Image by Gerd Altmann from Pixabay

April 10, 2023

1) Autism is linked to heart disease! From the JAMA Pediatrics study, "In this systematic review and meta-analysis of 34 studies that included 276,173 participants with autism and 7,733,306 participants without autism, individuals with autism had a higher associated risk of developing diabetes, dyslipidemia, and heart disease, but not hypertension or stroke. The associated risks of developing diabetes and hypertension were even higher among children with autism."(Dhanasekara et. al. 2023) The relative risk of developing type 2 diabetes mellitus was 2.5 and dyslipidemia was 1.6. Thus, individuals diagnosed with autism have a 1.6 fold increased risk of abnormal apolipoprotein B levels leading to CVD events over time. My take on this data is clear.

Our population of children with autism suffer from chronically poor quality diets, limited exercise and emotional distress. These upstream issues are the trifecta of CVD pathogenesis. This makes this data not surprising at all. My frustration remains that we know this data to exist and be true, yet as a society, we do little to reduce these risk factors. Nutrition remains the afterthought in psychiatry, behavioral medicine and society at large. Many and frankly most parents that I meet are reluctant to control the inputs of food at home leading to these concerns over time. This is not judgement. This is just my observation.

Aside: I just returned from a 5 day men's retreat in Texas. We stayed at a ranch which hosts a center for adults with disabilities where they have work opportunities that are guided and safe. It was a beautiful place, experience and moment to witness and be a part of. The problem was that the food served to the residents and us, unfortunately, was run based on the government and their guidelines for nourishment. It was a study in caloric volume and limited nutritional quality. In the five days that I was there, I did NOT see a colorful vegetable once. Processed potatoes, wraps, rice, beans, sugar based cereals were the main vegetables primarily as starches. Fruit was daily as bananas, apples and oranges. Lots of meat as chicken, beef and pork and lots of cheese. One fish meal as tilapia in 15 meals. Sugar beverages offered at every meal. Black coffee for me, thank God. By the end of the 15 meal struggle, I had lived on fruit and meat. I was spiraling into nutrition hell. I could not wait to get to the Austin airport where I promptly inhaled a large salad. My little pity party paled in comparison to the full time residents reality.

The consequences of the federal and state guidelines for nourishment are obvious to witness. It is like getting hit in the head with a sledgehammer of truth. Most of the residential adults were obese which saddened my heart. There is repeated pattern of nutritional dysfunction in schools, residential homes and government run entities. And we wonder why all health graphical trajectories are exponential in the wrong direction.

2) Machine learning algorithms are going to help us diagnose autism spectrum disorders earlier. From a new study in JAMA, Dr. Engelhard and colleagues from Duke University were able to predict autism dignosis with 90% accuracy by 30 days of age based on a host of criteria diagnostically. Each new diagnosis increased the likelihood of a positive ASD diagnosis. Gastrointestinal issues like milk protein intolerance, early visual concerns, needing physical therapy were some of the associated findings that were predictive. Another reason for me to walk away from vaccines as a significant cause of autism spectrum disorders. I keep falling back into the camp that ASD is starting in utero or even preconception. More to come.

3) Long term gastrointestinal issues post Covid are real and problematical. In a study by Dr. Xu in Nature Communications we see: "We show that beyond the first 30 days of infection, people with COVID-19 exhibited increased risks and 1-year burdens of incident gastrointestinal disorders spanning several disease categories including motility disorders, acid related disorders (dyspepsia, gastroesophageal reflux disease, peptic ulcer disease), functional intestinal disorders, acute pancreatitis, hepatic and biliary disease. The risks were evident in people who were not hospitalized during the acute phase of COVID-19 and increased in a graded fashion across the severity spectrum of the acute phase of COVID-19" (Xu et. al. 2022) This is not surprising as much as it is important to be aware of. Covid affects the GI tract in acute disease and increasing severity of disease likely leads to dysbiosis of the microbiome which is associated with all of these GI issues.

4) Celiac disease screening for first degree relatives of a person with celiac disease is warranted. From the study: "The incidence of celiac disease in first-degree relatives of affected individuals is higher than in the general population, yet the clinical characteristics of this unique subset of patients has not been well described. Through a retrospective review of patients seen in a tertiary care pediatric celiac disease clinic, we identified 49 patients diagnosed with celiac disease following screening due to an affected first-degree relative. Although 51% of patients screened due to an affected first-degree relative were asymptomatic, their disease histology was as severe as those screened for symptoms suggestive of celiac disease. These findings support current recommendations to screen all first-degree relatives of patients with celiac disease regardless of clinical symptoms." (Gould et. al. 2023) Very important data set for those with a family history of celiac disease. Uncontrolled celiac disease is associated with cancer and autoimmunity long term. Thus, screening and avoiding gluten containing foods is of paramount importance. If you have a primary relative with celiac disease get screened with a HLA DQ2/8 genetic test as well as celiac antibody profile.

5) Is strep throat or Group A streptococcal, GAS, infection associated with chronic motor tic disorders? A recent study in Neurology says no. (Schrag et. al. 2022) This remains a mystery to me as I have seen many children develop rapid onset motor tics, anxiety and OCD behaviors that were absolutely responsive to antimicrobials that treat GAS. The devil remains in the details of each case likely. But clearly as a class effect, GAS is not a clear cut cause of disease. Listen to the podcast with Dr. Nancy O'Hara for more on this topic. I think that as always the resolution to these issues is rooted in reducing total body inflammation.

6) Watching violent video content in early childhood is associated with mental health struggles at age 12 according to new data from Dr. Pagani in the Journal Developmental and Behavioral Pediatrics. "For girls, preschool violent televiewing was associated with increases in emotional distress and decreases in classroom engagement, academic achievement, and academic motivation at age 12 years. For boys, preschool violent televiewing was associated with increases in emotionally distressed, inattentive, conduct disordered, and socially withdrawn behavior, as well as decreases in classroom engagement, academic achievement, and academic motivation at age 12 years." (Pagani et. al. 2022) These data points are consistent with what I see in clinic. This is not causative as much as associative. The children that are allowed to watch violence in early childhood are often parented by adults that are not emotionally grounded and not protective of the child's mind. These children are left without boundaries leading to emotional fear and distress.

Children need and actually require boundaries for a sense of safety in the first decade of life. The emergence of streaming services providing real time graphical violence at a child's finger tips is a massive risk to our entire society. The simple answer is to keep children away from screens throughout the first decade of life and when they do watch, be present to keep content safe and structured.

7) In another study by Dr. Pagani in the same Journal we see a direct correlation with physical activity and mental health in children, especially boys! "We identified 3 emotional distress trajectories: “low” (77%), “increasing” (12%), and “declining” (11%). Boys who never participated in sport at age 5 years were more likely to be in the “increasing” emotional distress trajectories compared with boys who participated in any sporting activity. Furthermore, boys in the “low” emotional distress trajectory demonstrated better physical activity outcomes at age 12 years. These results, exclusively for boys, are above and beyond pre-existing individual and family factors." (Harbec et. al. 2022) Another reason to promote physical activity at all ages.

8) From Dr. Breit in PLOSOne: "The COVID-19 pandemic has affected schooling worldwide. In many places, schools closed for weeks or months, only part of the student body could be educated at any one time, or students were taught online. Previous research discloses the relevance of schooling for the development of cognitive abilities. We therefore compared the intelligence test performance of 424 German secondary school students in Grades 7 to 9 (42% female) tested after the first six months of the COVID-19 pandemic (i.e., 2020 sample) to the results of two highly comparable student samples tested in 2002 (n = 1506) and 2012 (n = 197). The results revealed substantially and significantly lower intelligence test scores in the 2020 sample than in both the 2002 and 2012 samples. We retested the 2020 sample after another full school year of COVID-19-affected schooling in 2021. We found mean-level changes of typical magnitude, with no signs of catching up to previous cohorts or further declines in cognitive performance. Perceived stress during the pandemic did not affect changes in intelligence test results between the two measurements." (Breit et. al. 2023)

This is one of a litany of studies showing the frustrating outcome of lockdowns and school closures on children worldwide. This study is particularly daunting as Germany has a more robust primary school system than the United States. Therefore, the lack of catch up portends even worse outcomes in the US. It may be time to rethink year long schooling until catch up is demonstrated lest society slip further into trouble academically.

That's all this week,

Dr. M

Dhanasekara JAMA Peds

Engelhard JAMA

Xu Nature Communications

Gould J Pediatric Gastro and Nutrition

Schrag Neurology

Pagani J Develop Behavior Pediatrics

Harbec J Develop Behavior Pediatrics

Breit PLOSOne