Eating the Right Foods and Weight Loss

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In a recent NY Times article, Rethinking Weight Loss and the Reasons We’re ‘Always Hungry’, the idea that too many calories causes obesity is challenged:

“…overeating doesn’t make you fat. The process of getting fat makes you overeat.”

Here’s an excerpt:

Dr. Ludwig, an obesity expert and professor of nutrition at the Harvard T.H. Chan School of Public Health, argues that weight gain begins when people eat the wrong types of food, which throws their hormones out of whack and sets off a cycle of cravings, hunger and bingeing. In his new book, “Always Hungry?,” he argues that the primary driver of obesity today is not an excess of calories per se, but an excess of high glycemic foods like sugar, refined grains and other processed carbohydrates…

Simply cutting back on calories as we’ve been told actually makes the situation worse. When we cut back on calories, our body responds by increasing hunger and slowing metabolism. It responds in an effort to save calories…

It’s the low fat, very high carbohydrate diet that we’ve been eating for the last 40 years, which raises levels of the hormone insulin and programs fat cells to go into calorie storage overdrive.

My take: The idea of changing the types of foods that we consume is not new in the fight against excessive weight gain.  Some of the best data on healthy eating is associated with the Mediterranean diet.

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Another review (from the NY Times) of the book ‘Happy Gut’ describes a diet promoted by a NY internist to help with problems like irritable bowel: Seeking a ‘Happy Gut’ for Better Health. “Cutting out dairy and gluten reversed many of his symptoms. Replacing processed foods with organic meats, fresh vegetables and fermented foods gave him more energy and settled his sensitive stomach.”

Banning Mills

Banning Mills

 

About Mentors

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I found a recent perspective (Y Tache. Gastroenterol 2015; 149: 1662-65) on mentoring of interest, particularly on the historic basis which I had forgotten.

“In Homer’s book, the Odysseus, Mentor was a loyal friend and adviser to Odusseus (Ulysses), King of Ithaca.  When Ulysses left his kingdom to participate in the Trojan War, he entrusted Mentor with the education of his son, Telemachus…This character of Greek mythology became famous only at the beginning of the 18th century in the context of the didactic French novel entitled “Les Aventures de Telemaque.”

My take: it is interesting to understand where the term “mentor” comes from.  I feel fortunate to have had some terrific mentors.

 

 

Continuous Feeds versus Bolus Feeds

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Briefly noted:

Another study (JB van Goudoever et al. JPGN 2015; 61: 659-64) indicates that bolus feeds are likely as safe as continuous feeds in preterm infants; though, the “continuous” feeding was atypical.  In this study, the bolus group received their feedings every 3 hours via gravity whereas the “continuous” feeding cohort received feedings by gravity by giving one-fourth of the hourly feeding every 15 minutes.

Key finding: In a study of 246 infants (<1750 g & <32 weeks gestational  age), there was no significant difference in reaching full enteral feedings between the group assigned to continuous feedings compared with bolus feedings

Related blog post:  Which is Safer -Drip Feeds or Bolus Feeds in Healthy Preterm …

 

Expect More on Microbiome Modulation with Enteral Nutrition

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Similar to a study reviewed on this blog (Why Does Enteral Nutrition Work for Crohn’s Disease? Is it due to the Microbiome?), another publication has shown decreased microbiome diversity associated with exclusive enteral nutrition (C Quince et al. Am J Gastroenterol 2-15; 110: 1718-29 -thanks to Ben Gold for this reference). The overall findings suggest that enteral nutrition makes the gut microbiome more ‘dysbiotic’ (more dissimilar to healthy controls) than prior to enteral nutrition.  This study examined 23 children with Crohn’s disease and 21 healthy children.

My take: Due to the increased ease and fascination of studying our stools, a lot more of this research is going to be published.  At some point, hopefully, these observational studies will transition to hypothesis-driven studies regarding which microbial species need to be modulated to improve inflammatory bowel disease.

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Salvage Therapy and Standard Therapy for H pylori

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A recent review (thanks to KT Park for reference) provides helpful resource for treating H pylori infection; this is becoming more important in this era of frequent antibiotic resistance. While this blog has reviewed expert recommendations for treatment, this article provides more insight into salvage treatments.  Table 1 reviews standard quadruple and triple regimens. Table 2 (below) provides dosing in adults for salvage therapy.

Thung, I., et al. (2015), Review article: the global emergence of Helicobacter pylori antibiotic resistance. Alimentary Pharmacology & Therapeutics. doi: 10.1111/apt.13497

Full link: Review article: the global emergence of Helicobacter pylori antibiotic resistance

 

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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.

Do You Know the Best Way to Use Antegrade Enemas?

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Currently, there is no best way to use antegrade enemas.  This is the obvious conclusion after reading a study by S Kuizenga-Wessel et al (JPGN 2016; 62: 71-9).  In this study, the authors reviewed 21 articles and also surveyed 23 physicians involved in the care of children who receive antegrade continence enemas (ACE). While the study provides a lot of details, the bottom-line is that there is wide variation in outcomes, definition of success, workup prior to institution of ACE, and irrigation solutions (16 out of 23 used saline).  The only areas of agreement seem to be the following:

  • use of ACE daily: 22 of 23
  • use of antibiotics with placement: 23/23 (though wide variation in specific regimen)
  • indications for ACE were largely in agreement, including constipation with fecal incontinence (21 of 23), anorectal malformations (22 of 23) and spinal abnormalities (23 of 23); however, only 8 of 23 considered due to functional non-retentive fecal incontinence as an acceptable indication

With regard to the type of enema, the vast majority of physicians (19 of 23) only add a stimulant to the solution after initial failure.  Though, one study (J Pediatr 2012; 161: 700-4) has reported “that subjects who use stimulants from the very beginning had significantly better outcomes.”

My take: Like of a lot areas in medicine and throughout pediatric gastroenterology, there is wide variation in clinical treatment approaches.  Variation in treatment is obvious in the use of ACE.  Collaborative work and consensus building in management would improve success; that is, after we define what success looks like.

In the same issue a link to “History of Pediatric Endoscopy” is provided.  This is a ~15 minute video with interviews with many pioneers/leaders in pediatric gastroenterology.

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Golden Gate Bridge

Golden Gate Bridge

Predicting a Bad End in Drug-Induced Liver Injury

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A recent study (VL Re et al. Clin Gastroenterol Hepatol 2015; 13: 2360-68) examined a retrospective cohort of 15,353 patients with presumed drug-induced liver injury (DILI) to formulate a more sensitive model for predicting liver failure.

The authors note that Hy’s Law has good specificity but poor sensitivity.  In their population, Hy’s Law had a specificity of 0.92, negative predictive value of 0.99, sensitivity of 0.68, and a positive predictive value of 0.02.

  • Hy’s law (named for Hyman Zimmerman): AST or ALT > 3 ULN and total bilirubin ≥2 ULN indicate serious hepatotoxicity with >10% mortality rate.

By incorporating data from platelet count and total bilirubin, the authors devised a Drug-Induced Liver Toxicity ALF Score which had a high sensitivity of 0.91 but a lower specificity of 0.76.

  • DrILTox ALF Score = -0.00691292*platelet count + 0.19091500*total bilirubin (per mg/dL)
  • Example: platelet count of 145 & total bilirubin of 3.0 yields a valued of -0.4296 which is above cut off of -1.081 indicating an increased risk of ALF.

Thus, low platelet counts and high bilirubins are strong predictors of acute liver failure (ALF) in the setting of DILI.

My take: Overall, the incidence of ALF due to drugs remains fairly low and determining that a specific drug induced liver injury remains problematic.  This study shows that ALF can occur in those who do not meet Hy’s Law criteria and that more sensitive predictors are needed.

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How Effective is Zinc Therapy for Wilson’s Disease?

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A study from France (R Santiago et al. JPGN 2015; 61: 613-18) examined the use of zinc therapy for Wilson’s disease. Though the national survey had 90 children from 6 centers, there were only 26 who were treated with zinc and only 9 who had received zinc as a first-line single therapy.

Despite the small numbers, data on treating children with Wilson’s disease are fairly sparse; as such, this article provides some helpful information.

The study reviews zinc’s mechanism of action:

“Oral zinc induces enterocyte synthesis of metallothionein, a cystic-rich protein acting as an endogenous chelator for metals, which preferentially binds copper in the enterocyte and inhibits its entry into the portal circulation. Thereby, it reduces copper intestinal absorption and leads to copper elimination in fecal contents within senescent enterocytes.”

Key results:

  • “Median transaminase level normalized within 6 months from treatment initiation” in the entire cohort of 26 children.  However, 10 of 26 children had abnormal ALT at 6 months into therapy.
  • Zinc dose was gradually increased such that 38% eventually had doses “exceeding recommended doses” which were >75 mg/day in 6-15 years and >150 mg/day in those ≥16 years.
  • Overall, the authors thought that zinc appeared to be less effective.  Failure with zinc occurred in 5 of 9 (3 due to ineffectiveness, 2 due to poor adherence).  The authors note that decompensation has been reported in children and adults on zinc monotherapy.

The authors indicate that zinc therapy is likely most appropriate after an induction phase with chelators in most children.  Criteria for changing to zinc include the following: “patients should be clinically well…with normal transaminase levels and hepatic synthetic function, non-ceruloplasmin-bound copper concentration within the normal range, and 24-hour urinary copper excretion in the range of 200-500 mcg/24 h.”

Additional precautions with zinc acetate (which is often better tolerated than chelators), 4 of 26 children in this study had gastric irritation, including one child with a perforation.  Therefore, a low threshold for endoscopy should be set in a child with epigastric pain. Adherence can be problematic due to the timing & frequency (TID) of zinc administration.  Monitoring urinary zinc excretion can be useful to monitor compliance.

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