Carolyn Newberry

Going Gluten Free: the History and Nutritional Implications of Today’s Most Popular Diet

Purpose of ReviewThe gluten-free diet (GFD) has become one of the most popular diets in modern history. Claims of improved health and increased energy fuel this popularity, though there is little evidence to substantiate these claims. The present review focuses on outlining known gluten-related disorders (GRD), discussing the GFD in the general population, exploring nutritional considerations, and providing advice for physicians in managing these patients.Recent FindingsCurrently, about a quarter of the population reports keeping a GFD despite GRDs affecting less than half of these individuals. Reduced intake of calcium, B vitamins, and fiber as well as enhanced consumption of fat and simple carbohydrates has consistently been reported and needs to be continually addressed.SummaryAlthough a necessity in proper management of GRDs, unforeseen nutritional complications may develop in patients who are gluten free for which enhanced physician awareness is vital to achieving optimal patient care.

Lactulose Hydrogen Breath Test Result Is Associated with Age and Gender

Small intestinal bacterial overgrowth (SIBO) is associated with chronic gastrointestinal diseases and structural/functional abnormalities of the gastrointestinal tract. SIBOs association with clinical characteristics is unclear. This study investigates the association between clinical factors and SIBO according to lactulose hydrogen breath test (LHBT) result. Methods. A cross-sectional study in a university-based gastroenterology practice was performed. Data was abstracted from the medical records of subjects undergoing LHBT from 6/1/2009 to 6/1/2013. Logistic regression analysis was performed to determine the association between predictor variables: age, sex, body mass index (BMI), and positive LHBT, the outcome of interest. Results. LHBT was performed in 791 subjects. Fifty-four percent had a positive LHBT. There was no statistically significant difference between the LHBT results according to age or BMI. In females, the likelihood of a positive LHBT increased with age (OR 1.02; 95% CI: 1.01–1.03). In males, the likelihood of a positive LHBT result decreased with age (OR 0.98; 95% CI: 0.97–1.00). Conclusion. There was an association between age, with respect to sex, and a positive LHBT. With increased age in females, the odds of a positive LHBT increased, while, in men, the odds of a positive LHBT decreased with age.

Can We Use Diet to Effectively Treat Esophageal Disease? A Review of the Current Literature

Purpose of ReviewEsophageal diseases represent a wide variety of conditions affecting esophageal anatomy, physiology, and motility. Therapy focuses on pharmacotherapy and endoscopic or surgical management. Dietary therapy can be considered in management algorithms for specific esophageal diseases. This review focuses on outlining the literature related to dietary therapy in gastroesophageal reflux disease, eosinophilic esophagitis, Barrett’s esophagus, and esophageal adenocarcinoma.Recent FindingsCurrently, data are strongest for dietary manipulation in eosinophilic esophagitis, specifically the six-food elimination diet. Dietary effects on gastroesophageal reflux disease are less clear, though newer research indicates that increased fiber with reduction in simple sugar intake may improve symptoms. In terms of Barrett’s esophagus and esophageal adenocarcinoma, antioxidant intake may affect carcinogenesis, though to an unknown degree.SummaryOutcomes data regarding dietary manipulation for the management of esophageal diseases is heterogeneous. Given the rising interest in non-pharmacological treatment options for these patients, continued research is warranted.

Future Therapies in Obesity

Although diet and exercise have been the cornerstone of therapy for obesity, efficacy is suboptimal and short lived. Surgical procedures are durable but invasive therapy for obesity. Supplemental therapies for obesity that are minimally invasive, low risk, and effective are needed. Several therapeutic options are being developed that offer obese patients and their health care providers alternatives to what is currently available.

How to Incorporate Quality Improvement and Patient Safety Projects in Your Training

QI and PS training is an important aspect to integrate within GI fellowship. There are a variety of ways to incorporate these efforts, including modifying existing divisional and departmental resources, building new curricula, completing available online modules and courses, and obtaining degrees through the university. There are numerous opportunities for scholarship within QI which fellows should be encouraged to pursue. Engagement in QI and PS efforts will help provide a more formal methodology for fellows to improve upon the practice of gastroenterology in the future.

Achalasia Patients Are at Nutritional Risk Regardless of Presenting Weight Category

BackgroundAchalasia is an esophageal motor disorder that leads to swallowing dysfunction and weight loss. Nutritional risk in achalasia patients is not well defined.AimsThe aims of this study were to define baseline body mass index (BMI), changes in weight, and nutritional risk over time in a large cohort of achalasia patients.MethodsThis was a retrospective cohort study of achalasia patients at a tertiary care center with documented BMI, symptom severity as per Eckardt score, and nutritional risk assessment as per the Malnutrition Universal Screening Tool, which considers BMI, degree of recent weight loss, and acuity of disease.ResultsAmong the 337 patients presenting for achalasia management, 179 had confirmed disease. Upon presentation 69.8% of patients were classified as overweight or obese. Using the Malnutrition Universal Screening Tool, we found 50% of patients to be at moderate or high risk for malnutrition at presentation. Eckardt score (OR 1.15, 95% CI 1.05–1.26), duration of disease (OR for each additional month 1.04, 95% CI 1.01–1.08), and female gender (OR 1.76, 95% CI 1.02–3.03) were independent predictors of increased risk for malnutrition. Nutrition risk score decreased after therapy in 93.3% of patients.ConclusionsDespite a high prevalence of overweight and obese status in achalasia patients, many are at risk of developing nutritional complications secondary to rapid weight loss. This risk frequently resolves post-treatment. Regardless of baseline BMI, we recommend all patients undergo nutritional assessment to identify high-risk patients who may benefit from dietary intervention and expedited therapy.

Use of Enteral Nutrition for Gastrointestinal Bleeding Prophylaxis in the Critically Ill: Review of Current Literature

Purpose of ReviewThis review provides a comprehensive overview of the etiology of stress-related mucosal disease, current acid suppression therapy recommendations, and the role enteral nutrition may play in disease prevention.Recent FindingsRecent literature indicates enteral nutrition may prevent complications of stress-related mucosal disease by increasing splanchnic blood flow, enhancing gastrointestinal motility, and promoting cellular immunity and integrity through local nutrient delivery.SummaryStress-related mucosal disease is a common complication of hospitalization in the critically ill which may lead to overt gastrointestinal bleeding and enhanced mortality. High-risk patients have historically been prescribed acid suppression therapy, though enteral nutrition may also have a role in disease mitigation.

Protein Intake in Chronic Kidney Disease

Purpose of ReviewThe purpose of this review is to better understand the protein needs in patients with chronic kidney disease (CKD) not on dialysis. Protein energy wasting is common in patients with chronic kidney disease, and the incidence increases as the kidney function declines. Typically, protein intake in patients with CKD is lower than the daily-recommended allowance for healthy adults, and that poor nutritional status has been associated with increase in morbidity and mortality. It is of interest to note that the current guidelines for protein intake vary in terms of both quantity as well as the quality, thus making it confusing for the practicing nephrologist.Recent FindingsRecent studies show that very low protein intake when supplemented by keto-analogues of essential amino acid could be helpful in slowing the progression of chronic kidney disease. However, it is important to understand that recommending low protein intake could be harmful in CKD patients especially those with poor nutritional status or during an acute illness.SummaryIn summary, it is important for the physician to understand that patients with chronic kidney disease have very complex nutritional requirements, and that recommendations for protein intake should be based on the individual patient needs.