Transcript TAKING CONTROL: Keeping Your Gut Happy

TAKING CONTROL:
Keeping Your Gut Happy
Jacqueline Wolf, M.D.
Associate Professor of Medicine
Harvard Medical School
Beth Israel Deaconess Medical Center
What are the issues
of the evening?
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Constipation
Diarrhea
Gas
Colorectal cancer
Top 10 Gut-Related Fears
10. Won’t get to work on time because you can’t
get off the toilet.
9. Can’t finish a bowel movement because the
kids are banging on the door.
8. Can’t eat out because the food will make you
sick.
7. Will have to rush to the bathroom in the middle
of a meal out.
6. Your “stomach growling” will focus all eyes on
you in public.
Top 10 Gut-Related Fears
5. Being unable to find a toilet in time when out
shopping or driving.
4. Being identified by others as the source of loud
or smelly gas.
3. Passing gas or stool when having sex.
2. Having to make daily medication choices
because there‘s not enough money to go
around.
1. Getting colorectal cancer.
What does the gut do?
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Absorbs nutrients and water
Eliminates indigestible substances
Harbors helpful and harmful bacteria
Acts as a barrier to harmful substances
and pathogens
• Contributes to the immune response
• Produces hormones and neurotransmitters
STOMACH
SMALL
INTESTINES
COLON
800-1000cc of fluid
(26-33 ounces)
ILEUM
200cc of fluid
(6-7 ounces)
RECTUM
What is normal gut function?
• Bowel movements 2x/day to 2-3x/week.
• Stool form varies from person to person, but is
usually well formed.
• Gas occurs in everyone. The amount depends on
what you eat.
• Constipation, diarrhea or heartburn can be caused
by various medications, including herbs and overthe-counter preparations.
• Occasional heartburn is common in many people.
What is normal if I’ve had part of my
bowel removed?
• The connection between the colon and small bowel
(ilealcecal valve) has been removed
– Increased number of bowel movements
About 2-4 bowel movements/day
• The colon has been removed and the ileum is connected
to the anus as an ileal pouch-anal anastomosis
About 4-7 bowel movements/day
• The colon has been removed and the ileum is brought to
the skin (ileostomy) with a bag
About 26-33 ounces (800-1000mL) of stool/day
Abnormal Bowel Function
Abnormal bowel function means different
things to different people
– Change in frequency of stool
– Change in consistency
– Change in ease of elimination of stool
– Occurrence of gas, cramping or pain
– A belief that the bowel movements should be
different than they are
The only way to keep your
health is to eat what you don't
want, drink what you don't like,
and do what you'd rather not.
Mark Twain
What does a usual diet lack that can
prevent constipation?
• Sufficient fiber
Most people consume only 10-15
grams of fiber. 25-30 grams is
important for good stool bulk.
• Sufficient water
8-10 eight ounce glasses of water/day
is optimal for proper stool consistency.
I have constipation.
What can I do to help myself?
• Add fiber from food or over-the counter products.
This should be a combination of insoluble fiber
(wheat, bran, rye, grains, vegetables) which
does not dissolve in water and soluble fiber
(pectin, oats, psyllium, guar, some fruits) which
dissolves in water.
• Increase water intake.
• Exercise
• Try elevating the feet about 4-8 inches on phone
books when having a bowel movement
Over-the-Counter Constipation
Remedies
• Fiber supplements
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Psyllium (Metamucil, Konsyl)
Methylcelluose (Citracel)
Guar (Benefiber)
Pectin
Flax seed
Calcium polycarbophil (Fibercon)
Inulin (Fiber choice)
• Lubricant (mineral oil)
• Stool softener (Colace, etc)
More Over-the-Counter Constipation
Remedies
• Suppositories and Enemas
• Laxatives
– Lactulose, cephulac-- indigestable sugar
– Miralax/glycolax--Polyethylene glycol which draws
water into the stool
– Magnesium--(Milk of magnesia, magnesium citrate)
– Senna-- (Senocot, smooth move tea, herbal teas)
– Bisacodyl--(Dulcolax, Correctol)
– Cascara sagrada
These treatments should be used infrequently
unless recommended by your physician
I have diarrhea.
What can I do to help myself?
• For a gut virus, Pepto-Bismol (2 Tablespoons or
tablets every 1/2 hour x 4 hrs) shortens the
period of symptoms.
• Try identifying and eliminating foods that may be
causing diarrhea. Dairy products, coffee, fats,
certain fruits (prunes, apricots), alcohol, artificial
sweeteners, and sources of gluten in patients
with celiac disease are common culprits.
• Stop eating lactose-containing foods for 1-2 wks.
Diarrhea Self-Help (continued)
• For stress-related diarrhea, try loperamide
(Imodium) before an event that frequently
causes the problem or after symptoms start.
• For IBS diarrhea, loperamide and sometimes
Pepto-Bismol or fiber (fibercon) may help.
• For certain conditions, probiotics may help.
CONSULT YOUR PHYSICIAN for bleeding,
severe abdominal pain, other associated
symptoms (such as fever, weight loss, joint pain)
or persistent diarrhea.
I have gas and bloating.
What can I do to help myself?
Gas is often caused because bacteria in the gut
digest the foods that we can’t and release gas in the
process.
• Reduce foods that cause gas (legumes, dairy products,
cabbage radishes, onions, broccoli, cauliflower, cucumbers,
potatoes, prunes apricots, apples, raisins, bananas,
carbonated beverages
• For lactose intolerance--Lactase
• For bean/legume ingestion--Beano
• For general gas
– Simethicone (Gas-ex)
– Enteric coated peppermint capsules (Pepogest)
• Sometimes reducing bread/carbohydrates helps
• Probiotics may help
What are probiotics?
Probiotics are living bacteria contained in foods,
such as yogurt, and in other supplements in the
form of capsules, powder or tablets, thought to
be healthy for the body to increase its defenses
and prevent disease
Probiotics and Gut Health
Intestinal Flora (A Balanced Ecosystem)
Potentially Harmful Bacteria
• Cause diarrhea/constipation
• Cause infections
• Produce toxins
Potentially Helpful Bacteria
Pseudomonas
• Help control and prevent infection
from outside and/or harmful
bacteria on the inside
• Stimulate immune functions
• Aid in digestion and/or absorption
• Make vitamins
Proteus
Staphylococci
Clostridia
Enterococci
E. coli
Lactobacilli
Streptococci
Eubacteria
Bifidobacteria
Bacteroides
From: Gibson GR. J Nutrition 1995; 125:1401-1412.
Probiotics
Probiotics
B. lactis Bb12
Ganeden
Lactobacillus
L. rhamnosus GG
L. casei Shirota
L. casei
L. reuteri
L. johnsonii
L. casei
Are probiotics effective?
NAME
PROBIOTIC
STRAIN
STUDIES AND RESULTS
Dannon Activia
Bifidus regularis
A similar type of bacteria speeds the
stool through the colon in healthy
women
Lactobacillus GG
10 Billion CFUs
Helps prevent diarrhea after antibiotics
Bifidobacterium
infantis 35624
1 Billion CFUs
In women with mild to moderate IBS,
significant improvement in abdominal
pain and discomfort. Relief significant in
diarrhea predominate group. Only 1/10
the recommended dose found to be
effective.
Yogurt
Contains gluten
Culturelle
Gluten free
Align
Gluten free
Are probiotics effective?
NAME
VSL #3
Gluten free
Florastor
Gluten
PROBIOTIC
STRAIN
STUDIES AND RESULTS
B. breve,
B.longum,
B.infantis,
L. acidophilus,
L. paracasei,
L.bulgaricus,
S. thermophilus
450 Billion CFUs
Equal to mesalamine for maintenance
of remission in UC. Better than
placebo for maintenance of remission
in chronic, relapsing pouchitis
Saccharomyces
boulardii
20 Billion CFUs
Treatment of antibiotic associated
diarrhea and prevention of
recurrences of Clostridia difficile
disease
In Crohn’s disease:
Decreased diarrhea versus placebo
Decreased relapse versus
mesalamine.
Colorectal Cancer (CRC)
• The third most common cause of cancer in women and
men (2nd overall)
• Slightly more common in men than women
• Decreasing incidence recently
• Generally starts as benign polyps
• Removing polyps prevents CRC
• In inflammatory bowel disease, cancer is not usually
preceded by polyps but by “dysplasia”
• Many cancers have no symptoms
• CRC can be cured if caught early
The Warning Signs of
Colorectal Cancer
• Change of stools
– new constipation
– narrowed stools
• Weight loss
• Bleeding from the rectum
• Abdominal pain
Probability of Developing Invasive CRC Cancer,
US 2001-2003
Birth39
60-79
70-
Birth to
Death
1 in 1342 1 in 107
1 in 60
1 in 20
1 in 17
Female 1 in 1469 1 in 138
1 in 86
1 in 22
1 in 19
Male
40-59
ACS, Surveillance Research 2007
Do gynecologic cancers increase
the risk for CRC?
• NoCervical cancer does not increase
the risk for CRC
• YesEndometrial cancer diagnosed
before age 50 increases the risk for CRC
• YesOvarian cancer increases the risk for
CRC if diagnosed before age 65 and
especially before age 50
• Probably notBreast cancer
When should I have my first
screening test for colon cancer?
• Average Risk Individuals
– Asymptomatic
– No family history of colon cancer or other
cancers associated with colon cancer
– No personal history of cancers associated
with colon cancer or inflammatory bowel
disease
AGE 50
When should I have my first
screening test for colon cancer?
• Moderate Risk Individuals
– Family History of CRC
• One first-degree relative with colorectal cancer
or adenoma
• Two second degree relatives with colorectal cancer
or adenoma
AGE 40 or
10 years younger than the earliest
age of diagnosis of CRC in one of the
relatives
When should I have my first
screening test for colon cancer?
• High Risk Individuals
– Hereditary nonpolyposis colorectal cancer
Age 20–25 years
– Familial adenomatous polyposis
Beginning at AGE 12 years
– Universal ulcerative colitis or Crohn’s
colitis
AFTER 8–10 years of disease
– Left-sided ulcerative colitis
AFTER 15 years of disease
Factors Affecting the Incidence
of Colorectal Cancer in Women
Increase
Cigarette Smoking
35 years
ObesityBMI29kg/m2
Cholecystectomy
for proximal
cancers
Helicobacter pylori
infection
No change
Decrease
Fiber
Aspirin15-20 years
Vitamin E
Multivitamin 15 years
(? Folate) for colon cancer
Higher calcium intake for
distal colon cancer
Hormone replacement
therapy (early stage
cancer)
Physical activity
Magnesium (colon not
Summary
• Eating the right foods can improve gut health.
• Over-the-counter products are available to
reduce the problems of constipation, diarrhea,
and gas.
• Probiotics have shown benefit for some
conditions, but the studies are very limited. What
type of probiotics might work best for a specific
individual is not known.
• Timely screening and a healthy lifestyle can
reduce the incidence of colorectal cancer.
YOU CAN PLAY AN ACTIVE ROLE IN
IMPROVING YOUR GUT HEALTH !
Acknowledgements
Monique S. Martin
Kirsten Doyle
Marsha L. Steinberg
Siobhan Connolly
QUESTIONS?