fact or fad? what’s new in nutritional therapy matthew riley, md pediatric gastroenterology...

Fact or Fad? What’s New in Nutritional Therapy

Matthew Riley, MDPediatric Gastroenterology

Northwest Pediatric Gastroenterology, LLC

Appreciations

• Thank you!– Oregon Academy of Family Physicians– Kerry Gonzales– North American Society of Pediatric

Gastroenterology, Hepatology and Nutrition– American Gastroenterological Association

Objectives

• Be aware of nutritional therapy options for Crohn’s disease and eosinophilic esophagitis.

• Be aware of current FDA regulation of gluten.

• Understand the medical indications for gluten-free and low FODMAP diets.

• Be able to counsel patients on pros and cons of various ‘fad’ diets.

Food as Medicine

• Let food be thy medicine and medicine be thy food. – Hippocrates, 460-370 BC

• Man should strive to have his intestines relaxed all the days of his life. – Moses Maimonides, 1135-1204 AD

• A good set of bowels is worth more to a man than any quantity of brains. – Josh Billings (Henry Wheeler Shaw), 1818-1885 AD

Therapeutic Diets

• Requires a patient to:– reduce or eliminate a certain type of food or

nutrient– add a certain type of food or nutrient– change the consistency of your food– change your pattern of eating

• for the purpose of treating or improving the symptoms of a medical problem

Therapeutic Diets

• Requires a good diagnosis

• Requires evidence to support its use for a particular problem

• Not FDA regulated

• Does not require a prescription

Sample Therapeutic Diet

Dx: cow milk protein allergy• Recurrent atopic symptoms

after exposure to cow milk protein

• Verified by elimination and challenge

• +/- supported by IgE or skin prick tests

• Rx: complete cow milk protein elimination

Dx: adult-type hypolactasia• Recurrent bothersome GI

symptoms after exposure to lactose

• Verified by hydrogen breath test or duodenal lactase measurement

• Rx: reduced lactose ingestion; often no more than 12g per meal

• Rx: Oral lactase supplements

Enteral Nutritional Therapy for Crohn’s Disease

• Has long been used as primary therapy in Europe

• Can replace steroid therapy

• Can be used for induction and maintenance of remission


• Induction requires 80-90% of nutrition to be given as whole protein formula (PO or NG)

• Clinical remission 70-80%

• Mucosal healing in 19-75%

• Recommended as 1st line therapy for Pediatric CD in European consensus guidelines

Ruemmele et al. J Crohn’s and Colitis, Oct 2014(8):1179-1207


• No high quality studies to support use of

– Gluten-free diet

– “Specific Carbohydrate Diet”

– Any other therapeutic diet

Eosinophilic Esophagitis

• Chronic eosinophilic infiltration of the esophageal mucosa

• Typically >15 eosinophils per high-powered field

• Not responsive to proton pump inhibitor therapy

Liacouras et al. Gastroenterology 2014: 147(6): 1238-1254


• Risk of esophageal stricture as high as 80% after 30-40 years of illness

• Diagnostic delay most important factor

• Treatment recommended to improve symptoms and prevent irreversible fibrosis


• Treatment Options– Swallowed steroids: fluticasone, budesonide– Therapeutic diet:

• Elemental diet• Targeted elimination diet• Six food elimination diet (SFED)• Four food elimination diet (FFED)• Cow milk elimination


• Elemental diet– Over 90% effective– Poor palatability and compliance– Usually requires NG tube– Costly– Requires multiple endoscopies as foods

reintroduced

Liacouras et al. Clin Gastroenterology Hepat. 2005(3): 1198-206


• Targeted Elimination– Based on skin prick, atopy patch, +/- food-IgEs– 33-72% effective– Skin prick alone poorly predictive– Atopy patch testing not well standardized– Requires consultation with Allergist– Usually requires multiple repeat endoscopies

Spergel et al. Ann Allergy Asthma Immunol. 2005(95): 336-343


• Six Food Elimination Diet– No cow milk, soy, egg, wheat, fish/shellfish,

peanut/tree nuts– 70-75% effective– Generally requires consultation with RD– Difficult– Requires multiple endoscopies as foods

reintroducedKagalwalla et al. Clin Gastroenterol Hepatol. 2006; 4(6); 1097-102Gonsalves et al. Gastroenterology. 2012; 142(7): 1451-9


• Four Food Elimination Diet– No cow milk, soy/legumes, egg, wheat– 55-75% effective– May require consultation with RD– Less difficult– Requires fewer endoscopies as foods reintroduced

Molina-Infantile et al. Journal All Clin Imm. 2014; 134(5): 1093-1099Kagalwalla AF. Dig Dis 2014; 32(1-2): 114-9


• Cow Milk Elimination– 65% effective– Relatively simple– Requires as few as 1 repeat endoscopy

Kagawalla et al. JPGN 2012; (55): 711-6


• Choosing the right therapy

• Medication vs. Diet

• Response rate vs. Ease/Expense

Gluten

• What’s new?

– Regulation

– Indications

Gluten

• Group of related proteins (prolamines)

• Found in wheat, rye, barley

• Contain glutamine- and proline-rich peptides which are resistant to digestion

• Cause T-cell activation and chronic autoimmune response in some genetically-susceptible individuals (= celiac disease)

Gluten Regulation

• 2004: Food Allergen Labeling and Consumer Protection Act of 2004 directed HHS to define and permit the use of the term "gluten-free" in the labeling of foods

• FDA issued final rule on August 5, 2013

• Compliance date was August 5, 2014

http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/Allergens/ucm362510.htm

Gluten Regulation

• Final rule defines "gluten-free" as meaning:– The food either is inherently gluten free (e.g. rice)– Or does not contain an ingredient that is:

• 1) a gluten-containing grain (e.g. spelt wheat); • 2) derived from a gluten-containing grain that has not been

processed to remove gluten (e.g. wheat flour); or • 3) derived from a gluten-containing grain that has been

processed to remove gluten (e.g. wheat starch),– if the use of that ingredient results in the presence of 20 parts per

million (ppm) or more gluten in the food.

• Also, any unavoidable presence of gluten in the food must be less than 20 ppm.

Gluten Regulation

• Rule applies to packaged foods

• Restaurants making a gluten-free claim on their menus should be consistent with FDA’s definition

Is there a Wheat Belly?

• Wheat Belly, published in 2011 • William Davis MD, Cardiologist• New York Times Bestseller list

• "The food you eat is making you sick and the agencies that are providing you with guidelines on what to eat are giving dangerous advice with devastating health consequences. You can change that today."

http://www.wheatbellyblog.com/


• Wheat was first cultivated ~8000 B.C.

• Currently the 3rd most produced grain on the planet

• 2nd most common crop for human food

• Relatively hardy and disease resistant


• 6 major species• 6 major classes grown in the US• A few components with potential non-allergic

health implications– Gluten– Fructans– Amylase trypsin inhibitors

Gluten-Free Diet

• Likely the most popular self-prescribed therapeutic diet in the US

• 100 million Americans will consume gluten-free products within a year

Gluten-Free Diet

• Indications

– Celiac Disease– ?Autism Spectrum Disorder– ?Irritable Bowel Syndrome– ?Non-Celiac Gluten-Sensitivity

Gluten-free & Casein-free Diet in Autism Spectrum Disorder

• The Theory: Opioid theory of ASD

• Proposed by Jaak Panksepp in 1979, based on rat data

• Autism may be "an emotional disturbance arising from an upset in the opiate systems in the brain“

• Potential absorption of gluteomorphins from gluten and beta-casomorphins from casein

Panksepp, J. Trends in Neurosciences. 1979(2): 174–177


Cochrane Database Syst Rev. 2008; Apr 16(2); Mulloy et al. Research in Autism Spectrum Disorders 2009; Buie et al. Clin Ther . 2013; 35(5):578–83; Dosman et al. Pediatr Rev. 2013 ; 34(10): e36-4; Mari-Bauset et al. J Child Neurol 2014; 29(12): 1718-1727

• The Science

• No abnormal concentrations of opioid peptides have been found in blood, urine or CSF in patients with ASD using modern methods

• Multiple meta-analyses and reviews have shown no quality evidence to support the use of GFCF diet for patients with ASD


• The Reality

• Many parents will try it

• Try to rule out celiac disease first

• Give a distinct endpoint

• Don’t ignore financial and quality of life burden

Non-Celiac Gluten Sensitivity

• First described in 1970s

• Definition– Clinical entity induced by ingestion of gluten– Intestinal and extra-intestinal symptoms– Symptoms resolve with gluten elimination– Celiac disease and wheat allergy have been ruled

outFasano et al. Gastroenterology 2015, published online, in press


• May show signs of immune activation– Breaks in tight junctions– Intraepithelial lymphocytes– May involve innate or adaptive immunity

• Do not show signs of autoimmunity – TTG IgA negative– Can have non-HLA DQ2 or DQ8 genotypes

Fristcher-Ravens at al. Gastroenterology 2013. (147):1012-20


• Potentially a distinct entity from IBS

• May not be related just to gluten

• May be related to amylase trypsin inhibitors (ATIs)

Amylase Trypsin Inhibitors

• Inhibit enzymes in common pests, e.g. mealworms, mealbugs

• ATIs in wheat, rye and barley active toll-like receptor 4

• Modern wheat contains several fold times more ATIs than ancient varieties

• Duodenal samples of patients with NCGS have higher levels of TLR-4

Junker et al. J Exp Med. 2012(209): 2395-2408


• Pathogenesis is poorly understood

• It’s not celiac disease ‘light’

• May involve relative abundance of ATIs in modern wheat varieties

• Stay tuned…

FODMAPs

• Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols

• Oligos: fructans, galactans

• Disaccs: lactose

• Monos: fructose

• Polyols: sorbitol, mannitol, xylitol, isomalt

FODMAPs

• Fructans occur in many plants– Energy storage– Confer tolerance to freezing

• Used as dietary fiber supplements

• Beans, Onions, Garlic, Peas, Artichokes, Asparagus, Leeks, Wheat, Rye

Low FODMAP Diet for IBS

• Multiple studies have shown clinical benefit of low FODMAP diet for IBS

• Mechanisms likely due to increased fermentation

• Can alter intestinal microflora

Staudacher et al. J Hum Nutr Diet 2011 Oct; 24(5): 487-95; deRoest et al. Int J Clin Pract 2013 Sep;67(9):895-903; Halmos et al. Gastroenterology 2014 Jan;146(1):67-75

Low FODMAP Diet for IBS

• Major limitations– Knowledge– Labeling– Adherence

• Tools– iPhone apps (Monash

University)– Knowledgeable RDs

Fad Diets

• What is a fad?

• “An intense and widely shared enthusiasm for something, especially one that is short-lived and without basis in the object’s qualities”

www.oxforddictionaries.com

Fad Diets

• What is fad diet?

– Not targeted to any specific medical condition

– Based loosely on scientific fact or on false ideas of human physiology

– Typically vilifies certain nutrients or food groups

– Often requires rigid focus and promoted for profit

Raw Food Diet

• Theory

– If food is heated over 104-120⁰F, vitamins and enzymes are destroyed and may become toxic

– Beneficial micro-organisms are destroyed by heat

– Pioneered by Dr. Maximilian Oskar Bircher-Benner; Swiss physician (1867-1939)

– Multiple proponents since to improve general health

Raw Food Diet

• Science

– Enzymes in food are denatured in gastric acid

– Most microorganisms are killed in gastric acid

– Some nutrients are better absorbed when cooked• Lycopene• Carotene

Raw Food Diet

Pros• Calorie intake tends to be lower• Increases intakes of fresh fruits

and vegetables

Cons• May increase risk of foodborne

illness• Risk of calcium and Vitamin D

deficiencies• Meal prep can become

complicated

Reality: Make raw, unprocessed plants a part of every meal.

IgG-based diets

• Theory

– IgG-mediated allergies are a major contributor to many diseases, including IBS, autism, ADHD, cystic fibrosis, rheumatoid arthritis and epilepsy

– Food-specific IgG levels can be done through many laboratories, even direct to patient

Atkinson et al. Gut 2004 Oct: 53(10): 1459-64; Alpay et al. Cephalagia 2010 July: 30(7): 829-37; Zar et al. Scand J Gastroenterology 2005 Jul: 40(7): 800-7

IgG-based diets

• Science

– “IgG4 against foods…are an indicator for immunological tolerance, linked to the activity of regulatory T cells.”

– Some studies have shown small treatment effect for IBS, migraine

http://www.aaaai.org/ask-the-expert/use-of-IgG-and-IgA-antibodies-in-diagnosis.aspx; Atkinson et al. Gut 2004 Oct: 53(10): 1459-64; Alpay et al. Cephalagia 2010 July: 30(7): 829-37; Zar et al. Scand J Gastroenterology 2005 Jul: 40(7): 800-7

IgG-based diets

Pros• Some potential benefit for

IBS, migraine• May offer a glimpse to

pathophysiology of IBS

Cons• Blood testing can be >$500• Not covered by insurance• High false-positive rate• Diets can be very limited• High drop out rate

Reality: Not mainstream, but many CAM providers order. Need to discuss with patients. Consider time-limited trial.

The Paleo Diet

• Theory

– Mimics pre-agricultural, hunter-gatherer diet

– Loren Cordain, PhD

– Revised in 2010

www.thepaleodiet.com

The Paleo Diet

• High protein (20-35% of calories)

• Lower carbohydrates and glycemic index

• High fiber

• Higher monounsaturated fats and omega-3 fats

• Low sodium, higher potassium

The Paleo Diet

• Science

– Low glycemic index diet can improve obesity and dyslipidemia

– Low glycemic index diet can improve diabetic control

Thomas et al. Cochrane Database Syst Rev. 2007 Jul(3)Thomas et al. Cochrane Database Syst Rev. 2009 Jan(1)

The Paleo Diet

Pros• Plenty of fresh fruits and

vegetables• Reduces intake of processed

food and refined sugars• May promote weight loss

and reduce CV risk• No calorie counting

Cons• Can be low on calcium and

Vitamin D• Hard to follow on vegan or

vegetarian diet• Can be expensive

Reality: Maybe I’ll try it…

Food as Medicine

• There are, in effect, two things: to know and to believe one knows. To know is science, to believe one knows is ignorance. –Hippocrates

• Isn’t it a bit unnerving that doctors call what they do “practice”? – George Carlin, 1937-2008

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fact or fad? what’s new in nutritional therapy matthew riley, md pediatric gastroenterology...

Documents

therapeutic diet slide

ad slide

prescription slide

enteral nutritional

medical problem slide

maintenance of remission

steroid therapy

primary therapy