Download Fact or Fad: What’s New in Nutritional Therapy

Fact or Fad?
What’s New in Nutritional Therapy
Matthew Riley, MD
Pediatric 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 glutenfree 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
Enteral Nutritional Therapy
for Crohn’s Disease
• 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
Enteral Nutritional Therapy
for Crohn’s Disease
• 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
Eosinophilic Esophagitis
• 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
Eosinophilic Esophagitis
• 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
Eosinophilic Esophagitis
• 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
Eosinophilic Esophagitis
• 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
Eosinophilic Esophagitis
• 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
reintroduced
Kagalwalla et al. Clin Gastroenterol Hepatol. 2006; 4(6); 1097-102
Gonsalves et al. Gastroenterology. 2012; 142(7): 1451-9
Eosinophilic Esophagitis
• 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): 1093-1099
Kagalwalla AF. Dig Dis 2014; 32(1-2): 114-9
Eosinophilic Esophagitis
• Cow Milk Elimination
– 65% effective
– Relatively simple
– Requires as few as 1 repeat endoscopy
Kagawalla et al. JPGN 2012; (55): 711-6
Eosinophilic Esophagitis
• 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/
Is there a Wheat Belly?
• 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
Is there a Wheat Belly?
• 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 glutenfree 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
Gluten-free & Casein-free Diet
in Autism Spectrum Disorder
• 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
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
Gluten-free & Casein-free Diet
in Autism Spectrum Disorder
• 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
out
Fasano et al. Gastroenterology 2015, published online, in press
Non-Celiac Gluten Sensitivity
• 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
Non-Celiac Gluten Sensitivity
• 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
Non-Celiac Gluten Sensitivity
• 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
Cons
• Calorie intake tends to be lower
• Increases intakes of fresh fruits
and vegetables
• 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
Reality: Maybe I’ll try it…
Cons
• Can be low on calcium and
Vitamin D
• Hard to follow on vegan or
vegetarian diet
• Can be expensive
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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