Posted tagged ‘diet’

Gluten and children’s health: The New Boogeyman?

July 27, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Alice asked, “These days it seems like all the cool moms are claiming that their children have gluten sensitivity and putting them on gluten-free diets. I’m skeptical because it seems like all the symptoms are non-specific– mood swings, irritability, poor attention span– which all seem to me like symptoms of normal childhood. What is the medical basis for gluten sensitivity? I’ve heard that eliminating gluten will reduce toddler tantrums and help children perform better in school. If that’s true I want to try it, but are there any reputable studies to that effect?”

Is gluten the New Boogeyman? It’s been implicated as the Root of Many Evils, not just limited to belly pain and other GI symptoms. Gluten is blamed for behavior issues, autism, ADD, “wheat belly”, “brain fog”, and, presumably, the second and third Matrix movies*. Can one food be the cause of so many symptoms?

Gluten is a protein (ok, a mixture of two proteins… let’s not get technical) that’s naturally found in wheat, rye, and barley. The word comes from the same root as glue, and the substance itself is kind of glue-like and sticky. It’s the stickiness that makes it useful in cooking—it holds strands together, giving bagels and French bread that chewy springy sort of texture. For some people, it definitely causes objective and serious health problems; for many other people, it doesn’t. Then there’s that grey zone in between.

wheatFirst, the definites: gluten is The Cause of celiac disease, an autoimmune-ish disorder that causes gut damage and problems in other organ systems, triggered by ingested gluten. Stop eating gluten—all gluten—and all of the symptoms of celiac ought to disappear. Celiac disease occurs in about 1 in 100 people, and can be reliably diagnosed by blood tests with biopsy confirmation. People with proven celiac disease should not eat gluten.

Another definite: some people are allergic to wheat proteins, including gluten. Symptoms can include classic (or IgE-mediated) symptoms like hives or wheezing; or intense, quickly-developing vomiting, diarrhea, and symptoms of dehydration (in young children, this can be so-called “FPIES”, or Food Protein Induced Enterocolitis Syndrome. Rice and other foods can cause this, too.) True wheat allergy can be established by a careful history and sometimes by an “open challenge” of eating the food under controlled circumstances, with treatment readily available (do NOT try this at home.) People with proven wheat or gluten allergy should not eat wheat or gluten.

Then we get into a bit of a grey zone. There are many people with non-specific gut symptoms including pain, bloating, diarrhea, constipation, or an unpleasantly fast urge to defecate that feel better if they reduce or eliminate the gluten in their diet. When tested, most of these people do not have objective evidence of celiac disease (by the way, anyone who does have these symptoms should be tested for celiac before deciding they don’t have it.) Often, diagnostically, children and adults with these symptoms who have a negative workup are said to have “irritable bowel syndrome,” or IBS. If it seems to be associated with wheat, it’s sometimes also called “non celiac gluten intolerance” or “wheat sensitivity”.

So should people with IBS try a diet that eliminates gluten? Maybe. What may be even more promising, though, is looking at broader dietary changes following a so-called “low FODMAP” diet. A few good studies have shown that it isn’t just the gluten—in many people, wheat is one of several foods that include certain carbohydrates (FODMAPs) that are difficult to digest. Focusing on wheat may help, some, because we eat a lot of it; but reducing all of the FODMAP sources may be both more effective and easier than eliminating all gluten.

But what Alice wanted to know about wasn’t abdominal pain or belly symptoms. She wanted to know if eliminating gluten could change her child’s behavior for the better. Symptoms like “mood swings, irritability, poor attention span”—symptoms that pretty much define early childhood—are being attributed to “gluten sensitivity”. Is there any reason to think that could be the case?

Now, it gets really murky. If “non celiac gluten sensitivity” or “wheat intolerance” represent a kind of diagnostic grey zone, isolated behavior changes caused by gluten are more of an “inky blackness.” There’s some enthusiasm for gluten-free diets for children with autism spectrum disorders, but it’s been difficult to document whether reported improvements are a real effect. Small, open-label or non-placebo studies based on parent reports have shown some promise; but the only truly blinded, placebo-controlled study of a gluten-free diet showed no effect at all.

And studies of gluten restriction to help behavior challenges in neurotypical kids? There are none.

So, Alice, there’s no evidence that reducing gluten is likely to help behaviors like mood swings, irritability, or poor attention span in your toddler, and no evidence that it’s likely to improve school performance either. And, I agree, it does seem to be a bit of a fad to blame all sorts of things on gluten. Could there be a (wheat) germ of truth to all of this? Maybe. But I haven’t seen it yet.

 

*And, obviously, the last three Star Wars movies. Jar Jar, I believe, was the result of an out of control wheat binge. Look it up.

 For more about FODMAPs, gluten, and the evolving story of non-celiac gluten sensitivity or wheat intolerance syndrome, visit my friend Jay Hochman’s blog and search for “gluten”. He’s a pediatric gastroenterologist with a great eye for science, and his blog does a great job reviewing and referencing the latest research.

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Water versus diet beverages: What’s best for weight loss?

June 16, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

A new study gives some support for the use of artificially sweetened drinks as part of a weight loss program for adults.

Researchers randomized 303 adults (mostly women, with an average age of 48) into two groups during a 12-week weight loss program. Both groups received the same behavioral weight loss strategies, but one was told to drink only water. The other group was encouraged to drink non-nutritive, artificially sweetened beverages like diet sodas, iced tea, and flavored water (none with more than 5 calories per serving.)

The average weight loss was better in the diet drink group than among those drinking only water—9 versus 13 pounds. And the people drinking diet beverages were less likely to report feeling hungry than those drinking only water.

Now, all of the study participants were enrolled in a comprehensive weight loss program, and this study only looked at a short-term, 12 week outcome. Diet soda alone is unlikely to help anyone.

There’s some fine print, too. This study was fully funded by “The American Beverage Association”—an organization, I think, that would benefit from increased sales of diet drinks. And 2 of the 9 authors of the paper received consulting fees from The Coca Cola Company. That doesn’t mean that the study is tainted or invalid, but it does mean that we ought to see some collaborative evidence before suggesting that dieters routinely drink Diet Coke or Crystal Light. For now, I’ll suggest that most children stick with water.

High BMI in children

April 10, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Stephanie wrote in about a very common problem:

 My daughter is 4 years old. She isn’t the tallest cat in town (she is about the 15th-25th percentile for height), and her BMI always ends up being in the high range (like over 85%). I worry about it. I am very health conscious for myself and my family. We live by all of the ‘rules.’ And yet.

The family doctor doesn’t worry – been shrugging it off since day one. Maybe because both Dad and I are very lean. Maybe because, as patients of hers, she knows we are a very healthy family (regular exercise, healthy diet, no smoking, healthy pregnancy with aforementioned child). Family doc knows we have never fed our kid a drop of juice, no fast food, homemade meals, limiting screen time, healthy choices…

So I’m stumped. Why the high BMI for my daughter? I would love to hear some solid, scientific data about why this could be, as opposed to: ‘Meh, she’ll be fine.’

We know that obesity, in the long run, isn’t good—but we can’t even agree on what “obesity” is. BMI, or Body Mass Index, is a single number that basically reflects weight-for-height. We figure that the more someone weighs for their height, the more likely they are to weigh “too much.” What we really need is a measure that tells us when someone’s weight is unhealthy, or likely to lead to ill health. Instead, we use that BMI number, a very poor predictor of individual health outcomes.

There are several reasons why BMI is not a great way to discriminate between healthy and unhealthy weights:

A BMI doesn’t reflect the difference between lean muscle mass and fat mass. What’s unhealthy is excess body fat, not excess body muscle. A muscular, lean individual with little body fat may have a “high” measured BMI because muscle has weight.

BMI doesn’t distinguish between kinds of body fat. We know that visceral fat—the kind in your belly, or the kind that contributes to an “apple” shape—has far more long term negative consequences for health than fat distributed in the lower body.

Criteria for “healthy” versus “unhealthy” BMI are based only on statistics, not on individual health outcomes. We’ve decided that anyone above the 85 percentile for BMI (down to age 2) is overweight, and anyone above the 95 percentile for BMI is obese. This compares a child or adult’s BMI against historical data, which assumes that people thirty years ago had a BMI distribution healthier than today. While that’s generally true for the population (obesity-related health problems are genuinely much more common now), that doesn’t mean it’s specifically true for each individual or child. In other words, relying on statistics forces us to oversimplify and generalize instead of focusing on ways to individualize our approach to maximize health.

Finally, improved diet and exercise habits improve health outcomes, even if the BMI doesn’t change. Over-focusing on BMI can lead to discouragement, preventing steps that can really improve well-being in children and adults.

So what should Stephanie’s mom do? Forget the BMI and keep up those good healthy life habits. Stay active. Turn off the TV. Eat moderate-sized portions, slowly, eating mostly plants and whole-grains. Eat as a family, and share cooking and cleaning chores together. Avoid eating out or doing take-out too often, and stay away from sweet drinks (soda and juice are equally unhealthy). Enjoy eating and playing, together as a family, and don’t worry about the numbers on the scale. The BMI is one thing, maybe a starting point to remind us to keep up healthy habits. But it’s a terrible target to use as a goal for your child’s body.

Children discover: Adults just fattening them up to eat them

Diet and ADHD: Anything new?

February 12, 2011

The Pediatric Insider

© 2011 Roy Benaroch, MD

The Lancet has published another terrible, worthless study guaranteed to confuse parents.

Back in 1998, the world-renowned British medical journal The Lancet published a study that singlehandedly created the entire MMR-autism “manufacturversy.” The study itself was an absolute fraud based on fake data, designed to make money for its lead author. Red flags about the study were ignored by The Lancet’s editorial board for years; but finally most of its authors retracted the study, and then The Lancet withdrew it. Still, the damage was done. Falling vaccine rates led to a return of measles and surging rates of pertussis. Fooled by an unscrupulous liar and a media relishing any opportunity to sensationalize garbage, many parents still distrust vaccines.

And now, The Lancet has done it again. A terrible, worthless study has been published, guaranteed to confuse parents. Maybe their motto ought to be “anything that’s fit to make headlines.”

The study, titled “Effects of a restricted elimination diet on the behaviour of children with attention-deficit hyperactivity disorder (INCA study): a randomised controlled trial”, was supposed to examine the relationship between diet and behavior in ADHD. It’s an important topic. Many children have trouble with focus and attention, and many parents feel that diet may play a role. Though many older studies have been unable to confirm a consistent effect of foods on behavior, a 2007 BMJ study did show at least a small effect of preservatives and dyes in worsening behavior in children.

What has made studying diet and behavior difficult is separating out what is called “confirmation bias.” Parents who are convinced that, say, a sugary meal will worsen their child’s behavior are very apt to notice when bad behavior follows a junk food meal. But those same parents probably don’t notice when relatively good behavior occurs after sugar, or when bad behavior doesn’t really come after a meal. This isn’t because those parents are dumb or delusional—it’s just human nature. We all subconsciously find evidence to support what we already believe, and ignore evidence to the contrary.

Good science seeks to minimize the effects of this kind of bias by using “blinded control groups”, where the observers don’t know if the child was exposed to a surgary diet or not. In the older 2007 BMJ study, the families were truly blinded: neither they nor the researchers knew which kids received a supplement that was a preservative-n-chemical cocktail, versus which ones got a supplement of “nothing”. Only after the parents made their behavioral observations, and after the researchers performed their statistics, were they allowed to know which kids got which diet. That’s good research. The BMJ study did show a statistically significant change in behavior, though the effect was fairly small. Still, it’s a tantalizing start, and the group is now pursuing a more-specific study trying to identify which chemicals and preservatives might be the culprit. It’s a slow process, but carefully-done, well-controlled research should give us a clear answer on this topic.

Unfortunately, the research group publishing in The Lancet didn’t feel the need to bother with these sorts of protocols. In the initial phase of their study, 100 kids were divided into two groups of 50. One group continued to get an ordinary diet (though they did receive counseling about healthy food choices), and the other group was put on a highly restrictive diet of mostly rice, meat, vegetables, pears, and water. But all of the parents knew exactly what group their child was in. At the end of this study period, about 60% of parents of children in the restricted diet group had improved, compared to “none” of the children in the non-restricted diet.

Wait a minute here. If something completely random happens—let’s say I ask parents to flip a coin, and tell me heads or tails—about 50% of the parents should report “tails.” In this behavioral study, if I ask parents to just decide, “did things get worse or better,” if there was just a random scatter of observations, 50% of the parents should say “worse”, and 50% should say “better.” How could “none” of the parents have seen any improvement? Surely at least some of the children had a few good weeks, even with no change in diet, no?

And if 60% improved in the restricted group, that means 40% didn’t improve, or got worse. A 60-40 split isn’t really that impressive, is it?

Besides, with no blinding whatsoever, what does it even mean?

The study gets worse. There was a phase 2 that took the “diet responders” and put them on even more restricted diets based on blood testing for allergies—but using an outdated, worthless test that’s been invalidated for years. This further phase found that the blood tests didn’t help guide parents to diets that would help, which is no surprise because those blood tests don’t work. We already knew that.

There you have it, another terrible study from The Lancet, which demonstrates nothing in a perniciously misleading way. Perhaps there is a link between diet, chemicals, preservatives, and behavior—and certainly, trying to put children on a diet that avoids these sorts of chemicals can’t do any harm. But these authors, and the editorial board of The Lancet, ought to be ashamed of publishing such a worthless study. Do you think the media, and the public, are ready to get duped again?

Diets for babies, part 2: A better alternative

February 6, 2011

The Pediatric Insider

© 2011 Roy Benaroch, MD

Part 1 and part 2 of this article originally appeared on WebMD.com, as a response to this somewhat nauseating story.

Dieting is a terrible idea for everyone—everyone, that is, who’s trying to reach or maintain a healthy weight. It’s especially a bad idea for babies, because it interferes with the most important, fundamental skill that babies need in order to keep a healthy weight throughout their lives.

Ready for the secret to a lifetime of no-dieting, eating enjoyment, and keeping a healthy weight?

The Hungry Rule: Eat when you’re hungry. Don’t eat when you’re not.

It’s simple enough, and in fact every human baby is born with this wonderful skill. But dieting short-circuits the mechanism, leading to food cravings and stress and a distorted view of what and when one ought to eat. Instead of dieting, families should do everything they can to reinforce “the hungry rule.”

Start by breastfeeding. A mother and her baby follow cues from each other about how much milk to supply and when to eat. Bottlefeeding is just guesswork—guess how much your baby can eat, guess how often, and guess when she’s done.

Though feeding is one way to soothe a fussy baby, it isn’t the only way—parents need to be taught other soothing skills besides the bottle or breast, so that babies can learn to soothe themselves without eating.

Introduce appropriate solids between 4-6 months, and allow your baby to decide how much to eat at every meal. Is he turning away? The meal is over. Parents can never know better than their baby when he is full. Bottle or breast-fed babies often start to wean themselves by 9 months or so, as they become more interested in exploring. They’re pulling away? Put them down, the meal is over.

Quickly move towards a family-style meal, including soft table foods that a baby can feed herself at nine months. Set a good example by eating slowly, drinking water, and talking and laughing during enjoyable meals. Don’t chide each other about how much or how little anyone is eating. Provide healthy choices, mostly plant-based, and then allow your baby to decide how much to eat (or even whether or not to eat certain dishes at all.)

Keep sugary drinks out of the house. Juice is no better than soda. However, don’t make any foods forbidden—that just makes them more desirable. Sure, Junior can have juice when he’s at a friend’s birthday party.

Don’t be in any hurry to start “fast food.” The marketing of these products is pervasive and effective—more toddlers recognize “The Golden Arches” than just about any other trademark. McBurgWendfil-a would love to get your child hooked early, and hooked often. Sometimes you’ll be busy, but the fast food “Unhappy Meal” ought to be avoided when your kids are young. Remember: eating is something to do when you’re hungry—not something to do because you get a cool toy or get to go to the restaurant that looks so special on TV.

Diets seem appealing because they promise success, but they’re not going to help you or help your baby. Effective ways of raising a child with a healthy attitude about food always reinforce “The Hunger Rule”—only the child can decide if he’s hungry, so only the child can decide how much to eat. Parents who try to control their child’s appetite and intake from a very early age may deprive their children of the nutrition they need while increasing their risk of obesity. Dieting is no good for anyone, and an especially bad idea for babies.

Diets for babies, part 1: A perfectly wrong approach

February 2, 2011

The Pediatric Insider

© 2011 Roy Benaroch, MD

Part 1 and part 2 of this article originally appeared on WebMD.com, as a response to this somewhat nauseating story.

Plenty of people are overweight—that’s not news. So if you’re a worried parent, why not start early. Could putting an infant or baby on a diet be a good way to prevent obesity?

No. The answer is no. It is the wrong thing to do.

Dieting is never, under any circumstances, an effective way to reach or maintain a healthy weight. The very idea of “going on a diet” implies that someday you’ll “go off the diet”. Even the most successful diet is a temporary step, a brief “holiday” of well-meaning improved eating to lose weight. Inevitably, dieting ends with a return of old habits, yo-yoing weight right back up to and often past where the victim started. Trying to be a healthful eater by dieting is like trying to drive safely by keeping your eyes open—but only for the next 10 weeks.

Dieting is especially a bad idea for the youngest people. Their bodies need nutrition, and plenty of it, to grow. Fat is essential for the developing brain. Healthy babies can seem quite chubby, especially before the baby fat melts away as crawling and exploring replaces eating as their main hobby.

Unfortunately, the very babies at the most risk for eventual weight problems are the ones most likely to be targeted for the unhealthy habits of dieting. Parents who themselves are weight-worried, or have suffered from psychological and physical harm from overweight, may be very motivated to prevent obesity in their children. But by restricting intake, parents dramatically  increase their children’s risk of obesity and eating disorders. The evidence is overwhelming that an overly restrictive feeding style is just about the best way to ensure that children will grow up without the ability to make healthful food choices of their own. Dieting is the wrong idea for all babies, but especially those at the most risk for overweight.

Parents who wish to prevent obesity in their children may look to diets as an effective approach—this despite the fact that dieting probably never helped themselves! Media hype about the latest diet and the latest celebrity stringbean model only adds to the pressure.

Fortunately, there are effective, simple steps during early childhood that parents can take to help ensure a lifetime of healthy eating for their children. The goal isn’t a specific weight at a specific age, but a healthy attitude about food that children can enjoy for the rest of their lives. Doesn’t that sound better than a diet?

Coming soon: Diets for babies, part 2: A better alternative

Slim Fast for kids

August 9, 2009

The Pediatric Insider

© 2009 Roy Benaroch, MD

Josie’s wondering if sharing her Slim Fast shake is a good idea: “My son is almost 2 (2 months shy) and ever since I let him have a sip of my Slim Fast shake (those chocolate milk drinks in a can), he cries and cries for one everyday. I understand that they are completely insufficient at providing him with the fat, protein, vitamins and minerals he needs on a daily basis, but my question is, is it horribly wrong for me to let him have one every once in a while?  The whole point in those shakes are to give you the minerals and vitamins you need, minus the fat, right? Other than the times I do let him have one, he eats plenty and has a very well balanced diet.”

From their web site, here’s a list of typical Slim Fast ingredients: fat-free milk, water, sugar, gum arabic, calcium caseinate, cellulose gel, canola oil, potassium phosphate, soybean lecithin, mono and diclycerides, artificial flavors, carrageen and dextrose. (Most of the flavors are more-or-less like this, with some variations.) After those items are a long list of added vitamins and minerals. I don’t see anything offensive in the list, though this wouldn’t be appropriate for those with milk or soy allergies.

Looking further at the label, an 8 oz Slim Fast has 220 calories, including 3 grams of fat, 35 grams of sugar, and 10 grams of protein. For comparison:

(all per 8 oz)

Calories

Fat, grams

Protein, grams

Sugar, grams

Slim Fast

220

3

10

35

Apple Juice

120

0

0

28

Skim Milk

80

0

8

11

Whole Milk

150

8

8

13

To me, the striking thing about Slim Fast is how high it is in sugar—higher than any of these other choices. It sort of has the protein content of milk, the sugar content of juice, and the fat of low-fat milk. It’s also very calorie-dense, much more so than even whole milk.

So: there’s nothing inherently wrong with Slim Fast, though if you use it as a substitute for milk (even whole milk), your child will get far more calories than you might expect. It’s meant to be a substitute for food. A little now and then will do no harm, but regular consumption of it as a beverage may end up putting your child at risk for overweight. A more cynical person might say that the manufacturer thinks that’s not such a bad idea.