Wellness Check: Nutrition

2 Minute Medicine is pleased to announce that we are launching Wellness Check, a new series dedicated to exploring new research evidence focused on wellness. Each week, we will report on articles examining different aspects of wellness, including (but not limited to) nutrition, sleep, reproductive health, substance use and mental health. This week, we explore the latest evidence-based updates in nutrition. 

Addition of azithromycin to standard treatment does not improve survival in childhood diarrhea

1. In this study, adding azithromycin to standard management of acute diarrhea in children lowered risk of hospitalization and reduced change-in-weight at 90-days post treatment.

2. Adding azithromycin to standard management for acute childhood diarrhea did not improve 180-day mortality.

Evidence Rating Level: 1 (Excellent)

The current WHO guidelines do not recommend routine use of antibiotics in treating children with acute watery diarrhea. However, given that a significant proportion of acute watery diarrhea in the low-and-middle income settings could be caused by bacterial infection, addition of antibiotics to standard of care for watery diarrhea in dehydrated or undernourished children may help reduce mortality and improve growth.

This randomized control trial examined the efficacy of antibiotic azithromycin addition to standardized care in 8266 children (54% male) aged 2 to 23 months with acute watery diarrhea, dehydration, and/or moderate wasting (decrease weight-for-length). Children were recruited from 2017-2019 and were from 36 outpatient hospitals or community health centers in Bangladesh, India, Kenya, Malawi, Mali, Pakistan, and Tanzania. Children were excluded if they had dysentery, suspected cholera, severe acute malnutrition, signs of other infections requiring antibiotics, and antibiotic use in last 14 days. Enrolled children were randomly assigned to either receive 10mg/kg oral azithromycin or placebo once daily for 3 days in addition to WHO standard care protocols for management of watery diarrhea. Each child was followed for 180 days. The primary outcome examined were changes in growth 90-days after enrollment and all-cause mortality up to 180 days after enrollment.

Results demonstrated there was a 21% lower risk of hospitalization or death in the 90-day period after azithromycin treatment and a smaller decrease in length-for-age in antibiotic group (-0.16) compared to control group (-0.19). However, at 180 days, the change in mortality was not significantly different between antibiotic (0.5%) and control group (0.7%). However, this study was limited in that it could neither demonstrate or exclude the possibility of a difference in mortality between the two groups considering the small risk of mortaltity in the control group (which would require a much larger sample size). Therefore, although the results of this study suggest continued adherence to current WHO protocols for acute watery diarrhea, future studies with more patients and assessment of additional outcomes may identify specific populations or circumstances in which antibiotic use could be helpful.

Childhood food insecurity is associated with worse functioning during adolescence

1. High risk of experiencing food insecurity during childhood was associated with lower household income, single parent household, and history of depression in parents.

2. High risk for childhood food insecurity was associated with more severe cannabis use, behavioral problem, and dropout potential in these children during adolescence.

Evidence Rating Level: 2 (Good)

Given the importance of proper nutrition in pediatric development, childhood food insecurity is an important public health issue to understand and combat. Several studies have demonstrated that food insecurity experienced during early childhood leads to academic difficulties and behavior problems several years later. However, whether household food insecurity experienced during childhood is associated with mental health outcomes during adolescences has not been well characterized.

This cohort study followed 1441 (52.2% female) infants in Quebec, Canada, starting from age 5 months until 15 years. Children were classified into either experiencing low-risk food insecurity (96.4%) or high-risk food insecurity (3.6%) based on surveys of mothers performed when children were aged 1.5, 4, 8, 10, 12, and 13. A value of “1” was given if any family member experienced hunger due to lack of food or money to buy food in the past 12 months. Subsequently, mental health and functioning outcomes were surveyed in these adolescents at 15 years of age.

Results demonstrated that even after adjusting for other factors that could modulate childhood development (such as household income, single parent household, and the presence of mental illness in parent), high risk for food insecurity was significantly associated with worse cannabis use, peer bullying, and school dropout potential. Limitations of this paper include a very low number of participants in high-risk food insecurity group (73), which is likely due to a high number of children being lost to follow-up (679) who were predominantly in single-parent households with lower socioeconomic status. Furthermore, this study only examined food insecurity in a binary fashion and did not assess quality or diversity of nutrition. Nonetheless, this study provides supporting evidence for additional prospective studies aimed at evaluating the efficacy of intervention programs targeting childhood food insecurity in modulating mental health outcomes during adolescence.

Vitamin D supplementation does not improve mental outcomes in adults with early psychosis

1. In this study, vitamin D supplementation in patients with first-episode psychosis did not lead to improved psychotic symptoms.

2. Black patients with first-episode psychosis had higher prevalence of vitamin D deficiency compared to white patients.

Evidence Rating Level: 1 (Excellent)

Patients with psychotic disorders can be at risk of vitamin D deficiency due to poor general health associated with sedentary lifestyles, less sun exposure, and poor nutrition. Specifically, 42% of patients with first-episode psychosis (FEP) were found to have vitamin D deficiency, with higher vitamin D levels at first presentation being associated with fewer symptoms of psychosis a year later. However, whether supplementation of vitamin D in these patients during first-episode psychosis (FEP) can improve mental and health outcomes has not been well studied.

This randomized control study examined 149 adults (59.7% male) aged 18-65, who were within 3 years of their first presentation of a psychotic disorder. Patients were from five different centers in the United Kingdom and were randomized to receive monthly supplement of 120,000 IU of Vitamin D or placebo. Patients who were currently taking Vitamin D supplements >400IU per day or cardiac glycosides, calcium channel blockers, corticosteroids, bendroflumethiazide, isoniazid, rifampicin, or had known calcium, parathyroid, liver, or renal dysfunction and malignancy were excluded. The primary outcome was number of psychotic symptoms as measured by total Positive and Negative Syndrome Scale (PANSS) score at 6 months. Secondary outcomes included other health outcomes such as level of function, depression scores, body mass index, glycated hemoglobin, total cholesterol, and C-reactive protein.

Of note, many patients at baseline were found to have very low Vitamin D levels, especially Black participants (93.4%) compared to White participants (60.5%). However, after 6 months, vitamin D supplementation did not lead to statistically significant improvement of all primary or secondary outcomes measured. This study was potentially limited by monthly dosing of Vitamin D instead of daily dosing, which is thought to be more therapeutically effective. Nonetheless, this study was significant in suggesting that supplementation with Vitamin D alone did not modulate mental and health outcomes in patients with FEP, and how Public health strategies could further explore replenishing vitamin D in vulnerable populations.

Image: PD

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