Transcript Slide 1

Building Demand for
California Dried Plums
2007-2008 Public Relations
Recommendations
June 28, 2007
Case Study
Mrs. K: 32 y/o AAF executive at her PMD’s office
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Feels “bloated”, gassy, infrequent stools
Lower abdominal cramps
Improved with BM’s (approx 3/week)
Occurs unpredictably, for last 7 months
Lasts for few days, then goes away
No interference w/ daily activities
Worried it might be “something serious”
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Case Study continued
Mrs. K: History and Physical
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PMH: “food poisoning” one year ago
PSH: none
MEDS: colace qd
FH: mother has “minor depression”
SH: married, highly active, no T/E/D
Physical exam: normal; BMI = 24
Labs: no anemia, ESR & CRP normal
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DIGESTIVE HEALTH:
THE RD’s PERSPECTIVE
Leslie Bonci,MPH,RD,LDN,CSSD
Director of Sports Nutrition
University of Pittsburgh Medical Center
WHAT ARE WE HEARING?
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Rock hard abs
Commercials for various GI medications
Increased product availability- OTC/supplements
Diarrhea/Constipation are dinner table
conversation
• Detox
• Colon cleansing
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THE FACTS
• Eating can be a trigger for gut problems
Good digestive health is the ability to digest,
absorb and utilize nutrients
• It is not just about the food, but also the
eating habits:
– Timing
– Quantity
– Where one eats
– How one eats
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GETTING TO GOOD DIGESTIVE
HEALTH
• Achieving/maintaining an appropriate
weight
• Eating a diet that is balanced, varied, and
individualized to address digestive
concerns
• Stress reduction
• Physical activity
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LIFESTYLE INFLUENCERS
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Stress
Irregular schedule
Travel’s effect on food choices
Busy lives
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BARRIERS
• Patients are not always forthcoming with
symptoms/complaints
• Patients may try to self-treat
• Power of suggestion
• Sensitive subject
• Food safety concerns
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TREATING DIGESTIVE
DISORDERS WITH DIET
• Not black and white
• No guarantee that symptoms will abate
• May have to experiment over several
months
• Outcomes may be more subjective than
objective
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DIETS THAT CAN AFFECT THE
GUT
• High protein/high fat
– Low-carb products
• High carbohydrate
– High fiber
• Fad diets
– Cabbage soup/food combining
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SUPPLEMENTS THAT AFFECT
THE GUT
• Vitamin Mineral supplements
– Mega dose Vitamin C
– Potassium supplements
– Calcium
– Iron supplements
– Large doses of Magnesium
• “Energy” Drinks
• Flaxseed/Flaxseed oil
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OTHER POTENTIAL OFFENDERS
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Echinacea
Chitosan
Dieter’s Tea
Glucosamine
Fish oil capsules
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THINGS TO KEEP IN MIND
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There is not ONE eating plan
Need to customize and individualize eating
Need to make changes gradually
Need to monitor eating to discover
potential food and habit stressors, as well
as foods that are well tolerated
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WHAT TO TELL PATIENTS
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Make meal times relaxed
Take time to eat
Allow time for food to digest
Eat at regular intervals
Eat smaller amounts at any given eating
episode
• Take small bites
• Focus on eating, not everything else
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WHAT SHOULD THEY DO?
• Keep a food/symptom diary listing :
– Foods eaten
– Quantity
– Time consumed
• Document outcomes:
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Symptom relief
Decrease in symptom frequency
Better sleep patterns
Improved energy
Different bowel patterns
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FOCUS ON FUNCTIONAL FOODS
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Yogurt- probiotics
Dried plums- fiber/sorbitol
Oats- beta-glucan,prebiotics
Orange juice, eggs, peanut butter,
spreads- Omega-3 enhanced foods
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TRAVEL GUIDELINES
• Bottled water on planes
• Travel with “safe” foods- packets of oatmeal,
nuts, dried fruits
• www.cdc.gov/travel
• List of food concerns if traveling to other
countries
• Travel with bouillon cubes, sports drink powder
• Wash hands frequently, or use wipes
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GOOD GUT TRAVEL KIT
• Nausea
• Sports drink
• Candied gingerroot
• Constipation
• Ground flaxseed
• Dried plums/fig bars
• IBS/Abdominal cramps
• Chamomile tea
• Diarrhea
• Raspberry tea/Blackberry root bark tea
• Sure-Jel or Certo
• Carob powder
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FINAL WORDS
• The emphasis needs to be on what
patients can have- NOT what they can’t!!!
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DIET RECOMMENDATIONS FOR
MRS K
• Ask about recent change in diet
• Food diary to ascertain potential offenders: bloat
and gas causing foods/beverages
• Discuss food habits- eating on the go, or sitting
down to meals
• Ask about supplement use
• Ask about exercise routine
• Discuss ways to GRADUALLY add fiber to the
diet, along with adequate fluids
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CONTACT
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Leslie Bonci, MPH, RD
Phone (412) 432-3674
e-mail: [email protected]
American Dietetic Association’s Guide to
Better Digestion!
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Identifying and Achieving Digestive
Health – A Look to the Future
UCLA
Specialty
Training and
Advanced
Research
Program
Leo Treyzon M.D.
Divisions of
Digestive Diseases &
Clinical Nutrition
David Geffen School of
Medicine at UCLA
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Disclosures
1.
2.
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NIH Training Grant
UCLA STAR Program
Annenberg GI Fellowship Award
UCLA Center for Human Nutrition
Digestive Health Organization and
CDPB
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Why is this an important topic?
• Unpredictable, uncomfortable and
embarrassing
• Large economic burden
• Next frontier in health care is prevention
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Hard to Define
I can’t describe it,
but… “I know
when I see it”
– Justice Stewart,
Ohio Supreme
Court
Jacobellis v. Ohio, 378 U.S. 184, 197 (1964)
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Defining Digestive Health
“Good digestive health indicates an ability to
process nutrients through properly
functioning gastrointestinal organs,
including the stomach, intestines, liver,
pancreas, esophagus and gallbladder. Most
people who are in good digestive health are
of appropriate weight and don’t regularly
experience symptoms like heartburn, gas,
constipation, diarrhea, nausea or stomach
pain. Eating a nutritious diet is needed to
maintain a healthy digestive system and may
prevent and treat certain digestive diseases.”
American Gastroenterology Association 27
Definition – Digestive Health
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Ability to digest, absorb and utilize nutrients
Eliminate waste products
Optimizes vitality, and resilience
Appropriate weight is central theme
Don't regularly experience bothersome
digestive symptoms
• This state of well-being is achieved by:
– consuming a nutritious diet
– minimizing emotional stressors
– embracing physical activity
• Oriented to the prevention of chronic
disease.
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Other Approaches to Health
Bio-Medical – the body as machine; disease
oriented
Behavioral – health as energy – lifestyle
Bio-psycho-social – attempts to address
deficiencies of behavioral model within
biomedical context
Socio-environmental – a means to realize
aspirations and change environments
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Strengths of Digestive Health Approach
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Individualized to the person
Creates energy and balance in self
Focus on individual responsibility
Focus on lifestyle change for health
and disease prevention
• Spiritual connection to natural
environment
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Leading GI Symptoms Prompting U.S. Outpatient
Clinic Visits in 2002
Rank
GI Symptom
# of Visits
(Millions)
Abdominal pain, cramps,
spasms
11.8
2
Diarrhea
3.7
3
Vomiting
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Rank
GI Symptom
# of Visits
(Millions)
Other GI Symptoms (unspecified)
0.89
10
Anorectal Symptoms
0.87
2.6
11
Melena
0.81
Nausea
2.1
12
Abdominal Distension
0.79
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Constipation
1.8
13
Dysphagia
0.76
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Rectal Bleeding
1.5
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Lower Abdominal Pain
0.75
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Heartburn
1.4
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Appetite Decrease
0.55
8
Dyspepsia
0.9
1
9
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Shaheen NJ et al . Am J Gastroenter 2006.
National Ambulatory Medical Care Survey 2002.
Physician Diagnoses for GI Disorders
in Outpatient Clinic Visits
Rank
Number of Visits
(Millions)
Diagnosis
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GERD
5.51
2
Abdominal Pain
4.17
3
Gastroenteritis
3.32
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Constipation
2.56
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Dyspepsia, Gastritis
2.29
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Irritable Bowel Syndrome
2.06
7
Hemorrhoids
1.54
8
Diverticular Disease
1.49
9
Hepatitis C infection
1.24
10
Hernia, noninguinal
1.23
Shaheen NJ et al . Am J Gastroenter 2006.33
National Ambulatory Medical Care Survey 2002.
Physician Visits per Year
(GI and non-GI)
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5
MD
Visits
Per
Year
GI
Non-GI
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3
2
1
0
IBS
Complaints
Normal
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Drossman DA, et al., Dig Dis Sci 1993; 38:1569
Work or School Absences
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12
10
Days
per Year
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6
4
2
0
IBS
Normal
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Drossman DA, et al., Dig Dis Sci 1993; 38:1569
Beyond the economic costs…
QOL matters too!
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Barriers toward Digestive
Health Promotion
• Medical culture oriented towards cure
– Doctors’ preference vs. patients’ preference
– ER and House vs. “The Preventionist”
• If you cannot avoid an illness, at least catch
it early and prevent it from causing harm.
• Identification of risk factors
• Modification of risk factors early in course
• “Periodic Health Examination”
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Where is Digestive Health
Accomplished?
• Health Provider Level
– learning how to screen effectively
– counseling effectively (integrative health approach)
• Societal Level
– public education
– regulations oriented toward healthy lifestyle
– national prevention guidelines
• Patient Level
– being inquisitive
– taking interest in health
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What is new in Digestive Health
research in 2007?
• Dietary fructose
• Weight Disorders
– CNS role in eating behaviors
– Weight Loss and Longevity
– Doctor-Dietitian Duo
– Gut ecology and Obesity
• Probiotics
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Fructose Malabsorption in
Normal Persons
• Dose-response study from which they
developed a fructose malabsorption
breath test .
• 20 persons got on 4 separate days:
– 10% solution of 15 g, 25 g, or 50g fructose
– 33% solution 50 g fructose
• Analyzed H2 and CH4 over 5 hours
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Rao, S, et al. Clin Gastro and Hepatol 2007.
H2 and CH4 concentration
after intake of different doses of fructose
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Rao, S, et al. Clin Gastro and Hepatol 2007.
Results
• No subject tested (+) with 15 g. No gender differences.
• 10% (+) with 25 g fructose but were asymptomatic.
• 50 g (10% solution)
– 80% (+) breath test
• H2 - 65%
• CH4 in 5%
• Both H2 and CH4 10%
– 55% had symptoms
• 50 g (33% solution)
– 60% (+)
– 45% experienced symptoms.
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Rao, S, et al. Clin Gastro and Hepatol 2007.
Conclusions
• Healthy subjects absorb up to 25 g
• Many exhibit malabsorption and
intolerance with 50 g
• For suspected malabsorption: 25 g
should be test dose, and measure at 30
minute intervals for 3 hours
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Rao, S, et al. Clin Gastro and Hepatol 2007.
Brain Areas Involved in the Regulation of Food Intake
and Schematic Representation of Their Interactions
Alonso-Alonso, M. et al. JAMA 2007;297:1819-1822.
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Mean Percent Weight Change during a 15-Year Period in
the Control Group and the Surgery Group, According to
the Method of Bariatric Surgery
Sjostrom L et al. N Engl J Med 2007;357:741-752
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Unadjusted Cumulative Mortality
Sjostrom L et al. N Engl J Med 2007;357:741-752
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Survival According to BMI in the Surgery Group
and the Control Group
Adams TD et al. N Engl J Med 2007;357:753-761
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Effect of Onsite Dietitian (D) Counseling on
Outpatient Weight Loss and Lipids
in a Physician (MD) Office
• Intro: D sees patients at same visit w/ MD (fully
reimbursable).
• Intervention: D counsels on diet (DASH) + exercise
(30 min/d). One f/u w MD and D.
• Results: Max WL = 5.6%; average WL @ 2.6 years =
5.3%; Δ LDL = - 9%; Δ TG = - 34%; Δ HDL = + 10%; Δ
SBP = - 3 mmHg; Δ DBP = - 4 mmHg.
• Conclusion: concurrent counseling is effective in
achieving & maintaining WL & is reimbursable
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Welty, FK et al. Am J Cardiol 2007;100:73–75
Using Bugs
as Drugs:
How to be a
Probioticist
in 2007
Definitions
Probiotic:
• live microorganisms that when administered in adequate amounts
confer a health benefit on the host
Prebiotic:
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nondigestible food ingredients (e.g. oligasaccharides) that may beneficially
affect the host by selectively stimulating the growth and/or the activity of a
limited number of bacteria in the colon
Synbiotics:
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combination nutritional supplements comprised of probiotics and prebiotics
Neutraceutical:
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Original: food that provided medical or health benefit
Current: dietary supplements that contain a concentrated form of a bioactive
substance originally derived from a food.
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FAO/WHO. Guidelines for the evaluation of probiotics in food. 2002
L. Salvarius
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B. Infantis
Placebo
Composite Likert Score
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4
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2
Treatment Period
0
-2
1
4
8
12
Figure 1. O’Mahony et al. Gastroenterology 2005 (128)541-551.
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300
p=0.001
Pre treatment
Post treatment
IL-10:IL-12 ratio
250
200
150
100
50
0
B. infantis 35624
L. salvarius 4331
Placebo
Healthy
Volunteers
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’
551. (128)541
O” Mahony et al. Gastroenterology 2005
C. Diff
6 Trials
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McFarland, LV. AJG 101 (4), 812-822. 2006.
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Ley et al. Nature. 2006
The case of Mrs. K
• 32 y/o executive with 2 months of
bloating, gas, constipation
• Most likely diagnosis: Bloating
• What do others call this?
• Why do I not label her as IBS? She
fulfills criteria?
• Where do I see her?
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Mrs. K – 32 y/o AAF executive
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Feels “bloated”, gassy, infrequent stools
Lower abdominal cramps
Improved with BM’s (approx 3/week)
Occurs unpredictably, for last 7 months
Lasts for few days, then goes away
No interference w/ daily activities
Worried it might be “something serious”
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Mrs. K: History and Physical
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PMH: “food poisoning” one year ago
PSH: none
MEDS: docusate qd
FH: mother has “minor depression”
SH: married, no T/E/D, unemployment
soon
• Physical exam: normal; BMI = 24
• Labs: Nl. CBC, Chem-10, ESR & CRP
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How are we treating IBS?
STRATEGY 1: Symptom based therapy
Pain
Diarrhea
Bloating
Constipation
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Courtesy of Pimentel, M.
STRATEGY 2: Hypothesis-based
BRAIN-GUT AXIS
SEROTONIN
Agonist/Antagonist
DYSMOTILITY
IBS
ACUTE
GASTROENTERITIS
Salmonella, E. coli,
Campylobacter, …
Courtesy of Pimentel, M.
S
I
B
O
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What Next?
Digestive Health Approach
• Reassurance that its not serious
• Symptom and food diary
• Screen for lactose and fructose
intolerance
• Write a Dietary Rx:
• Diet without flatulogenic foods
• Slowly increase H20 and fiber content
of foods over weeks (dried plums,
apples, etc).
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The Challenge of Digestive
Health:
"Live sensibly —
among a thousand
people, only one
dies a natural death,
the rest succumb to
irrational modes of
living.“
-Maimonides 1135-1204 A.D.
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THE END