Excess Omega-6 Fat Damages Infants' Livers

A nurse friend of mine sent me an e-mail a few weeks ago with a very interesting observation:

On the unit I work on we get lots of babies who have "short gut syndrome" due to a variety of causes who have to be on parenteral nutrition to supplement their nutrition while their GI system grows and hopefully heals fast enough. The big problem (among many) with TPN (total parenteral nutrition) is that it destroys the liver and kids get horribly jaundiced (which also causes brain damage) and often they die of liver failure or need a liver transplant before their GI system grows enough to take them off TPN.

Boston Children's has done some amazing work showing that this is largely due to the fact that the lipids part of the TPN was a soybean based oil so they started using Omegaven instead which is a fish oil based IV lipid solution. So far the results have been amazing and reversed the damage in lots of kids livers and prevented it in those started on Omegaven at birth.

Babies born with short gut syndrome can't absorb nutrients properly due to their unusually short small intestine. They're temporarily fed intravenously (total parenteral nutrition; TPN), until their intestines can develop enough to digest food normally.

The typical TPN formula contains soybean and safflower oils as the fat, both of which are over 50% omega-6 linoleic acid. Soybean oil also contains 7% omega-3 alpha-linolenic acid. You can't get the kids started too early on a "heart-healthy" diet!

The solution was to replace the vegetable oil with fish oil, which prevents or rapidly reverses the severe liver damage caused by TPN rich in omega-6 vegetable oils. I don't think this is a great solution, but it certainly beats vegetable oil. The ideal solution would be to replace the vegetable oil with a fat that approximates the composition of breast milk: mostly monounsaturated and saturated fat, with a little bit of linoleic acid, alpha-linolenic acid and long-chain fats such as AA and DHA. You could do this pretty easily with a mix of lard and fish oil; or palm oil and fish oil; or coconut oil, olive oil and fish oil. Breast milk composition varies with diet, and the amount of linoleic acid in the breast milk of Western populations is unusually high.

Excess linoleic acid, particularly when combined with excess fructose and insufficient omega-3 fat, is toxic to the liver. Modern Western nations are experiencing an epidemic of non-alcoholic fatty liver disease (NAFLD), which animal studies indicate is probably the result of replacing animal fats with polyunsaturated vegetable oils and increasing sugar intake (see links below for more detail). Fatty liver was seen primarily in alcoholics three decades ago. An estimated 1/4 of Americans now have NAFLD. It's the number one cause of liver damage in the U.S.

Where the liver goes, the rest of the body follows.

How to Fatten Your Liver
Nonalcoholic Fatty Liver Disease
The Liver: Your Metabolic Gatekeeper
More Liver Functions

Nutrition and Infectious Disease

Dr. Edward Mellanby's book Nutrition and Disease contains a chapter titled "Nutrition and Infection". It begins:

There is general agreement among medical men that the susceptibility of mankind to many types of infection is closely related to the state of nutrition. The difficulty arises, when closer examination is given to this general proposition, as to what constitutes good and bad nutrition, and the problem is not rendered easier by recent advances in nutritional science.

Dr. Mellanby was primarily concerned with the effect of fat-soluble vitamins on infectious disease, particularly vitamins A and D. One of his earliest observations was that butter protected against pneumonia in his laboratory dogs. He eventually identified vitamin A as the primary protective factor. He found that by placing rats on a diet deficient in vitamin A, they developed numerous infectious lesions, most often in the urogenital tract, the eyes, the intestine, the middle ear and the lungs. This was prevented by adding vitamin A or cabbage (a source of beta-carotene, which the rats converted to vitamin A) to the diet. Mellanby and his colleagues subsequently dubbed vitamin A the "anti-infective vitamin".

Dr. Mellanby was unsure whether the animal results would apply to humans, due to "the difficulty in believing that diets even of poor people were as deficient in vitamin A and carotene as the experimental diets." However, their colleagues had previously noted marked differences in the infection rate of largely vegetarian African tribes versus their carnivorous counterparts. The following quote from Nutrition and Disease refers to two tribes which, by coincidence, Dr. Weston Price also described in Nutrition and Physical Degeneration:

The high incidence of bronchitis, pneumonia, tropical ulcers and phthisis among the Kikuyu tribe who live on a diet mainly of cereals as compared with the low incidence of these diseases among their neighbours the Masai who live on meat, milk and raw blood (Orr and Gilks), probably has a similar or related nutritional explanation. The differences in distribution of infective disease found by these workers in the two tribes are most impressive. Thus in the cereal-eating tribe, bronchitis and pneumonia accounted for 31 per cent of all cases of sickness, tropical ulcers for 33 per cent, and phthisis for 6 per cent. The corresponding figures for the meat, milk and raw blood tribe were 4 per cent, 3 per cent and 1 per cent.

So they set out to test the theory under controlled conditions. Their first target: puerperal sepsis. This is an infection of the uterus that occurs after childbirth. They divided 550 women into two groups: one received vitamins A and D during the last month of pregnancy, and the other received nothing. Neither group was given instructions to change diet, and neither group was given vitamins during their hospital stay. The result, quoted from Nutrition and Disease:

The morbidity rate in the puerperium using the [British Medical Association] standard was 1.1 per cent in the vitamin group and 4.7 in the control group, a difference of 3.6 per cent which is twice the standard error (1.4), and therefore statistically significant.

This experiment didn't differentiate between the effects of vitamin A and D, but it did establish that fat-soluble vitamins are important for resistance to bacterial infection. The next experiment Dr. Mellanby undertook was a more difficult one. This time, he targeted puerperal septicemia. This is a more advanced stage of puerperal sepsis, in which the infection spreads into the bloodstream. In this experiment, he treated women who had already contracted the infection. This trial was not as tightly controlled as the previous one. Here's a description of the intervention, from Nutrition and Disease:

...all patients received when possible a diet rich not only in vitamin A but also of high biological quality. This diet included much milk, eggs, green vegetables, etc., as well as the vitamin A supplement. For controls we had to use the cases treated in previous years by the same obstetricians and gynecologists as the test cases.

In the two years prior to this investigation, the mortality rate for puerperal septicemia in 18 patients was 92%. In 1929, Dr. Mellanby fed 18 patients in the same hospital his special diet, and the mortality rate was 22%. This is a remarkable treatment for an infection that was almost invariably fatal at the time.

Dr. Mellanby was a man with a lot of perspective. He was not a reductionist; he knew that a good diet is more than the sum of its parts. Here's another quote from Nutrition and Disease:

It is probable that, as in the case of vitamin D and rickets, the question is not simple and that it will ultimately be found that vitamin A works in harmony with some dietetic factors, such as milk proteins and other proteins of high biological value, to promote resistance of mucous membranes and epithelial cells to invasion by micro-organisms, while other factors such as cereals, antagonise its influence. The effect of increasing the green vegetable and reducing the cereal intake on the resistance of herbivorous animals to infection is undoubted (Glenny and Allen, Boock and Trevan) and may well indicate a reaction in which the increased carotene of the vegetable plays only a part, but an important part.

And finally, let's not forget the effect of vitamin D on infection resistance. Low vitamin D is consistently associated with a higher frequency of respiratory infections, and a controlled trial showed that vitamin D supplements significantly reduce the occurrence of flu symptoms in wintertime. Vitamins A and D are best taken together. Did someone say high-vitamin cod liver oil??

P.S.- I have to apologize, I forgot to copy down the primary literature references for this post before returning the book to the library. So for the skeptics out there, you'll either have to take my word for it, or find a copy of the book yourself.

Mozambique, Cape Verde First Ladies Bring Global Health Message To Washington

Back home in the United States capital, I woke up early this morning to attend perhaps the first advocacy event since the African First Ladies Health Summit earlier this week – that being a news conference for U.S. lawmakers, implementers and media rounding up the Summit’s activities and looking forward to actions being taken by the first ladies.

Two of the first ladies who attended the summit – Mrs. Maria da Luz Guebuza of Mozambique and Mrs. Adelcia Barreto Pires of Cape Verde decided to make a stop in Washington, D.C., on their way back from Los Angeles to make sure that the summit messages were heard by all partners involved – from the donor level to the country level to civil society. The event – organized by the Global Health Council – took place at the National Press Club.

Both First Ladies through their Portuguese interpreters laid out the major health issues in their countries and how they have and plan to address them in the future. Perhaps the most important part of the news conference was the feeling by both first ladies that they were energized to build on the partnerships they worked on at the Summit to work toward real results in bettering the health of women, children and families in their countries.

The highlight of the day came from Rep. Gwen Moore, D-WI, vice-chair of the Congressional Caucus on Women’s Issues, who gave a thunderous and enthusiastic speech about the U.S. response to global health issues and on the accomplishments of the two first ladies. Rep. Moore on behalf of the Global Health Council presented the first ladies of Mozambique and Cape Verde with 2009 Global Health Awards for the first ladies’ outstanding contributions toward improving the health of people in Africa. The smiling and hugging between Rep. Moore, Mrs. Guebuza and Mrs. Pires then commenced, to the delight of those in the audience.

Wrapping up the event, the Global Health Council's very own Executive Vice President Maurice Middleberg took a couple questions answered by the first ladies. As I review in my head what I have witnessed this week – a couple of thoughts. First, these gatherings will not alone help solve the major health issues facing Africa. However, we have seen in countries such as Rwanda and Mozambique that progress on key indicators in global health is possible if there is the political and social will to do so. If the gathering of the African first ladies is properly leveraged into spirited and concrete action in their home countries, then all the glamour of Hollywood and rhetoric of Washington will be worth it for the people living in their countries. I know that the Global Health Council and civil society stands to ready to work with them.

    – Vince Blaser

Sarah Brown Brings the House Down, African First Ladies Leave Summit Spurred to Action

Los Angeles, CA.: Dr. Hajiya Turai Umaru Yar'Adua, First Lady of Nigeria, talks about a three-wheeled ambulance that was designed to aid pregnant women in remote regions of her country. Photo by Stephen Osman

There were fewer cameras and less Hollywood star power at day two of the African First Ladies Health Summit in Los Angeles, but the heavy hitters of the policy arena stepped to the stage and the summit dug deep into the major health issues facing Africa.

Sarah Brown, wife of United Kingdom Prime Minister Gordon Brown, delivered an amazing keynote in the morning – bringing the African first ladies and partners in the audience to their feet. Mrs. Brown talked passionately about the issue of maternal health. She laid out an impressive argument about how averting maternal deaths and complications are keys to achieving all of the U.N. Millennium Development Goals.

There was a palpable sense after Brown’s speech that the energy level was raised in the room. Shortly after, Her Excellency Dr. Hajiya Turai Umaru Yar’Adua, the first lady of Nigeria, took the stage and began delivering her prepared remarks for a maternal health panel. Until this speech, many of the first ladies understandably delivered their remarks exactly as written, not looking up much at the audience. While many of these speeches were very informative, they did not do much to really involve the audience.

The Nigerian first lady’s speech started in much the same manner for a couple minutes. Then, she looked up, scanned the audience, adjusted her clothes and began to speak off the cuff.  Dr. Yar’Adua began talking passionately about a project she has supported that involves distribution of small, three-wheel ambulances that can maneuver through narrow roads (and non-existent) roads to the rural areas of Nigeria. She said that many pregnant women do not go to health clinics because their husbands disallow it. But the beauty of these ambulances is that quality maternal care can come to them. The ambulance is parked in villages and pregnant women are given “mama kits” that includes supplements and information on safe maternal care. A midwife and a nurse travel with the doctor in these ambulances – which the first lady says are about one-fifth the cost of a full ambulance we see on our streets.

At the moment the First Lady’s staff finally got the pictures of the ambulances up on the video screen, and the First Lady was reinvigorated even further, I dropped any cynicism I had about the value of this Summit. The First Ladies and leaders from all sectors of the global health field came to share stories and ideas such as the three-wheel ambulance in Nigeria. Effectiveness in global health programs are correctly measured by quality data indicators, and we here in Washington D.C. are constantly pouring over them. However, I think and hope that the first ladies connected to each other with personal stories of their work and now are more motivated than before to return to their countries with an even stronger will to use their political and social power to improve health in their countries in a time of economic recession.

   – Vince Blaser