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Mother’s milk is the First Choice for Feeding Preterm Infants

Mother’s milk is the First Choice for Feeding Preterm Infants

Human milk is biologically, clinically and nutritionally most effective feeding mode for preterm infants

Nutrition Remarks Health News Highlights (July 25, 2013)

Written by Deeksha Sharma, Ph.D., Health News Writer for Nutrition Remarks, Solon, OH, USA

Reviewed by Dr. Bertino Enrico Neonatal Unit, University of Turin, Italy

Breastfeeding is identified as the normative standard for infant feeding and nutrition. However, human milk (HM) should be fortified to ensure optimal nutrient intake in preterm Very Low Birth Weight (VLBW) infants. Considering the short and long-term clinical, metabolic, immunologic and neurodevelopmental advantages of breastfeeding, individualized and adjustable fortification of HM is found most effective for these infants.

Growing evidence supports use of human milk for sick and preterm infants in Neonatal Intensive Care Units (NICUs). Human milk is composed of bioactive and immunomodulatory factors that modulate the immune response and modify intestinal bacterial flora, while ensuring adequate host defense against infections.  The presence of bioactive and immunomodulatory factors such as Human Milk Oligosaccharides (HMOs), Glycosaminoglycans (GAGs), Immunoglobulin A (IgA) and its low lactose concentration highlights the importance of breastfeeding  preterm infants, who are  at greater risk of developing infections.

Necrotizing Enterocolitis (NEC) is a life-threatening condition that affects the large intestine of preterm babies. Infants fed with HM have shown to reduce the incidence of NEC. Furthermore, early enteral feeding with HM also significantly reduces the risk of late onset sepsis. Research also indicates that  HM also improves clinical feeding tolerance and attainment of early and total enteral feeding  in VLBW preterm infants.

Though, HM is the optimal feeding choice, it needs fortification to meet nutritional requirements of preterm infants, where low protein intake often results in growth failure. Individual fortification of HM is useful for VLBW infants in order to compensate high variability of expressed breast milk composition. Individual fortification of HM is achieved through either adjustable- or targeted- fortification. The targeted fortification analyze HM and fortify it in a way that infant always receive same amount of nutrients. However, adjustable fortification is based on infant’s metabolic response and safeguards infants against excessive protein intakes. Long-term studies of preterm infants suggest that HM feeding is associated with lower rates of metabolic syndrome, reduced risk of hypertension and low-density lipoprotein (LDL) concentrations in adolescence.

Further, neurodevelopmental outcome of preterm infants is improved by feeding with HM. Long-term studies suggest that white matter and total brain volumes are greater in subjects who received HM in NICU. Extremely preterm infants who received greatest proportion of HM in NICU had significantly greater scores for mental, motor, and behavior ratings at ages 18 months and 30 months. Breastfeeding creates a greater emotional involvement and a sense of gratification in mothers as well. Therefore, benefits of breastfeeding outweigh purely nutritional aspects of it and can be considered part of Newborn Individualized Developmental Care and Assessment Program (NIDCAP).

American Academy of Pediatrics in its policy statement on breastfeeding recommends that pasteurized Donor Milk (DM), appropriately fortified, should be used for preterm infants if mother’s own milk is unavailable or its use is contraindicated. Donor milk banks are not only meant to collect, process and store donated milk, but they also represent an instrument for breastfeeding promotion and support. Though, analysis of costs and an evaluation of acceptability are required while exploring different cultural, religious and social attitudes to DM.

Besides meeting immediate nutritional needs, early nutrition has potentially long-lasting or lifelong biological effects through metabolic “programming” of infant. Authors suggest that to achieve growth potential in preterm VLBW infants with good health and neurological development, breastfeeding and use of human milk are the best tools.

This news highlight is based on the following article published by Bertino E et al. Additional general background information was acquired from PubMed.

Bertino E, et al. Biological, nutritional and clinical aspects of feeding preterm infants with human milk. J Biol Regul Homeost Agents. 2012 Jul-Sep;26(3 Suppl):9-13.



Optimal Nutrition for Low Birth Weight infants

Optimal Nutrition for Low Birth Weight infants

Feeding guidelines to meet nutritional requirements of Small for Gestational Age (SGA) infants

Health News Highlights of Nutrition Remarks (July 25, 2013)

Written by Deeksha Sharma, Ph.D, Health News Writer for Nutrition Remarks, Solon, OH, USA

Reviewed by Prof. David Tudehope, Mater Medical Research Institute, South Brisbane, Queensland,  Australia.

Small for gestational age (SGA) means a developing baby in the womb or an infant is smaller in size than normal for the baby’s gender and gestational age. After birth, the goal is to provide enough nutrients to achieve postnatal growth similar to that of normal fetus. Mother’s own milk is recommended for SGA infants, as it meets their nutritional requirements besides providing short and long term benefits. Also, SGA infants need to “room-in” with their mothers to promote breastfeeding, mother-infant attachment, and skin-to-skin contact to assist with thermoregulation.

SGA babies may be constitutionally small and at no greater risk than normal sized babies or small due to intrauterine growth restriction (IUGR). IUGR babies are at higher risk of perinatal morbidity and mortality. Likewise, SGA infants can be term or preterm, where latter category is more at risk of neonatal and infant mortality. Each year, average 16% (more than 20 million) infants are born with Low birth weight (LBW) worldwide.

The main nutrients for the healthy fetus are glucose, lactate, ketone bodies and amino acids. The growth-restricted fetus receives fewer of these nutrients which reduces lean mass, body fat, bone mineral content and glycogen stores and increases the risk of hypoglycemia. Compared with their Appropriate for Gestational Age (AGA) peers oxygen consumption and energy expenditure of SGA infants are high (due to a large brain: body ratio and need for catch-up growth), while fat and protein absorption in SGA infants is lower. While providing postnatal nutrient supply to SGA infant, one must consider the balance of risks associated with under and over feeding. It is recommended that catch-up growth be gradual, not too much and not too fast, as it increases risk for metabolic syndrome (“Thrifty phenotype” hypothesis, where fetal programming for adaptation to an adverse intrauterine environment results an increased insulin resistance and increased risk of hypertension, dyslipidemia, central obesity and type II diabetes associated with excess wt. gain in later life).

Breastfeeding is recommended as the optimal feeding method and nutrition for all infants but is particularly important for SGA infants because it reduce the incidence and/or severity of a wide range of infectious diseases, including necrotizing enterocolitis (NEC), bacterial meningitis, bacteremia, gastroenteritis, respiratory tract infection, otitis media, and urinary tract infection. Breastfeeding decreases the rate of sudden infant death syndrome, and the incidence of insulin-dependent (type I) and noninsulin-dependent (type II) diabetes mellitus, obesity, certain cancers, hypertension, hypercholesterolemia, and asthma in older children and adults. Breastfeeding is also associated with better speech and jaw development and improved visual acuity. Breast milk feeding is preferred over formula feeding because of benefits related to reduced infection and improved neurodevelopment.

Authors conclude that breastfeeding should be promoted and actively supported for SGA infants. They also recommend encouraging kangaroo mother-baby skin-to-skin contact, attempting breastfeeding as early as feasible, and initiating feeds within 30 minutes of birth with breastfeeding or expressed breast milk (mother’s or donor milk). Key principle underpinning feeding guidelines include developmentally supportive care, support of breastfeeding and the individual feeding plan developed by parents and a multidisciplinary team. Intravenous (IV) fluids are recommended if enteral feeding is not possible or problematic hypoglycemia occurs, while continue to place infant on the breast frequently and expressing and administering colostrum. Weight is not the major criteria for discharge of SGA infants rather physical stability, feeding well, starting to gain weight, maternal competency, and adequate community support. Maternal nutritional interventions (iron and other micronutrients) must be focused during preconception or pregnancy to prevent SGA birth.

This news highlight is based on the following article published by Dr. David Tudehope et al. Additional general background information was acquired from PubMed and NIH sources.

 Tudehope D et al. Nutritional requirements and feeding recommendations for small for gestational age infants. J Pediatr. 2013 Mar; 162(3 Suppl):S81-9.

Breastfeeding reduces the obesity risk in American Samoan Infants

Breastfeeding reduces the obesity risk in American Samoan Infants

Breastfeeding slowed down the weight gain in overweight/obesity prone Samoan infants

Nutrition Remarks Health News Highlights (July 24, 2013)

Written by Deeksha Sharma, Ph.D, Health News Writer for Nutrition Remarks, Solon, OH, USA

Reviewed by Dr. Hawley NL, International Health Institute, Department of Epidemiology, Brown University, Providence, Rhode Island, USA; Weight Control and Diabetes Research Center, The Miriam Hospital, Providence, Rhode Island, USA

American Samoan adults often have high body mass index and prevalent obesity. Infancy is a critical period in the development of obesity so this study examines how choice of feeding modes affects the growth trajectories of American Samoan infants. Breastfeeding is found associated with slower weight gain in these infants suggesting its protective benefits for obesity risk.

Global prevalence of obesity and associated chronic non-communicable diseases are on rise, therefore identifying potential intervention targets to stem obesity epidemic is a public health priority. American Samoans have greatest mean BMI worldwide (59% adult males (aged 18–74 years) and 71% adult females to be obese (BMI ≥32 kg m-2). This study investigate the age at which obesogenic growth trajectories are established in Samoan infants to identify the ideal age at which obesity prevention programs should be targeted. Further, growth of breast and formula-fed infants were analyzed to find out whether breastfeeding attenuates the risk of obesity in Samoans.

At birth, mean weight-for-length in both sexes was close to the median of CDC reference population. While length of these infants rose steadily throughout infancy, weight gain in early infancy occurred far more rapidly in Samoan infants than in the CDC reference. By 4 months, mean weight-for length z-scores had risen to 0.98 (84th centile) in boys and 0.76 (78th centile) in girls. Prevalence of overweight was established early, but obesity was initially low, it rose with increasing age and by 15 months, 23.3% boys and 16.7% girls were obese. The level of overweight fell from a peak of 30.5% in 4-month-old boys and 23.0% in 3-month-old girls to 16.1% and 14.0% in 15-month-old boys and girls, respectively. Combined, the prevalence of overweight and obesity peaked at 39% at 4–6 months. At 15 months of age, 35.2% of infants in American Samoa exceeded the CDC 85th percentile and were overweight or obese; 20.1% of them above 95th percentile and obese. The prevalence of obesity observed here was four times greater than the expected value. It is noteworthy that while the prevalence of obesity increased between birth and 15 months of age, after 4 months of age the prevalence of overweight decreased. This suggests that infants classified as overweight in early infancy were becoming obese over time but very few infants who remained in normal weight range at 4 months were then becoming overweight.

There were significant effects of feeding at 4 (±2 months) on weight and length. Boys who were formula-fed had a significantly faster rate of postnatal growth, gaining 1.08 kg/year and 2.33 cm/year more than breastfed boys. Mixed-fed boys also gained length significantly faster than breastfed boys (1.13 cm/year). Mixed- and formula-fed girls gained weight more rapidly than breastfed girls by 0.63 and 0.60 kg/year, respectively. In these Samoan infants formula feeding is, in boys, associated with more rapid growth in early infancy and greater overweight and obesity in late infancy. Girls who are fed a combination of breast milk and formula are at greater risk than their peers.

This could be due to, breastfeeding promotes self-regulation of energy intake by infant, mothers may also learn to recognize their infant’s hunger and satiety cues earlier, and mothers who choose to breastfeed may be those who adopt other healthy dietary and lifestyle habits. Mothers who choose to formula feed may also introduce solid foods at an earlier age, which is in itself, associated with greater weight gain during infancy and greater weight and adiposity in childhood. Further study of American Samoan infant feeding is needed to understand these postnatal growth patterns and feeding choices in context of economic and cultural modernization, especially the changing and expanding roles of women.

Comparability of these findings with other studies is difficult, largely because of the use of different references for growth. The CDC 2000 references were employed here because of their continued use in clinical practice in American Samoa and feeding characteristics of the CDC reference population were similar to those observed here.

The level of adult obesity seen in American Samoan women of childbearing age, a probable contributor to infant obesity, is likely to foreshadow the experience of other developing countries as they undergo similar economic, demographic and nutritional transition. Findings suggest that obesity prevention efforts in Samoans must be targeted at the very youngest infants with a focus on maintaining normal weight by 4 months of age. Also findings suggest that protective effects of breastfeeding for later obesity are generalizable outside of European-derived populations. Alongside other health benefits of breastfeeding, the promotion of exclusive breastfeeding may be a suitable cost-effective and sustainable intervention for the reduction of overweight and obesity risk.

This news highlight is based on the following article published by Hawley NL et al. Additional general background information was acquired from PubMed.

Hawley NL et al. The contribution of feeding mode to obesogenic growth trajectories in American Samoan infants. Pediatr Obes. 2013 Feb 5.

Association between Breastfeeding Duration and Cognitive Development

Association between Breastfeeding Duration and Cognitive Development

A dose-response relationship links longer duration of breastfeeding with better cognitive and motor development in children

Nutrition Remarks Health News Highlights (June 21, 2013)

Written by Deeksha Sharma, Ph.D., Health News Writer for Nutrition Remarks, Solon, OH, USA

Reviewed by Jonathan Y. Bernard, Inserm, Center for research in Epidemiology and Population Health (CESP), U1018, Epidemiology of Diabetes, Obesity and Renal Diseases: Lifelong Approach Team, F-94807, Villejuif, France; Univ Paris-Sud, UMRS 1018, F94807, Villejuif, France.

In a mother-child cohort study, ever-breastfed children scored higher than never-breastfed children on language ability and overall development assessments, after adjustments for many potential confounders. Findings suggest a significant association between longer breastfeeding duration and better cognitive and motor development in 2- and 3-year-old children.

Breastfeeding is found associated with better language and cognitive abilities but these results could be due to the differences between confounding factors like the socio-demographic and occupational characteristics of mothers who breastfed and those who did not. Therefore, new data on the relationship between breastfeeding duration and the child’s cognitive development are required to make national public health policies, especially for countries where breastfeeding rates are low. This study examines the dose–response relationship between breast milk consumption and cognitive development, with an accurate, prospective data collection of breastfeeding from a large cohort.

French EDEN Mother-Child Cohort Study is an ongoing birth-cohort study that aims to investigate the role of pre- and post-natal determinants of child growth, development, and health. From the maternal declarations about child feeding modes in questionnaires at birth, 4, 8, 12 and 24 months, exclusive and any (exclusive and mixed) breastfeeding durations were estimated. The parent-reported questionnaires Communicative Development Inventory (CDI) and Ages and Stages Questionnaire (ASQ) were used respectively to evaluate language ability in 2-year-old and overall development in 3-year-old children.

In multivariable linear models, after adjustment for potential confounders, ever-breastfed scored 3.7 ± 1.8 (mean ± SE, P = .038) higher on the CDI and 6.2 ± 1.9 (P = .001) points higher on the ASQ than never-breastfed children. Among breastfed children, adjusted linear associations between breastfeeding durations and cognitive assessments were significant and positive. For any breastfeeding duration, an additional month was related with an increase of 0.58 ± 0.20 (P = .004) CDI points and 0.60 ± 0.20 (P = .003) ASQ points. An additional month of exclusive-breastfeeding was associated with an increase of 0.75 ± 0.33 (P = .02) CDI points, and 1.00 ± 0.33 (P = .002) ASQ points. Tests of hypotheses of non-linearity of the associations between breastfeeding durations and cognitive assessments were rejected. No interaction was found between breastfeeding durations and sex, gestational age, parental education, or household income.

Exclusive breastfeeding duration was more strongly associated with both cognitive development assessments than any breastfeeding duration, which is a further argument in favor of a dose–response relationship. The main biological hypothesis to explain this association between breastfeeding and child cognitive development is based on the content of breast milk, especially long-chain poly-unsaturated fatty acids (LCPUFA) that may be essential for brain maturation in the newborn.

Study results agree with previous studies showing a relationship between breastfeeding and cognitive and motor development in early childhood. In addition, by suggesting a dose–response relationship, it brings new evidence to the possible benefits of breastfeeding. This builds a stronger argument to public health professionals for promoting longer duration and continuation of breastfeeding as well, while promoting early initiation of it.

This news highlight is based on the following article published by Jonathan Y. Bernard et al. Additional general background information was acquired from PubMed.

Bernard JY et al. Breastfeeding Duration and Cognitive Development at 2 and 3 Years of Age in the EDEN Mother-Child Cohort. J Pediatr. 2013 Jan 10. pii: S0022-3476(12)01425-4.




Mediterranean Diet May Reduce the Risk of Major Heart Diseases

Mediterranean Diet May Reduce the Risk of Major Heart Diseases

A diet rich in Fruits, Nuts & olive oil can keep heart diseases at bay

Health News Highlights of Nutrition Remarks (June 07, 2013)

Written by Suhanki Rajapaksa, MBBS., Health News Writer for Nutrition Remarks, Solon, OH, USA.

Reviewed by Dr. MA Martinez-González MD, PhD, MPH., Professor and  Chairman, Department of Preventive Medicine and Public Health. Medical School, University of Navarra, Spain.

Coronary Heart Disease (CHD) is explained as narrowing of the small blood vessels that supply blood and oxygen to the heart. CHD is also called coronary artery disease and is the most common type of heart disease. In the United States, CHD is the number one cause of death for both men and women.  It alone costs the United States $108.9 billion each year, when taking into account the cost of health care services, medications, and lost productivity.

Grilled salmonLifestyle changes, medicines, and medical procedures can help prevent or treat CHD. These treatments may reduce the risk of related health problems. Among these preventive lifestyle modifications, dietary interventions have come upon close scrutiny in the recent past.

The Mediterranean diet in particular has been under the spotlight with regards to prevention of heart diseases. The traditional Mediterranean diet is characterized by a high intake of olive oil, fruit, nuts, vegetables, and cereals; a moderate intake of fish and poultry; a low intake of dairy products, red meat, processed meats and sweets; and wine in moderation, consumed with meals.

A team of researchers led by Drs. Ramón Estruch of the Instituto de Salud Carlos III, Madrid Department of Internal Medicine and Miguel A. Martínez-González of the Preventive Medicine and Public Health dept, University of Navarra, Pamplona Spain has  conducted an interesting study which highlights the benefit of a Mediterranean diet with regards to preventing CHD. They studied a starting group of 7447 people from 2003 to June 2009 randomly assigning them into three groups according to their Diets.

The differentiation of the groups was mainly by the consumption of Mediterranean & non-Mediterranean food items.

The 2 groups on a Mediterranean diet were encouraged to eat the following items:

*Olive oil

*Tree nuts and peanuts

*Fresh Fruits


*Fish & other seafood


*Sofrito sauce

*White meat

*Wine with meals (IF the subjects were habitual drinkers)

Soda drinks, commercial bakery goods such as sweets & pastries, spread fats, Red & processed meats were discouraged from their diet.

One of these two groups received virgin olive oil as a gift; the other Mediterranean group received mixed tree nuts (wlanuts, almonds and hazelnuts).

The third group was the control group and they were encouraged to eat:

*Low fat dairy products

*Bread, Pasta, Rice

*Potatoes, Fresh vegetables & Fruit

* Lean fish & seafood.

They were asked to stay away from all vegetable oils including olive oil, nuts and fried snacks, red and processed fatty meats. fatty fish, canned seafood in oil, and sofrito, spread fats.

It’s important to note that none of the people enrolled in this study had a history of cardiovascular disease at the time the study started. But they did have risk factors such as either type 2 diabetes mellitus or at least three of the following which are identified to be major risk factors for heart disease; smoking, hypertension, elevated levels of low-density lipoprotein (LDL) cholesterol, low levels of high-density lipoprotein (HDL) cholesterol, being overweight or obese, or a family history of premature coronary heart disease.

Beginning on October 1, 2003, participants were randomly assigned to one of the three dietary intervention groups: a Mediterranean diet supplemented with extra-virgin olive oil, a Mediterranean diet supplemented with nuts, or a control group whose diet included low fat food and excluded the main Mediterranean dietary components as explained above. Questionnaires were given to the participants to test their diet and physical activity yearly. On a random basis urine & blood product tests were run to test if the subjects were complying with the recommended diets.

Over the time frame of a median of 4.8 years the study subjects were observed for cardiovascular events – Primarily Myocardial infarction, Stroke and Death from Cardiovascular causes.

Interestingly the groups on a Mediterranean diet supplemented with either virgin olive oil or nuts showed an absolute risk reduction of 3 cardiovascular events per 1000 person-years at risk. For a relative risk reduction of approximately 30%, among high risk persons who were initially free of cardiovascular disease.

The risk of stroke was reduced significantly in the two Mediterranean-diet groups.

The findings in this study confirm the observations made in previous studies which have shown that a Mediterranean diet help to reduce the incidence of cardiovascular diseases, And are comparable to the findings in the Women’s Health Initiative Dietary Modification trial which showed no benefit of a low-fat dietary approach on cardiovascular risk reduction. It also supports an inverse association between the Mediterranean diet or olive-oil consumption and incidence of stroke as proven by previous epidemiological studies. The study takes the observations of the Lyon Diet heart study a step further by taking into account a larger number of cardiovascular events over time on at-risk persons and by studying primary prevention (persons who were initially healthy) instead of secondary prevention (only survivors of a heart attack, as were the participants of the Lyon study).

Though further research will be necessary to explore the exact causes and mechanisms of risk reduction, these trials undoubtedly favor the idea that a Mediterranean diet supplemented with extra-virgin olive oil or nuts, plays an important role in the primary prevention of coronary heart diseases among high-risk persons.

And it will be beneficial for us all to add more nuts, olive oil and Fresh fruits & Vegetables to our diets as well as substitute fish and white meat for red and processed meats.

This information is primarily based on the following article published by Drs. Ramón Estruch and Miguel A. Martínez-González. Additional information abstracted from PubMed, CDC , National Heart, Lung, and Blood Institute (NHLBI), American Heart Association Journals, American journal of clinical nutrition and other reliable sources.

Estruch R., et al Primary Prevention of Cardiovascular Disease with a Mediterranean Diet. The New England Journal of Medicine. 2013, 368:1279-1290.

Other resources:










Gluten free diet may help in diarrhea linked to irritable bowel syndrome

Gluten free diet may help in diarrhea linked to irritable bowel syndrome

Gluten free diet may help in ameliorating the symptoms of irritable bowel syndrome associated diarrhea in HLA DQ2/8 gene positive patients

Health News Highlights of Nutrition Remarks (May 13, 2013) Print PDF of  Gluten free diet may help in diarrhea linked to irritable bowel syndrome

Written by Ajay Kumar, M.S., Health News Writer for Nutrition Remarks, Solon, OH, USA.

Reviewed by Dr. Michael Camilleri, M.D., Professor, Mayo Clinic, Rochester, Minnesota. USA.

Gluten is a protein found in several grains such as wheat, rye and barley; it is a significant source of protein in vegetarian diets and provides texture to the foods. However, for some individuals, eating gluten can cause serious allergic reactions.

The Gluten protein is mainly found in the endosperm of grain Kernel (seed)

The Gluten protein is mainly found in the endosperm of grain Kernel (seed)

Generally, gluten is avoided in the diets of wheat-sensitive patients, and patients diagnosed with celiac disease (an autoimmune intestinal disease). Gluten free diets are also suggested to prevent many other gastrointestinal ailments, including Irritable Bowel Syndrome (IBS); however, there is a dearth of scientific evidence supporting the positive effects of gluten-free diets in people suffering from IBS in clinical practice [1]. Studying the effects of gluten in IBS patients could be difficult as IBS patients may vary in their genetic constitution and can therefore respond differently to the same stimuli. For instance, Human Leukocyte Antigen (HLA) is a gene found in humans and plays a role in immune function. DQ2 and DQ8 are subtypes of HLA and their presence increases the risk of celiac disease [2]. HLA DQ2/8 gene is also present in asymptomatic (having no symptoms of disease) people and in symptomatic IBS patients without celiac disease and they may respond differently from the IBS patients who don’t have HLA DQ2/8 genes; for example, they may have faster small intestinal transit (movement of content through the intestines), slower colonic transit and increased intestinal permeability [3, 4].

In the United States, 10- 15% people are afflicted with IBS. IBS is characterized by altered bowel habits and abdominal discomfort. Clinical studies have shown the benefits of gluten free diets in celiac patients. However, the recommendation of gluten free diets in IBS cases has not been established in depth. A recent study published in the journal of Gastroenterology, by Dr. Michael Camilleri, M.D. and colleagues (Vazquez-Roque et al, 2013 [5]) reported that gluten free diets may reduce some of the IBS symptoms particularly the frequency of bowel movements.

In this randomized controlled study, 44 patients (22 HLA DQ2/8 gene positive and 22 HLA DQ2/8 negative) with IBS- related diarrhea were selected. Patients were divided into 2 groups (each groups had 11- HLA DQ2/8 positive, 11- HLA DQ2/8 negative) and were randomly assigned to gluten containing or gluten free diets for 4 weeks.  All meals were prepared by a specialized diet kitchen.

At the end of study, subjects on gluten containing diets had more bowel movements as compared to subjects on gluten free diets. The effects of the gluten-containing diet were greater in HLA DQ2/8 positive than HLA DQ2/8 negative patients. Similarly, small bowel permeability (a measure of the barrier of the lining of the small intestine) was less in subjects who were on gluten free diets, compared to diets including gluten. The positive effects of gluten free diets were more conspicuous in HLA DQ2/8 positive subjects as compared to HLA DQ2/8 negative subjects. However, another study where patients previously had a clinical response to gluten withdrawal, did not find any differences in clinical responses to gluten free diet between HLA DQ2/8 positive and negative IBS patients [6].

According to the authors of the study, the subjects were not selected on the basis of prior gluten sensitivity and the participants were randomly assigned to the gluten-free or gluten-containing diets; hence, these observations have the potential for generalization. Though, further comprehensive studies are required to understand the exact mechanisms and effects on other symptoms such as pain and bloating, this study from Dr. Michael Camilleri’s group highlight the potential importance of gluten-free diets in management of bowel disturbance in patients with diarrhea- predominant IBS.


1.         Verdu, E.F., Editorial: Can gluten contribute to irritable bowel syndrome? Am J Gastroenterol, 2011, 106,  516-8.

2.         Biagi, F., P.I. Bianchi, C. Vattiato, A. Marchese, et al., Influence of HLA-DQ2 and DQ8 on Severity in Celiac Disease. Journal of Clinical Gastroenterology, 2012, 46,  46-50.

3.         Vazquez-Roque, M.I., M. Camilleri, P. Carlson, S. McKinzie, et al., HLA-DQ genotype is associated with accelerated small bowel transit in patients with diarrhea-predominant irritable bowel syndrome. European Journal of Gastroenterology & Hepatology, 2011, 23,  481-487.

4.         Vazquez-Roque, M.I., M. Camilleri, T. Smyrk, J.A. Murray, et al., Association of HLA-DQ gene with bowel transit, barrier function, and inflammation in irritable bowel syndrome with diarrhea. American Journal of Physiology-Gastrointestinal and Liver Physiology, 2012, 303,  G1262-G1269.

5.         Vazquez-Roque, M.I., M. Camilleri, T. Smyrk, J.A. Murray, et al., A controlled trial of gluten-free diet in patients with irritable bowel syndrome-diarrhea: effects on bowel frequency and intestinal function. Gastroenterology, 2013, 144,  903-911 e3.

6.         Biesiekierski, J.R., E.D. Newnham, P.M. Irving, J.S. Barrett, et al., Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial. Am J Gastroenterol, 2011, 106,  508-14; quiz 515.


Relationship Between Obese Moms and Kids – epigenetics, home environment or both?

Can moms’ healthy food and exercise habits make any difference?

Frontier Voice of Nutrition Remarks (May 10, 2013) Print PDF of  Relationship Between Obese Moms and Kids †epigenetics home environment or both

Nalin Siriwardhana, Ph.D., interviewed Dr. Kristi B. Adamo, PhD., Research Scientist and CIHR New Investigator, Director of HALO Research Laboratory at Children’s Hospital of Eastern Ontario (CHEO) Research Institute, 401 Smyth Rd. Ottawa ON K1H 8L1.

It is now well known that mother’s obesity status and obesogenic home environment plays a significant (possibly a synergistic) role in childhood obesity. Obese kids face both physiological and psychological challenges during childhood. Childhood obesity is known to dramatically increase the risk for heart diseases, diabetes and bone problems. Being obese is also associated with negative behavioral and physiological changes in children.  Further, childhood obesity is a significant risk factor of child’s future health in the early years and beyond.  Most obese kids will be obese adults and are subsequently predisposed to type 2 diabetes, heart diseases (stroke and atherosclerosis), several types of cancer (breast, colon, endometrium, esophagus, kidney, pancreas, gall bladder, thyroid, ovary, cervix, and prostate cancers and  multiple myeloma), and osteoarthritis.

Relationship Between Obese Moms and Kids – epigenetics, home environment or both

Relationship Between Obese Moms and Kids – epigenetics, home environment or both?

Nutrition Remarks interviewed Kristi B. Adamo, PhD. to understand the potential health risks that children can be exposed to due to mothers’ obesity status and obesogenic home environment.  Below is a concise summary of the interview:

 Question from Nutrition Remarks: What are the statistics of major health risks associated with childhood obesity?

 Answer from Dr. Adamo:  In 2002, the World Health Organization reported pediatric obesity to be the most prevalent, non-communicable disease in developed countries and for many children, obesity can be more than an aesthetic condition. If untreated, obesity-related risk factors such as sleep apnea, cardiovascular disease, non-alcoholic fatty liver disease and type 2 diabetes to name a few co-morbidities can develop in children. Population-based data from the Bogalusa Heart Study have shown that 70% of obese youth (5- 17 years old) had at least one risk factor for cardiovascular disease. Furthermore, these children are also at greater risk of bone and joint problems and children struggling with obesity are likely to carry their excess adiposity into adulthood. According to the Center of Disease Control, an estimated four of every five obese children will remain obese as adults, increasing their risk of chronic obesity and obesity-related disease (e.g. heart disease, diabetes, stroke, osteoarthritis and certain cancers). Many groups have also studied the psychosocial effects of childhood obesity. Evidence suggests that overweight children frequently develop negative self-image and low self-esteem accompanied by sadness, loneliness, nervousness and risk-taking behaviors in later part of the life. It is clear that obesity is associated with considerable health care burden. For example, obese children in the U.S. (research by Finkelstein and Trasande), Germany (research by Wenig and Breitfelder) and Canada (research by Kuhle) have proven to visit their pediatrician more often than children of healthy weight.

Question: How frequently will an obese mom’s kids also become obese?

 Answer: Most countries do not have this type of surveillance data available. We know from reviewing large population-based studies or birth cohorts from the U.S.A., U.K., Australia and Scandinavia that there is a greater probability that a child of an obese mother will go on to become obese themselves and there are many potential reasons for this (e.g. sub-optimal intrauterine environment, obesogenic post-natal environment, genetic or epigenetic predisposition). This cycle is by no means a guarantee. It is possible for a child of an obese mother to not experience obesity themselves (conversely, the child of a normal weight mother may go on to develop obesity in an unhealthy environment).

 Question: What is the contribution from the home environment?

Answer: If a child was not exposed to an optimal intrauterine environment they are not ‘doomed’ but rather they can be set on the right track by parents or caregivers who model and encourage healthful behaviors. This includes, but is not limited to, high quality and age-appropriate nutrition, daily physical activity and good sleep hygiene. Thus if the prenatal growing environment was suboptimal (i.e., mother consumes large quantities of food that are high in saturated fats and refined sugar, gains excessive weight and is sedentary), an exemplary post-natal environment is imperative and protective health factors such as physical activity and healthy eating have proven to result in significant benefits for children and youth.

Question: What is the contribution from epigenetics?

Answer: The analogy we like best is this: if we consider genetics to be the alphabet of life – specifically the letters of the DNA sequence (A, C, G, T) carry the information – epigenetics is the grammar of life or the ‘markings’ that can modify the message. In short, epigenetic changes are heritable changes in gene expression that operate outside of changes in DNA itself. While the message remains the same (i.e., DNA) the way it is expressed (i.e., epigenetics) and thus the way proteins, organs and systems function can be altered by environmental exposures in utero.

Epigenetic regulation is a natural process that is required to ‘turn-on’ or ‘turn-off’ genes in certain systems or at specific points in time that contribute to typical development throughout life. However, different environmental conditions or disruptions can change the expected epigenetic patterns and thus lead to increased susceptibility to disease later on. In other words, epigenetic modifications can also be acquired over time, a simple example of which is gene-environment interaction. We know that identical twins have the same genetics but their epigenetic patterns in later life can be markedly different. This is because each twin may have been exposed to very different environments which have impacted their epigenetics markings and thus you can see differences when observing twins who grew up in different environments (this includes their lifestyles).

Question: What do we know about kids born to moms who were obese for long time vs. short time?

Answer: This is tough to answer as the data is not currently available although there are research teams exploring this issue.

While we are waiting for the evidence regarding the impact of the length of maternal obesity on offspring, there is some interesting evidence on the impact of maternal obesity on the intrauterine environment that comes from bariatric surgery. Children born to obese mothers prior to surgery have worse outcomes (ie, macrosomia and susceptibility to obesity) when compared to siblings from the same mother born after bariatric surgery.

 Question: Why are minute changes during pregnancy and early childhood growth important in terms of childhood obesity?

Answer: Small decreases in birth-weight or adiposity, as demonstrated by maternal lifestyle interventions during pregnancy, can have dramatic effects at the population level with respect to shifting the birth-weight distribution of the entire population to one that begins closer to the appropriate for gestational age range. This does not come at the expense of increasing the number of small for gestational age neonates but rather lessens the effects of macrosomia (or big babies) by shifting the birth-weight distribution to the left (ie. more average for gestational age neonates). Given the strong relationship between high birth-weight and downstream obesity risk research suggests that even small changes during pregnancy and early childhood that aim to have every child grow within the optimal range (10th-90th percentile) are vital to child obesity prevention strategies over the long term.

 Question: What do we know about kids born to moms who used to have normal weight and faced unusual weight gain during pregnancy?

Answer: Gestational weight gain (GWG) is an important factor for both mom and baby. The evidence clearly illustrates that excessive gestational weight gain can pose a significant challenge for both mom and baby. However, unlike maternal pre-pregnancy BMI (body mass index), GWG is a modifiable risk factor for many pregnancy related complications that all women should focus on. High GWG is associated with short and long-term obesity risk for the child regardless of the mom’s pre-pregnancy weight. Often women who gain too much weight during pregnancy (i.e. above the Institute of Medicine Guidelines) also retain weight after pregnancy and therefore can enter a second or third pregnancy at a higher weight than the first which can propagate the cycle of obesity. Additionally, research also points to an intergenerational cycle of obesity whereby an overweight or obese mom (or a mom who exceeds GWG recommendations) gives birth to a large for gestational age infant who may continue to follow an inappropriate growth trajectory and continue through life struggling with weight issues.

Question: As kids are in the growing phase, can there be a synergy between obesogenic home environment and accumulated epigenetic changes?

 Answer: Research by pioneers in the field of epigenetics and obesity, like Sir Peter Gluckman from the Liggins Institute in New Zealand, have clearly shown that the environment (e.g. what you eat) can impact epigenetic markings. This leads me and my colleagues to believe that the obesogenic home environment does contribute to epigenetic changes. Animal models and human evidence increasingly suggests that exposure to certain environmental factors during sensitive periods of development (e.g. before or after birth) can affect the ‘make-up’ of an individual (e.g.  their body composition, their responsiveness to the environment, their susceptibility to disease etc.) later in life through adaptation or epigenetics. This could further contribute to the development of undesirable metabolic processes. In our opinion, it is very important for children to be exposed to the most healthful post-natal environment possible to ‘counter-act’ any risk-promoting adaptations or epigenetic changes that they may have inherited and to potentially build new ‘protective’ mechanisms within the body.

 Question: What other important information would you like to address?

Answer: Ideally entering pregnancy at a healthy weight and engaging in a healthy active lifestyle during the gestational period gives babies the best start to life. However, knowing that the majority of pregnancies are unplanned this poses a challenge. Focusing on behaviors that can be ‘controlled’ such as eating habits, physical activity and sedentary behavior is key to keeping gestational weight gain within expected ranges. Pregnancy is not an excuse for ‘eating for two’ and halting all physical activity. The evidence supports that regular moderate intensity exercise is protective for mom and baby.

This interview was based on the following original scientific article published by Dr. Adamo. Additional general background information was acquired from PubMed, CDC and NIH sources.

Adamo et al, Can We Modify the Intrauterine Environment to Halt the Intergenerational Cycle of Obesity? Int. J. Environ. Res. Public Health 2012, 9(4), 1263-1307.

Dr. Kristi Adamo, a Research Scientist at the Children’s Hospital of Eastern Ontario Research Institute, is supported by a Canadian Institutes of Health Research (CIHR) New Investigator Award from the Institute of Human Development, Child and Youth Health. In addition to CIHR, her work is supported by other funding institutions including the Ontario Ministry of Research and Innovation, the Canada Foundation of Innovation, the Ottawa Dragon Boat Foundation and the W. Garfield Weston Foundation. Her colleague, Dr. Zachary Ferraro is a research associate with her ‘prevention in the early years’ team.

More about Dr. Adamo



Written by Swarnalatha Perera, Ph.D., Professor, Sri Jayawardhanapura University, Nugegoda, Colombo Sri Lanka.

Polyphenols in your diet may regulate food intake

Polyphenols in your diet may regulate food intake

Role of dietary polyphenols in food intake

Frontier Voice of Nutrition Remarks (May 06, 2013) Print PDF of Polyphenols in your diet may regulate food intake

Nalin Siriwardhana, Ph.D., interviewed Dr. Kiran Panickar, Ph.D., Assistant Professor, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD and Diet, Genomics, and Immunology Laboratory, Beltsville Human Nutrition Research Center, Agriculture Research Service, USDA, Beltsville MD.

Dietary polyphenols may regulate food intake due to potential effects on certain brain regions (hypothalamus),  nervous system (neuroregulators), adipose tissue, digestive system and metabolism related hormones (Ghrein, Leptin, and Insulin)

Dietary polyphenols may regulate food intake due to potential effects on certain brain regions (hypothalamus), nervous system (neuroregulators), adipose tissue, digestive system and metabolism related hormones (Ghrein, Leptin, and Insulin)

Among healthy dietary phytonutrients, polyphenols are well studied, characterized and recognized as important dietary bioactives that can lower variety of risk factors links with cardiovascular, neurodegenerative, and metabolic diseases as well as certain cancers.

New research indicates that the dietary polyphenols may have a potential in regulating food intake. In a recent review article published in the journal of Molecular Nutrition and  Food Research journal, by Dr. Kiran Panickar, the potential effects of dietary polyphenols on neuroregulatory factors, the neural signaling pathways and/or the peripheral feedback mechanisms that modulate food intake has been discussed.

Nutrition Remarks interviewed Dr. Kiran Panickar, Ph.D., to clarify the role of dietary polyphenols in food intake. Below is a concise summary of the interview:

Question from Nutrition Remarks: In general, how is human food intake and satiety regulated?

Answer from Dr. Panickar: The process of food intake and satiety is complex at the cellular and molecular level.  The precise mechanisms involved are not clear although we know more about it today than we did a few decades ago. The functions of several peptides including those of neuropeptide Y, leptin, and ghrelin are important in food regulation in human, and they act on the region in the brain called the hypothalamus which is an important area that controls food intake and satiety. However, it is not just such peptides acting on food-regulating regions in the brain that is important but there is also a psychological component mediated chiefly by the hippocampus, another region in the brain, that may mediate food-related memories that should also be considered before we understand how food intake in regulated. So now in addition to the peripheral factors that interact with the central nervous system, a clearer understanding of how different regions in the brain interact with each other is also required before we can appreciate how food intake and satiety is regulated.

Question: How do polyphenols modulate/influence the neuroregulatory factors?

Answer:  Several polyphenols including those from cinnamon and cocoa appear to improve insulin sensitivity in humans. Also, polyphenols from soy has been shown to increase plasma peptide YY (PYY), a satiety hormone, in women. Whether these polyphenols do that by acting in the brain in humans is not known. But it could be a possibility if you collectively take the information that is also obtained from cell culture and animal studies. Several other polyphenols including resveratrol, green tea polyphenols and berries, also influence neuroregulatory factors and a more detailed list of such polyphenols can be found in my article published in Molecular Nutrition and Food Research (Panickar, KS. Effects of dietary polyphenols on neuroregulatory factors and pathways that mediate food intake and energy regulation in obesity. Molecular Nutrition and Food Research, 2013; 57:37-47).

Question: What are the polyphenols or polyphenol classes that will increase or decrease food intake?

Answer: Following table is not an exhaustive list but will give a fair idea of the sources of polyphenols and some of their potential effects that has been taken from animal and human studies.

Polyphenol/ polyphenol classes Food source Functions
Type-A polyphenols  Cinnamon, cocoa Improves insulin sensitivity and thus regulates glucose levels
Resveratrol Red grapes Improves insulin resistance
Apigenin Celery, parsley Decreases food intake in animals fed a high-fat diet
Green tea polyphenols Green tea Decreases ghrelin levels in the liver of rats
Blueberry polyphenols Blueberries Improves insulin and leptin sensitivity
Curcumin Turmeric May improve insulin and leptin resistance

Question: What are the effective amounts (intake vs serum levels) of potentially beneficial polyphenols?

Answer: This is an important question. Unfortunately, this can not be answered with certainty. Dietary intake of polyphenols appears to vary amongst countries. The rough estimates of polyphenol intake from different studies appear to be 500 mg-1g/day in the United States, 23 mg/day for the Dutch, 863 mg/day in Finland, and approximately 1 gm/day for the French. As far as spices are concerned, that may be rich in polyphenols, in Nepal and India, the average consumption of turmeric may range from 0.5g/person to 1.5 g/person. In New Zealand the average intake of spices appears to be 0.36 kg/person/year whereas in Europe it is 0.18kg/person/year and in the United States it is 2.8 kg/person/year [c.f. Fowles J et al., Assessment of cancer risk from ethylene oxide residues in spices imported into New Zealand. Food Chem Toxicol. 2001, 39(11), 1055-1062]. In addition the bioavailability of polyphenols also appears to be variable with studies reporting less than 0.1% for anthocyanins to about 5% for quercetin and to 10-15% for flavonols.

Question: How do the polyphenols from our diet or other sources interact with the functioning of some of the enzymes in our body?

Answer: . One example of this is vitexin in millet that can inhibit thyroid peroxidases and thus when taken in excess may contribute to thyroid toxicity in humans. Estrogenic activity of soy flavones is also well-known. In addition, polyphenols can interact with various enzymes in the body that are responsible for the metabolism of drugs and so care should be taken and medical supervision should be sought before taking such polyphenols when taking any other medications. For instance, grapefruit juice can inhibit or reduce the activity of CYP3A4, an enzyme that is involved in drug metabolism and a study has shown that if taken with benzodiazepines it may increase the serum levels of benzodiazepines, an effect that may not have been accounted for in the dosage prescribed. Another example is that of apigenin which can inhibit the activity of CYP2C9, another enzyme involved in drug metabolism. So such interactions have to be taken into account and therefore the need for medical supervision.

Question: Based on currently available evidence what is your opinion on role of dietary polyphenols for a healthy life?

Answer: Dietary polyphenols especially from cinnamon appear to have a beneficial effect in regulating blood glucose and insulin sensitivity in humans. In addition, cinnamon polyphenols also appear to have antioxidant effects in people with impaired fasting glucose that are overweight or obese (Qin, B et al for review, J Diabetes Sci Technol. 2010 May 1;4(3):685-93). Nevertheless, there are some studies that do not show a clear beneficial effect of cinnamon but these reported studies have to be examined in detail to see where such discrepancies arise from when compared to other published studies that show a beneficial effect. In addition other polyphenols including those from green tea and berries also appear to have several beneficial effects but their effects on dyslipidemia and hyperglycemia may not be clear. In short, diets rich in fruits and vegetables are important in maintaining a healthy lifestyle and preventing several chronic conditions. However, further clinical studies are needed to better understand their role in in glucose regulation, improving insulin sensitivity, and regulating LDL-cholesterol levels.

Question: Are there any other important information that we did not discuss here?

Answer: One important aspect that is not covered here is the potential beneficial effects of polyphenols in neural disease and injury including cerebral ischemia, stroke, Alzheimer’s disease and traumatic brain injury.  Several articles are however available that the reader can refer to on these topics. The research on the effects of polyphenols is growing at a fast pace and any one review article may not be able to cover all aspects of the role of polyphenols in diet and nutrition in various disease conditions. Therefore closely following  interesting and relevant literature/articles on healthy polyphenols will increase the  knowledge and understanding.

This news release was based on the following original scientific article published by Dr. Panickar. Additional general background information was acquired from PubMed, CDC and NIH sources.

Panickar K.S, Effects of dietary polyphenols on neuroregulatory factors and pathways that mediate food intake and energy regulation in obesity, Mol.Nutr. Food. Res. 2013 Jan;57(1):34-47.

Dr. Panickar would like to acknowledge the support provided in part by a Beltsville Human Nutrition Research Center, United States Department of Agriculture-initiated CRADA with the University of Maryland School of Medicine, Baltimore, MD. The author does not have any conflict of interest to disclose but does collaborate with scientists who have funding from Integrity Nutraceuticals (Spring Hill, TN, USA) and a trust agreement with Tang-An Nutritional Health Care Products, Beijing, China.

The views and opinions expressed in this article are those of the author and do not necessarily reflect the official position of the University of Maryland School of Medicine, Baltimore, or any agency of the U.S. government.  


High Protein Breakfast May Help Energy Balance In Overweight Teen Girls

High Protein Breakfast  May Help Energy Balance In Overweight Teen Girls 

Breakfast can alter appetite hormones and key brain regions

Written by Nalin Siriwardhana, Ph.D, Editor In Chief for Nutrition Remarks, Solon, OH, USA

Reviewed by Dr. Heather Leidy, PhD, Assistant Professor, Dept. of Nutrition & Exercise Physiology, University of Missouri, Columbia, MO. USA

Nutrition Remarks Health News Highlights (April  26, 2013) Print PDF of High Protein Breakfast May Help Energy Balance In Overweight Teen Girls

There are many reasons why many Americans skip breakfast. But the consequences can be detrimental, particularly for teens who are overweight/obese. Breakfast skipping might increase the desire to eat larger dinner meals, eat in-between meals, or even eat unhealthy snacks throughout the evening. Thus, the addition of breakfast might play a significant role in obesity treatment and/or prevention.

Obese youngsters are likely to be at high risk for heart diseases, diabetes and even some types of cancer.

An interesting study led by Prof. Leidy at the University of Missouri and published in American Journal of Nutrition, revealed the potential of  high protein breakfast meals in reducing unhealthy snacking in overweight/obese ‘breakfast skipping’ teens.


Brain regions which displayed reduced activation eight hours after the consumption of the high protein breakfast

Brain regions which displayed reduced activation eight hours after the consumption of the high protein breakfast

In the study,  20 late-adolescent overweight/obese ‘breakfast skipping’ girls ate, on separate weeks, normal protein ready-to-eat cereal-based breakfast meals or  high protein egg and lean beef-based breakfast meals or continued to skip breakfast  The study findings reveal that the high protein breakfast increases satiety, reduces food motivation and reward, and reduces unhealthy evening snacking (on high fat and high sugar foods) compared to skipping breakfast or eating a normal protein cereal breakfast.

Though the study is limited for 20 girls for only 7 days/pattern, the study focused both on physiologic and non-physiologic aspects and used detailed blood sample analysis and brain fMRI imaging. Compared to the normal protein breakfast, the high protein breakfast led to reduced dinner-time brain activation in the hippocampus and parahippocampus areas-which are brain regions controlling food reward/cravings. Authors anticipate that if the same eating pattern continues more than 7 days and for up to a longer period of time, there may be a significant reduction in daily energy intake leading to weight loss. This hypothesis is further supported by other previous studies that described breakfast skipping is associated with weight gain. A study published in 2010, in the International Journal of Obesity by Dr. Tasi’s group (Buddhist Tzu Chi General Hospital, Taipei Branch, Taipei, Taiwan), reported that breakfast plays a potential role in obesity prevention. Another recent study published in Public Health Nutrition journal by Dr. Manios’s group (Harokopio University of Athens, Greece), highlights that higher dairy consumption with a more adequate breakfast is one of the important initiatives to be considered for childhood obesity prevention.

Though further comprehensive studies are required to better describe exact mechanisms, this study from Dr. Leidy’s group and other related studies highlight the importance of breakfast with optimal protein for energy intake regulation and weight management specifically in overweight/obese youngsters.

This information is primarily based on the following article published by . Dr. Heather Leidy, PhD. Additional information abstracted from PubMed, CDC , USDA and other reliable sources.

Leidy et al. Beneficial effects of a higher-protein breakfast on the appetitive, hormonal, and neural signals controlling energy intake regulation in overweight/obese, “breakfast-skipping,” late-adolescent girls. American Journal of Nutrition.

Copyright © 2013 Nutrition Remarks. All rights reserved          



Children born preterm need expert nutritional care

Premature birth is associated with higher long-term chronic diseases risk

Frontier Voice of Nutrition Remarks (April 12, 2013) Print PDF Children born preterm need expert nutritional care

Nalin Siriwardhana, Ph.D., interviewed  Dr. Nicholas Embleton BSc, MD, FRCPCH from
Newcastle Neonatal Service, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK .

Most preterm kids need comprehensive medical attention and nutrition care to ensure proper development and future wellbeing. Infants born prior to complete 37 weeks of the pregnancy are considered as preterm babies. The weeks and months before and after child birth is critically important to complete the development of important organs such as brain, lungs, liver and immune system.

Unfortunately, preterm births are not very uncommon. According to Centers for Disease Control and Prevention (CDC), one in every 9 infants born in United States (US) are preterm kids. Statistics from World Health Organization (WHO) reports 15 million preterm infants annually and it is even more than one in every 10 children.

In a recent scientific article published in World Review of Nutrition & Dietetics journal, Dr. Embleton highlighted the importance of nutrition for preterm kids. According to him “Preterm infants need close attention to nutrient intakes in the first few weeks, especially protein and energy, but also minerals, vitamins and other micronutrients.”

Intravenous, feeding tube and bottle feeding for a preterm infant at hospital

Intravenous, feeding tube and bottle feeding for a preterm infant at hospital

Nutrition Remarks interviewed Dr. Nicholas Embleton, a Consultant Neonatal Pediatrician, to clarify the role of nutrition in prematurely born children. Below is a concise summary of the interview:

Question from Nutrition Remarks: Why high level of nutrition care is important to preterm kids?

Answer from Dr. Embleton: Nutrition in the first few days and weeks are critical for later life outcomes. Brain growth is particularly rapid in the last trimester of pregnancy and the first few weeks after birth so inadequate nutrition during this period may result in worse long-term cognitive outcome. Most very premature babies require intravenous (parenteral) nutrition for the first few days and weeks until milk feeds are established. Mother’s own breast milk is the best for preterm babies and is associated with improved short-term outcomes (less infections and gut diseases) and better long-term outcomes such as bone health and lower rates of cardiovascular disease. However, on its own mother’s own breast milk will not meet macronutrient (especially protein) or micronutrient requirements without fortification or supplementation.

Question: What are the potential major health consequences associated with insufficient nutrition care on preterm kids?

Answer: Inadequate nutrition in the first few days is associated with growth failure, inadequate lean mass deposition, impaired brain growth and a range of other adverse outcomes. Sub-optimal nutritional status may impair ability to withstand stresses such as infections and impair recovery from respiratory illness. Failure to provide sufficient energy in the first few days may mean that body protein (in muscles and organs) is catabolised to meet energy requirements. Any loss of lean tissue will impair function, and this may be compounded by failure to provide sufficient protein for growth and repair. Children and adults who were born preterm have a range of altered metabolic outcomes in later life, including earlier onset of puberty, and an increased incidence of insulin resistance, higher blood pressure and decreased levels of bone mineral density. Inadequate nutrition is also associated with alterations to brain structure, particularly the caudate nucleus (one of the basal ganglia). One study measured the caudate nucleus in adolescents born preterm using MRI and showed that it’s volume was related to early nutrient intakes and was associated with verbal IQ. Whilst several studies have shown associations between nutrition, growth and brain outcomes, the data linking early nutrition per se to adverse later life metabolic outcomes (such as insulin resistance) are not clear.

Question: What are the critical nutrients for preterm kids?

Answer: Preterm infants need close attention to nutrient intakes in the first few weeks, especially protein and energy, but also minerals, vitamins and other micronutrients. Protein requirements per kg for babies at 24 weeks gestation are almost twice that at term, whilst energy requirements may only be 20-30% higher. Preterm infants need higher intakes of calcium and phosphorus, essential fatty acids, iron and some vitamins. This means that just giving more milk is not the answer, preterm infants need fortifiers or supplements with differing nutrient compositions and ratios. Nutritional status is a broader concept than dietary intake so there are many other aspects in addition to considering macro- and micro-nutrient intakes. Breast milk is the best milk for preterm infants and a ‘gram for gram’ comparison of nutrients with formula milk is not appropriate. Breast milk has more than 300 individual components including cells, growth factors and enzymes most of which are not available in formula.

Question: According the available scientific evidence, what is the role of epigenetics in metabolic disease risk of preterm kids?

Answer: Early nutrition and growth might exert long-term effects through a range of mechanisms. Inadequate nutrient intakes may impair structural development of organs, but there is also evidence of ‘programming’, a concept through which nutritional (or other) exposures at sensitive periods during development exert long-term effects. This appears particularly true for the “first 1000 days” – a period spanning the time from conception through to 2 years of age. Programming suggests that cells ‘memorize’ early exposures, and it now seems likely that many of these are due to what are termed ‘epigenetic’ mechanisms. Epigenetics (literally ‘above genetics’) is the study of chemical changes to our DNA that do not alter the nucleotide sequence but result in differing gene expression and protein transcription. The best explored example of this is DNA methylation, where methyl groups are attached to certain CpG nucleotide dense regions of the DNA. Differences in DNA methylation are strongly associated with health and disease and are important not only in nutritional programming, but also cancer and many other diseases. These concepts are part of the ‘Developmental Origins of Health and Disease’ (DOHaD) hypothesis.

Question: What are the scientific evidence available for preterm kids borne to obese moms?

Answer: Programming and epigenetic changes are a feature of all animals and probably evolved as a response to changing nutrient environments. Many millenia ago, periodic shortages of food supply were common, so an ability to adapt and trade off longevity in order to promote short term survival was advantageous. In modern times, food shortages are not common, whilst rates of obesity are rapidly rising. Mothers who are obese are likely to have larger babies with altered metabolism and increased later life risks. There appears to be an optimal range of birthweights – being too big may be as harmful as being too small.  In addition, rapid early growth may also be harmful. Proportional growth and body composition are also important concepts. Two babies of the same birthweight may have differing levels of fat and lean mass, and differing later life risks.

Question: According to available scientific evidence, why and how preterm brain is exquisitely vulnerable to undernutrition ?

Answer: Unlike many other mammals, humans are born relatively immature. Compared to a newborn chimpanzee who can hold to its mother’s fur, or a lamb, which can stand unsupported shortly after birth, human infants are very reliant on their mothers for several years. The length of human pregnancy is a compromise  – if humans were born with a similar level of brain maturity to other primates, the placenta would struggle to meet energy requirements, and the head would be too large to fit through the pelvis  – which itself has to be of a certain size and shape for humans to walk on two legs. The human brain grows rapidly in the weeks and months before and after delivery. Impaired nutrient intakes during this period such as might occur in infants born premature will result in altered brain development.

This news release was based on the following original scientific article published by Dr Nicholas Embleton. Additional general background information was acquired from PubMed, CDC, WHO, USDA  and NIH sources.

Embleton ND, Early nutrition and later outcomes in preterm infants, . World Review of Nutrition & Dietetics, 2013;106:26-32.

Dr Nicholas Embleton is a Consultant Neonatal Paediatrician at Newcastle Hospitals NHS Foundation Trust, and Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK. His research collaborations have been funded by BBSRC, HTA programme of the NIHR, Tiny Lives charity, UK Department of Health, Flexibility and Sustainability Funding Newcastle Hospitals, and SPARKS charity.

More about Dr Nicholas Embleton


and http://www.researchgate.net/profile/Nicholas_Embleton/

Written by Nalin Siriwardhana, Ph.D.


Copyright © 2013 Nutrition Remarks. All rights reserved