Bisher AKIL, MD

Archive for the ‘Kids & teens’ Category

Hold the Popcorn!

In General Health, Kids & teens on November 22, 2019 at 4:07 pm

Although electronic cigarettes (e-cigarettes) were initially marketed as a potential smoking-cessation aid and a safer alternative to smoking, the long-term health effect of e-cigarette use (“vaping”) is unknown. Vaping e-liquids expose the user to several potentially harmful chemicals, including diacetyl, a flavoring compound known to cause bronchiolitis obliterans (inflammatory obstruction of the lung’s tiniest airways, called bronchioles. The bronchioles become damaged and inflamed by chemical particles or respiratory infections) with inhalational exposure (“popcorn worker’s lung”- described from a number of workers in factories making microwave popcorn developed “popcorn lung” after inhaling the flavoring chemical diacetyl, which is also used in e-liquids ). Here is a case reported by Canadian physicians,  of a 17-year-old male youth who presented with intractable cough, progressive dyspnea (difficult or labored breathing)  and malaise after vaping flavored e-liquids and tetrahydrocannabinol(one of at least 113 cannabinoids identified in cannabis. THC is the principal psychoactive constituent of cannabis) intensively.  He required intubation (a procedure by which a tube is inserted through the mouth down into the trachea – the large airway from the mouth to the lungs), invasive mechanical ventilation and venovenous extracorporeal membrane oxygenation (ECMO) for refractory hypercapnia (a condition of abnormally elevated carbon dioxide (CO2) levels in the blood. Carbon dioxide is a gaseous product of the body’s metabolism and is normally expelled through the lungs). The patient’s condition improved with high dose corticosteroids. He was weaned off ECMO and mechanical ventilation, and discharged home after 47 days in hospital. Several months after hospital discharge, his exercise tolerance remained limited and pulmonary function tests showed persistent, fixed airflow obstruction with gas trapping. The patient’s clinical picture was suggestive of possible bronchiolitis thought to be secondary to inhalation of flavoring agents in the e-liquids, although the exact mechanism of injury and causative agent are unknown. They concluded that this  case of severe acute bronchiolitis, causing near-fatal hypercapnic respiratory failure and chronic airflow obstruction in a previously healthy Canadian youth, may represent vaping-associated bronchiolitis obliterans. This novel pattern of pulmonary disease associated with vaping appears distinct from the type of alveolar injury predominantly reported in the recent outbreak of cases of vaping associated pulmonary illness in the United States, underscoring the need for further research into all potentially toxic components of e-liquids and tighter regulation of e-cigarettes.

Source:  Simon T. Landman, Inderdeep Dhaliwal, Constance A. Mackenzie, Tereza Martinu, Andrew Steele and Karen J. Bosma CMAJ November 20, 2019 cmaj.191402; DOI:

Summary reported in NEJM_ Journal Watch

Comments:  Yet another one!_BA

Six teaspoon of added sugar, no more!

In General Health, Heart, Kids & teens on August 23, 2016 at 8:00 pm

The American Heart Association now recommends that children limit their added sugar intake to 25 g daily or less, the equivalent of 6 teaspoons of sugar, or 100 calories. On average, children currently consume about 80 g daily.

Some definitions are needed here:

Sugar: Although commonly used more broadly, the US Federal Drug Administration defines the term sugar as a sweet ,crystalline substance, obtained chiefly from the juice of the sugarcane and the sugar beet.

Total Sugars: The term total sugars is used conventionally to describe the monosaccharides: glucose, galactose, and fructose, as well as the disaccharides sucrose, lactose, maltose, and trehalose (sunflower seeds, shiitake/mushroom, oyster). Total sugars include all sugars in a food or beverage from any source, including those naturally occurring (such as fructose in fruit and lactose in milk) and those added to foods.

Naturally occurring Sugars include those that are an innate component of foods (eg, fructose in fruits and vegetables and lactose in milk and other dairy products).

Extrinsic and Intrinsic Sugars terms originated from the UK Department of Health.  Intrinsic sugars are defined as sugars that are present within the cell walls of plants (eg, naturally occurring sugars)  and are always accompanied by other nutrients. Extrinsic sugars are those not located within the cellular structure of a food and are found in fruit juice, honey, and syrups and added to processed foods. The term non- milk extrinsic sugars is used to differentiate lactose- containing extrinsic sugars from all  others  because the metabolic response for the 2 types of sugars differs  substantially.

Free Sugars a term used by the World Health Organization that refers to all monosaccharides and disaccharides added to foods by the manufacturer, cook, and consumer (eg, added sugars) plus sugars naturally present in honey, syrups, and fruit juices (eg, non-milk extrinsic sugars).

The Risk:

  1. Excess weight gain and obesity
  2. Elevated blood pressure and uric acid levels
  3. Dyslipidemia
  4. Nonalcoholic fatty liver disease and
  5. Insulin resistance and diabetes mellitus.

Data source: They  used publicly available data from the most recent cycles of the National health and Nutrition Examination Survey ( NHANES)  (2009–2012) to estimate current levels of added sugars intake. These estimates may be conservatively low because it is well established that self-reported dietary assessments under report. Their analysis demonstrates that US children 2 to 19 years of age consume an average of 80 g added sugar daily . Absolute intake is higher among boys than girls (87 versus 73 g), but there were no differences when intake was assessed in relation to total energy intake (16.1% for both). Added sugars intake increases with age . Intake of free sugars, the combination of added sugars and sugars that occur naturally in honey, syrups, and juices, is 91 g and 18.5% total energy. Foods and beverages each contribute half of the added sugars in children’s diets, 40 g each. The top contributors to added sugars intake include soda, fruit- flavored and sports drinks, and cakes and cookies. Previous research has suggested that most added sugars are consumed at home rather than away from home.

Sobering findings: 

  1. Children consuming 3.5% to 6.8% of calories as sucrose (the lowest consumption group) had lower triglycerides and higher High density lipoprotein(HDL) than higher consumers.
  2. Children consuming no sugar-sweetened- beverages (SSBs) such as sodas,  compared with those consuming an average of 8 oz/d had lower C-reactive protein, smaller waist circumference, and higher HDL cholesterol.
  3. Each additional Sugar- sweetened beverages (SSB) equivalent (≈1 cup or 8 oz) consumed by children daily was associated with a 5% increase in Homeostatic model assessment and insulin resistance (HOMA-IR – , a method used to quantify insulin resistance and beta-cell function) 16-mm increase in systolic blood pressure, a 0.47-cm increase in waist circumference, a 0.90-percentile increase in BMI for age, and a 0.48-mg/dL decrease in HDL concentrations. The low consumers in this analysis consumed a mean of 0.1 oz of SSBs per day.
  4. Adolescents who consumed >10% of their total energy as added sugars had lower HDL levels, higher triglycerides, and higher low-density lipoprotein cholesterol levels than those who consumed less. Overweight or obese adolescents had higher insulin resistance (as assessed with HOMA-IR).

They concluded,  the available evidence found that associations with increased cardio-vascular disease (CVD) risk factors are present at levels far below US children’s current added sugars consumption levels. Current evidence supports the associations of added sugars with increased energy intake, increased adiposity (severe or morbid overweight), increased central adiposity, and increased dyslipidemia (elevation of plasma cholesterol, triglycerides (TGs), or both, or a low high-density lipoprotein level that contributes to the development of atherosclerosis, all of which are demonstrated CVD risk factors. Importantly, the introduction of added sugars during infancy appears to be particularly harmful and should be avoided. Although added sugars can mostly likely be safely consumed in low amounts as part of a healthy diet, little research has been done to establish a threshold between adverse effects an health, making this an important future research topic.

Summary appeared in JWatch, August 23 2016

Citation: published ahead of print

Comments: This is my review of the paper. The conclusions are: Children and adolescents should limit their intake of sugar-sweetened beverages (like sodas) to one 8-oz serving per week, or less, and for those under 2 years of age, added sugars should be avoided entirely_BA