.”

Methods: Using food questionnaires, the authors prospectively followed 116 087 adults aged 35-70 years from 21 low, middle, and high income countries from 2003 to 2016 (median follow-up of 9.7 years).

Key findings:

  • After adjustment for potential confounding factors, higher intake of ultra-processed food was associated with a higher risk of incident IBD with a hazard ratio of 1.82 for ≥5 servings/day and 1.67 for 1-4 servings/day (compared to <1 serving/day)

Since this is an observational study, this does not prove a causal association between these foods and inflammatory bowel disease. Nevertheless, limiting the consumption of ultraprocessed foods is a good idea as these foods may increase the risk of other health problems as well, including cardiometabolic disease and cancer (Gastroenterol 2022; 162: 652-54). This will be difficult, though, as in the U.S. more than half of calories consumed are from ultraprocessed foods.

My take: This study supports the notion that more fresh foods in our diets is beneficial.

Related blog posts:

Artist near Azalea Drive (Chattahoochee River, Atlanta)

Call For Action: Adolescent Nutrition Series

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Day-to-day, I find I am focused (?inundated) on problems that are literally right in front of me. Every once in a while, it is important to look more broadly and try to consider/address the larger issues.

Along those lines, I would recommend a series of important articles on adolescent nutrition published by The Lancet. Thanks to William Balistreri for sharing these references.

1. GC Patton et al. Nourishing our future: the Lancet Series on adolescent nutrition. DOI:https://doi.org/10.1016/S0140-6736(21)02140-1

This is an introduction to the series of articles. “Given these increasingly transnational
dimensions of the ultra-processed food industry, it is timely for WHO, the Food and Agriculture Organization of the UN, and their partners to revisit calls for global regulatory frameworks to assist governments in taking action. Given the speed of nutritional change, there is perhaps no greater immediate threat to the health of adolescents. Equally, tackling adolescent nutrition presents an unparalleled opportunity to interrupt intergenerational cycles of malnutrition and respond to the urgent challenges of planetary change”

2. SA Norris et al. Nutrition in adolescent growth and development. DOI:https://doi.org/10.1016/S0140-6736(21)01590-7

  • The review highlights how nutrition in youth/adolescence influences weight, height, BMI as well as the timing of puberty, neurodevelopment, cardiorespiratory fitness, immune function, body composition and bone mass
  • Adolescents are “growing up at a time of momentous shift—ie, rapid urbanisation, climate change, food systems shifting towards foods with an increased caloric and decreased nutritional value, the COVID-19 pandemic, and growing socioeconomic inequality. The consequences of these changing contexts have profound impacts on adolescent nutrition and development”

3. LM Neufeld et al. Food choice in transition: adolescent autonomy, agency,
and the food environment. DOI:https://doi.org/10.1016/S0140-6736(21)01687-1

Key points:

  • “Adolescents have a lot to say about why they eat what they eat, and the factors that might motivate them to change. Adolescents must be active partners in shaping local and global actions that support healthy eating patterns. Efforts to improve food environments and ultimately adolescent food choice should harness widely shared adolescent values and desire for social interaction around food”
  • The article reviews in depth information from prior surveys including India’s Comprehensive National Nutrition Survey and the Global School-based Student Health Surveys. However, they note that nationally representative detailed dietary intake data are still scarce
  • Food choices by adolescents in modern communities is more heavily influenced by convenience and autonomy; in more traditional communities, family and community priorities often supersede individual considerations of adolescents
  • In the setting of the pandemic, more families (worldwide) are being pushed into food insecurity and shifting towards lower-cost, less nutritious non-perishable foods.
  • “Even in less food-insecure contexts, social isolation is resulting in negative trends among some adolescents, such as reported weight gain, poor eating habits, and stress eating”

4. D Hargreaves et al. Strategies and interventions for healthy adolescent growth,
nutrition, and development. DOI:https://doi.org/10.1016/S0140-6736(21)01593-2

Key Points:

  • “Adolescence (10–24 years of age) is “characterised by transition, exploration, and openness to change [good and bad], offering opportunities for radical shifts in diet, physical activity, and other risks for non-communicable diseases. This same novelty-seeking and openness to change also makes adolescents a vulnerable group to commercial exploitation and other unhealthy influences, with lifelong and intergenerational consequences”
  • “Despite micronutrient deficiencies and food insecurity persisting in many places, and overweight and obesity rapidly increasing, adolescents have been largely overlooked in global nutritional policy frameworks. Targets should be established for adolescent nutrition in its global tracking and accountability mechanism”
  • “Greater government fiscal and policy action to both restrict the availability of highly processed foods and enhance healthy and diverse adolescent diets is urgently needed”
  • Nutrition education needs to be leveraged in schools: “knowledge of dietary diversity, food environment, and practical skills; use opportunity of school curricula to support nutrition and food preparation; improving choice architecture”
  • Social media has become a huge influence on dietary choices, body image, and psychological well being, both through advertising and marketing to adolescents and subsequent peer interactions

My take: If we truly hope to improve population health, improving diet choices cannot remain the province of only the well-educated wealthy. Adolescence offers a chance to change health trajectories before habits are more rigid and before the development of fixed health consequences.

Related blog posts:

Another Beach Sunset at Siesta Key, FL. Can there be too many?

NY Times: Year in Health Articles

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Personal item: If any blog follower has experience using biologics (eg mepolizumab, benralizumab) in a young child (1 yo) with eosinophilic colitis and marked eosinophilia, please send me a personal email: jjhochman@gmail.com.

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NY Times: The Year in Fitness: Shorter Workouts, Greater Clarity, Longer Lives
By Gretchen Reynolds

Key points:

  • “Another series of studies from the University of Texas found that four seconds — yes, seconds — of ferocious bicycle pedaling, repeated several times, was enough to raise adults’ strength and endurance, whatever their age or health when they started.”
  • “As I wrote in July, the familiar goal of 10,000 daily steps, deeply embedded in our activity trackers and collective consciousness, has little scientific validity. It is a myth that grew out of a marketing accident, and a study published this summer further debunked it, finding that people who took between 7,000 and 8,000 steps a day, or a little more than three miles, generally lived longer than those strolling less or accumulating more than 10,000 steps.”
  • “Exercise also has a disproportionate impact on our odds of enjoying a long, healthy life. According to one of the most inspiring studies this year, overweight people who started working out lowered their risk of premature death by about 30 percent even if they remained overweight, with exercise providing about twice as much benefit as weight loss might…Exercise enhances our brain power, too, according to other, memorable experiments from this year”
  • “In the study, which I wrote about in May, active people reported a stronger sense of purpose in their lives than inactive people….In effect, the more people felt their lives had meaning, the more they wound up moving, and the more they moved, the more meaningful they found their lives.

NY Times: The Secrets to Successful Aging in 2022

Key points:

  • For successful aging, recognize one’s issues and adapt accordingly. “Sooner or later, we all must recognize what is no longer possible and find alternatives,” says Jane Brody (Personal Health columnist) –“Inspired by Steven Petrow’s book, “Stupid Things I Won’t Do When I Get Old.”
  • Learning from ‘Super-Agers’ — “past research has revealed lifestyle factors that contribute to resilience such as obtaining a high level of quality education; holding occupations that deal with complex facts and data; consuming a Mediterranean-style diet; engaging in leisure activities; socializing with other people; and exercising regularly”
  • The sweet spot for longevity lies around 7,000 steps a day (or 30 minutes of exercise).

NY Times: How to Improve Your Mental Health in 2022 By Dani Blum and Farah Miller

NY Times: Favorite Pieces of Advice (7 tips) includes being kind to yourself and advice to learn/do new things

The Legacy Trail -Sarasota County, FL

Bariatric Surgery Outcomes in Adolescents

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F Qureshi et al. JPGN 2021; 73: 677-683. Longitudinal Outcomes in Adolescents After Referral for Metabolic and Bariatric Surgery

Key findings (study period 2015-2020):

  • Only 22% underwent bariatric surgery (Laparoscopic sleeve gastrectomy (LSG)), mainly due to lack of interest in those referred
  • Reasons for NoLSG: 171 (62% of the NoLSG group) did not return for a 2nd visit, 28 (10%) were considered non-adherent to clinical recommendations, 14 (6%) had insurance denials, 16 (6%) had psychological contraindications including recent suicidal ideations, and 29 (11%) are still considering/pursuing LSG
  • Only 8 (2.3%) of entire cohort were self-pay
  •  LSG patients had 21% total weight loss and 22% total BMI loss at 24 months whereas NoLSG patients had 4% total weight gain and 3% BMI gain (P < 0.01)
  • LSG group had improvement in obesity-associated conditions compared to group without surgery (P < 0.01)
  • Follow-up in both groups was poor (40% for LSG group and <20% for the NoLSG group) 1 year after bariatric referral. This is of particular interest in the LSG group b/c for surgery, patients are required to agree to a 5 year f/u period (though this lacks an enforcement mechanism). The authors note some improvement in f/u coincident with recent broader adoption of telemedine

My take: This single-center found that most patients referred for consideration of bariatric surgery did not have this surgery.

 Related blog posts:

Best Allergy Articles 2021 -Cow’s Milk Allergy (Part 3)

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In Pediatrics, supplement 3 summarizes 76 articles: Synopsis Book: Best Articles Relevant to Pediatric Allergy, Asthma and Immunology

Some of the studies that are most relevant to pediatric GI doctors I am reviewing for this blog over the next/past few days.

VM Martin et al. Pediatrics 2020; 146: e20200202. Open Access: Increased IgE-Mediated Food Allergy with Food-Protein-Induced Allergic Proctocolitis.

In this study of 153 infants with food protein-induced allergic proctocolitis (FPIAP) with documented blood in the stool, more children with FPIAP developed IgE-Food Allergy (IgE-FA) (11%) compared with healthy children.

Key points (from commentary by MT Kraft and D Stukus):

  • “Although conventional teaching is to wait until 12 months of age to reintroduce dairy to infants with FPIAP, it can likely be introduced much earlier.”
  • The diagnosis of FPIAP was associated with with an increased risk of IgE-FA, “although diagnosis was not confirmed through oral food challenges”

My take: Children with FPIAP are more likely to receive a diagnosis of IgE-FA. Prolonged restriction of milk, when no longer required, could contribute to this; in addition, some children are mislabeled as food allergic without appropriate confirmation (based on faulty testing).

Best Allergy Articles 2021 -Cow’s Milk Allergy (Part 2)

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In Pediatrics, supplement 3 summarizes 76 articles: Synopsis Book: Best Articles Relevant to Pediatric Allergy, Asthma and Immunology

Some of the studies that are most relevant to pediatric GI doctors I am reviewing for this blog over the next few days.

R Nocerino et al. J Pediatr 2021; 232: 183-191. Open Access: The Impact of Formula Choice for the Management of Pediatric Cow’s Milk Allergy on the Occurrence of Other Allergic Manifestations: The Atopic March Cohort Study

Methods: In a 36-month prospective cohort study (n=365), the occurrence of other atopic manifestations (eczema, urticaria, asthma, and rhinoconjunctivitis) and the time of immune tolerance acquisition were comparatively evaluated in children with oral food challenge-confirmed IgE-mediated cow’s milk allergy (CWA). 5 groups were treated with extensively hydrolyzed casein formula containing the probiotic L. rhamnosus GG (EHCF + LGG), rice hydrolyzed formula, soy formula, extensively hydrolyzed whey formula (EHWF), or amino acid–based formula.

Key finding:

  • The use of EHCF + LGG for CMA treatment was associated with lower incidence of atopic manifestations and greater rate of immune tolerance acquisition.

The risk ratios:  

  • 2.37 (1.46-3.86, P < .001) for rice hydrolyzed formula vs EHCF + LGG
  • 2.62 (1.63-4.22, P < .001) for soy formula vs EHCF + LGG
  • 2.31 (1.42-3.77, P < .001) for EHWF vs EHCF + LGG
  • 3.50 (2.23-5.49, P < .001) for amino acid–based formula vs EHCF + LGG

Limitations: non-blinded study, exclusion of patients with anaphylaxis-CMA

Best Allergy Articles 2021-Cow’s Milk Allergy

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In Pediatrics, supplement 3 summarizes 76 articles: Synopsis Book: Best Articles Relevant to Pediatric Allergy, Asthma and Immunology

Some of the studies that are most relevant to pediatric GI doctors I am reviewing for this blog over the next few days.

T Sakihara et al. J Allergy Clin Immunol 2021; 147: 224-232.e8. Randomized trial of early infant formula introduction to prevent cow’s milk allergy

In this randomized trial, infants (n=491 enrolled) in Japan were randomly allocated to ingest at least 10 mL of CMF (cow’s milk formula) daily (ingestion group) or avoid CMF (avoidance group) between 1 and 2 months of age. In the avoidance group breast-feeding was supplemented with soy formula as needed. Oral food challenge was performed at 6 months of age to assess CMA development. Continuous breast-feeding was recommended for both groups until 6 months of age.

Key findings:

  • There were 2 CMA cases (0.8%) among the 242 members of the CMF ingestion group and 17 CMA cases (6.8%) among the 249 participants in the avoidance group (risk ratio = 0.12; 95% CI = 0.01-0.50; P < .001).
  • Approximately 70% of the participants in both groups were still being breast-fed at 6 months of age.

My take: This study adds to the growing body of evidence that early introduction of allergenic foods lowers the likelihood of developing food allergies.

Related blog posts:

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Favorite Posts of 2021

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I am happy to say that this is the last nightcall that I will have this year!

Today, I’ve compiled some of my favorite posts from the past year. I started this blog a little more than 10 years ago. I am grateful for the encouragement/suggestions from many people to help make this blog better. Also, I want to wish everyone a Happy New Year.

GI:

IBD:

LIVER:

Nutrition:

Other Topics:

Thanks to Jennifer

Timing of Solids and Weight Trajectory

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CJ D’Hollander et al. J Pediatr 2022; 240: 102-109. Timing of Introduction to Solid Food, Growth, and Nutrition Risk in Later Childhood

Methods: A longitudinal cohort study was conducted among healthy children 0-10 years of age participating in The Applied Research Group for Kids study between June 2008 and August 2019 in Toronto, Canada.

Key findings:

  • Of 8943 children included, the mean (SD) age of infant cereal introduction was 5.7 (2.1) months
  • Children who were introduced to infant cereal at 4 vs 6 months had 0.17 greater body mass index z score (95% CI 0.06-0.28; P = .002) and greater odds of obesity (OR 1.82; 95% CI 1.18-2.80; P = .006) at 10 years of age. 
  • Earlier cereal introduction was associated with a less-favorable eating behavior score at 18 months to 5 years of age (0.18 units higher; 95% CI 0.07-0.29; P = .001).

Limitation: This study did not randomize children into early vs late cereal introduction; thus, there may be unidentified confounders that contribute to weight gain in children offered cereal at a younger age.

My take: This study indicates that introduction of cereal at 6 months of age, rather than 4 months of age, may be beneficial in limiting excess weight gain.