Building Demand for  California Dried Plums 2007-2008 Public Relations Recommendations June 28, 2007
Case Study  <ul><li>Mrs. K: 32 y/o AAF executive at her PMD’s office   </li></ul><ul><li>Feels “bloated”, gassy, infrequen...
Case Study continued <ul><li>Mrs. K: History and Physical </li></ul><ul><li>PMH: “food poisoning” one year ago </li></ul><...
DIGESTIVE HEALTH: THE RD’s PERSPECTIVE Leslie Bonci,MPH,RD,LDN,CSSD Director of Sports Nutrition University of Pittsburgh ...
WHAT ARE WE HEARING? <ul><li>Rock hard abs </li></ul><ul><li>Commercials for various GI medications </li></ul><ul><li>Incr...
THE FACTS <ul><li>Eating can be a trigger for gut problems </li></ul><ul><ul><li>Good digestive health is the ability to d...
GETTING TO GOOD DIGESTIVE HEALTH <ul><li>Achieving/maintaining an appropriate weight </li></ul><ul><li>Eating a diet that ...
LIFESTYLE INFLUENCERS <ul><li>Stress </li></ul><ul><li>Irregular schedule </li></ul><ul><li>Travel’s effect on food choice...
BARRIERS <ul><li>Patients are not always forthcoming with symptoms/complaints </li></ul><ul><li>Patients may try to self-t...
TREATING DIGESTIVE DISORDERS WITH DIET <ul><li>Not black and white </li></ul><ul><li>No guarantee that symptoms will abate...
DIETS THAT CAN AFFECT THE GUT <ul><li>High protein/high fat </li></ul><ul><ul><li>Low-carb products </li></ul></ul><ul><li...
SUPPLEMENTS THAT AFFECT THE GUT <ul><li>Vitamin Mineral supplements </li></ul><ul><ul><li>Mega dose Vitamin C  </li></ul><...
OTHER POTENTIAL OFFENDERS <ul><li>Echinacea </li></ul><ul><li>Chitosan </li></ul><ul><li>Dieter’s Tea </li></ul><ul><li>Gl...
THINGS TO KEEP IN MIND <ul><li>There is not ONE eating plan </li></ul><ul><li>Need to customize and individualize eating <...
WHAT TO TELL PATIENTS <ul><li>Make meal times relaxed </li></ul><ul><li>Take time to eat </li></ul><ul><li>Allow time for ...
WHAT SHOULD THEY DO? <ul><li>Keep a food/symptom diary listing : </li></ul><ul><ul><li>Foods eaten </li></ul></ul><ul><ul>...
FOCUS ON FUNCTIONAL FOODS <ul><li>Yogurt- probiotics </li></ul><ul><li>Dried plums- fiber/sorbitol </li></ul><ul><li>Oats-...
TRAVEL GUIDELINES <ul><li>Bottled water on planes </li></ul><ul><li>Travel with “safe” foods- packets of oatmeal, nuts, dr...
GOOD GUT TRAVEL KIT <ul><li>Nausea </li></ul><ul><ul><ul><li>Sports drink  </li></ul></ul></ul><ul><ul><ul><li>Candied gin...
FINAL WORDS <ul><li>The emphasis needs to be on what patients can have- NOT what they can’t!!! </li></ul>
DIET RECOMMENDATIONS FOR MRS K <ul><li>Ask about recent change in diet </li></ul><ul><li>Food diary to ascertain potential...
CONTACT <ul><li>Leslie Bonci, MPH, RD </li></ul><ul><li>Phone (412) 432-3674 </li></ul><ul><li>e-mail:  [email_address] </...
Identifying and Achieving Digestive Health – A Look to the Future <ul><li>Leo Treyzon M.D. </li></ul><ul><li>Divisions of ...
Disclosures <ul><li>NIH Training Grant </li></ul><ul><li>UCLA STAR Program </li></ul><ul><li>Annenberg GI Fellowship Award...
Why is this an important topic? <ul><li>Unpredictable, uncomfortable and embarrassing </li></ul><ul><li>Large economic bur...
Hard to Define <ul><li>I can’t describe it, but… “I know when I see it” </li></ul><ul><ul><li>Justice Stewart, Ohio Suprem...
Defining Digestive Health <ul><li>“ Good digestive health indicates an ability to process nutrients through properly funct...
Definition – Digestive Health <ul><li>Ability to digest, absorb and utilize nutrients  </li></ul><ul><li>Eliminate waste p...
Other Approaches to Health <ul><li>Bio-Medical  – the body as machine; disease oriented </li></ul><ul><li>Behavioral  – he...
Strengths of Digestive Health Approach <ul><li>Individualized to the person </li></ul><ul><li>Creates energy and balance i...
 
Leading GI Symptoms Prompting  U.S. Outpatient Clinic Visits in 2002 Shaheen NJ et al .  Am J Gastroenter  2006. National ...
Physician Diagnoses for GI Disorders in Outpatient Clinic Visits  Shaheen NJ et al .  Am J Gastroenter  2006. National Amb...
Physician Visits per Year  (GI and non-GI) Drossman DA, et al.,  Dig Dis Sci  1993; 38:1569 MD Visits Per Year IBS Normal ...
Drossman DA, et al.,  Dig Dis Sci  1993; 38:1569 Work or School Absences IBS Normal 0 2 4 6 8 10 12 14 Days per Year
Beyond the economic costs… QOL matters too!
Barriers toward Digestive Health Promotion  <ul><li>Medical culture oriented towards cure </li></ul><ul><ul><li>Doctors’ p...
Where is Digestive Health Accomplished? <ul><li>Health Provider Level </li></ul><ul><ul><li>learning how to screen effecti...
What is new in Digestive Health research in  2007? <ul><li>Dietary fructose </li></ul><ul><li>Weight Disorders  </li></ul>...
Fructose Malabsorption in Normal Persons <ul><li>Dose-response study from which they developed a fructose malabsorption br...
H2 and CH4 concentration  after intake of different doses of fructose   Rao, S, et al.  Clin Gastro and Hepatol  2007.
Results <ul><li>No subject tested (+) with 15 g. No gender differences. </li></ul><ul><li>10% (+)  with 25 g fructose but ...
Conclusions <ul><li>Healthy subjects absorb up to 25 g  </li></ul><ul><li>Many exhibit malabsorption and intolerance with ...
Alonso-Alonso, M. et al. JAMA 2007;297:1819-1822. Brain Areas Involved in the Regulation of Food Intake and Schematic Repr...
Mean Percent Weight Change during a 15-Year Period in the Control Group and the Surgery Group, According to the Method of ...
Unadjusted Cumulative Mortality Sjostrom L et al. N Engl J Med 2007;357:741-752
Survival According to BMI in the Surgery Group and the Control Group Adams TD et al. N Engl J Med 2007;357:753-761
Effect of Onsite Dietitian (D) Counseling on Outpatient Weight Loss and Lipids in a Physician (MD) Office <ul><li>Intro : ...
Using Bugs as Drugs: How to be a Probioticist in 2007
Definitions <ul><li>Probiotic : </li></ul><ul><li>live microorganisms that when administered in adequate amounts confer a ...
 
IL - 10:IL - 12 ratio ’ 250 150 50 0 100 200 300 B. infantis 35624 L. salvarius 4331 Placebo Healthy  Volunteers 250 150 5...
C. Diff 6 Trials McFarland, LV.  AJG  101 (4), 812-822. 2006.
 
Ley et al. Nature. 2006
The case of Mrs. K <ul><li>32 y/o executive with 2 months of bloating, gas, constipation </li></ul><ul><li>Most likely dia...
Mrs. K – 32 y/o AAF executive <ul><li>Feels “bloated”, gassy, infrequent stools </li></ul><ul><li>Lower abdominal cramps  ...
Mrs. K: History and Physical <ul><li>PMH: “food poisoning” one year ago </li></ul><ul><li>PSH: none </li></ul><ul><li>MEDS...
How are we treating IBS? STRATEGY 1:  Symptom based therapy Pain Bloating Diarrhea Constipation Courtesy of Pimentel, M.
STRATEGY 2:  Hypothesis-based DYSMOTILITY ACUTE GASTROENTERITIS S I B O SEROTONIN IBS BRAIN-GUT AXIS Salmonella, E. coli, ...
What Next?
Digestive Health Approach <ul><li>Reassurance that its not serious </li></ul><ul><li>Symptom and food diary </li></ul><ul>...
The Challenge of Digestive Health: <ul><li>&quot;Live sensibly — among a thousand people, only one dies a natural death, t...
THE END
Upcoming SlideShare
Loading in …5
×

Breakfast Symposium PowerPoint

567 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
567
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
3
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • No major change in diet Irritable Bowel Syndrome - At least 3 months, with onset at least 6 months previously of recurrent abdominal pain or discomfort** associated with 2 or more of the following: Improvement with defecation; and/or Onset associated with a change in frequency of stool; and/or Onset associated with a change in form (appearance) of stool **Discomfort means an uncomfortable sensation not described as pain.
  • Why is digestive health not talked about? 1. we talk about CV and mental and bone health? 2. Is it not as sexy as to talk about gas and bloating as it is an MI 3. Why did I become a gastroenterologist? The Challenge of Digestive Health: to figure out how to integrate preventive medicine principles in order to achieve rationale modes of living.
  • this information shapes research agendas of government, industry, and private foundations. We could use this information to evaluate and modify priorities and resource allocations of agencies that fund research or pay for health care services. symptoms of poor digestive health, such as heartburn/abdominal pain, diarrhea and constipation can be embarrassing, unpredictable and disruptive to everyday life.
  • Dave Heber challenged me to come up with a definition of digestive health. The other “healths”: CV, women’s, bone, mental The “unsexiness” factor Less mortality, more morbidity The difficulty of defining obscenity was memorably summarized by Justice Stewart in a concurring opinion when he said: &amp;quot;I know it when I see it.&amp;quot;  In 1964, Justice Potter Stewart tried to explain &amp;quot;hard-core&amp;quot; pornography, or what is obscene, by saying, &amp;quot;I shall not today attempt further to define the kinds of material I understand to be embraced . . . [b]ut I know it when I see it . . .”
  • Everyone is different. Normal laxation is different for different people. Cultural norms are important considerations.
  • Digestive Health indicates an ability to digest, absorb and utilize nutrients, and eliminate waste products in a manner that optimizes an individual&apos;s health, vitality, and resilience.  Digestive healthy individuals are of appropriate weight and don&apos;t regularly experience bothersome digestive symptoms such as constipation or heartburn. This state of well-being is achieved by consuming a nutritious diet, minimizing emotional stressors, and utilizing physical activity, all of which are oriented to the prevention of chronic disease. World Health Organization: Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity Successful Aging = optimal state of being
  • The Gastrointestinal System is a Huge Complex: Many organs, so much more complex than the heart for example if you ask me. They all have different fnctions, mostly oriented toward harnessing the richness of foodstuffs. The complexity of the system is probably grossly underappreciated: we have relatively understanding how the brain conducts the symphony of organs.
  • NOTE. Source: a The total number of outpatient visits was estimated from a random sample of 27,369 patient visits to 1388 physicians participating in the National Ambulatory Medical Care Survey 2000. 1 Abdominal pain 789.00–789.09 5,241,850 2 Gastroesophageal reflux disease 530.11, 530.81 4,591,403 3 Gastroenteritis 558.90 3,431,259 4 Gastritis 535.00, 535.40, 535.50 2,400,034 5 Hemorrhoids 455.00–455.90 1,568,274 6 Irritable bowel syndrome 564.10 1,557,133 7 Hernias—noninguinal 551.00–554.90 1,544,000 8 Benign neoplasm of colon 211.30 1,516,086 9 Colorectal cancer 153.90, 154.00, 154.10, V10.05 1,491,134 10 Inguinal hernia 550.00–550.93 1,242,747 11 Diverticulosis of colon 562.10, 562.11 1,072,545 12 Dyspepsia 536.80, 536.90 1,001,114 13 Constipation 564.00 794,047 14 Gallstones 574.00–574.50 778,632 15 Occult gastrointestinal blood loss 792.10 762,527 16 Acute or chronic hepatitis C 070.51, 070.54 756,774 17 Crohn’s disease 555.90 725,157 18 Anal/rectal bleeding 569.30 596,948 19 Ulcerative colitis or proctitis 556.20, 556.90 487,893 20 Gastric or duodenal ulcer 531.00–533.90, V12.71 457,153
  • NOTE. Source: a The total number of outpatient visits was estimated from a random sample of 27,369 patient visits to 1388 physicians participating in the National Ambulatory Medical Care Survey 2000. 1 Abdominal pain 789.00–789.09 5,241,850 2 Gastroesophageal reflux disease 530.11, 530.81 4,591,403 3 Gastroenteritis 558.90 3,431,259 4 Gastritis 535.00, 535.40, 535.50 2,400,034 5 Hemorrhoids 455.00–455.90 1,568,274 6 Irritable bowel syndrome 564.10 1,557,133 7 Hernias—noninguinal 551.00–554.90 1,544,000 8 Benign neoplasm of colon 211.30 1,516,086 9 Colorectal cancer 153.90, 154.00, 154.10, V10.05 1,491,134 10 Inguinal hernia 550.00–550.93 1,242,747 11 Diverticulosis of colon 562.10, 562.11 1,072,545 12 Dyspepsia 536.80, 536.90 1,001,114 13 Constipation 564.00 794,047 14 Gallstones 574.00–574.50 778,632 15 Occult gastrointestinal blood loss 792.10 762,527 16 Acute or chronic hepatitis C 070.51, 070.54 756,774 17 Crohn’s disease 555.90 725,157 18 Anal/rectal bleeding 569.30 596,948 19 Ulcerative colitis or proctitis 556.20, 556.90 487,893 20 Gastric or duodenal ulcer 531.00–533.90, V12.71 457,153
  • Physician Visits per Year U.S. Data - Based on the U.S. Householder study, those with IBS are significantly more likely to see physicians for non-gastrointestinal complaints (3.9 vs 1.7/year; p&lt;0.0001) as well as for gastrointestinal complaints (1.6 vs 0.1/year; p&lt;0.0001). Another population study by Talley et al. found that the odds of incurring medical charges was 1.6 greater for persons with IBS when compared to healthy controls, and the median annual health costs were $742 for vs $429 for others. Drossman DA, Li Z, Andruzzi E, et al. U. S. Householder Survey of Functional Gastrointestinal Disorders: Prevalence. Sociodemography and Health Impact. Dig Dis Sci. 1993; 38:1569-80 Talley NJ, Gabriel SE, Harmsen WS, Zinsmeister AR, Evans RW. Medical costs in community subjects with irritable bowel syndrome. Gastroenterol. 1995; 109:1736-41 .
  • Work and School Absences U.S. Data These data from the U.S. Householder study, compares illness-related work and school absenteeism in the previous year between those with IBS symptoms, and with no bowel symptoms. The IBS group has almost three times more absences (13.4 vs 4.9%; p&lt;0.0001). This study also found that 11.3% of those with IBS, compared to 4.2% of those with no bowel symptoms were too sick to work or go to school. Drossman DA, Li Z, Andruzzi E, et al. U. S. Householder Survey of Functional Gastrointestinal Disorders: Prevalence, Sociodemography, and Health Impact. Dig Dis Sci. 1993; 38:1569-80. (3).
  • Beyond the economic costs, individuals are truly affected by the severity of their digestive symptoms. QOL is extremely important Volume 128 , Issue 5 , Page 1158 (May 2005) Quality of Care in Gastroenterology: Beyond the Bell Curve Robert S. Sandler (Associate Editor) Article Outline • Copyright We are on the brink of what is likely to be a dramatic shift in payment for health care. Increasingly, we will see reimbursement based on delivery of health care that is high in quality. The Institute of Medicine has defined quality as the degree to which the delivery of health care is consistent with practices that have been shown to improve clinical outcomes. As gastroenterologists, we need to begin paying attention to defining quality and implementing quality care in our practices. The idea of quality is not a new one. In 1910, Ernest A. Codman, an orthopedic surgeon and self-described eccentric, promoted the “end results idea,” namely that every hospital should follow every patient long enough to determine whether or not treatment was successful, and then to inquire “if not, why not” with a view to preventing similar failures in the future. He believed that, to improve, hospitals must compare their results with those of other hospitals and must welcome publicity for not only their successes but also their failures. Codman resigned his position at the Massachusetts General Hospital and opened his own hospital that was referred to as the “End Results Hospital,” where results were monitored and published. The hospital was not a financial success and closed. Other medical pioneers emulated Codman. Charles and William Mayo, who, in 1914, established the famous clinic that bears their name, emphasized the importance of health care quality improvement. In a recent interview after his 95th birthday, the legendary Joseph Kirsner, Louis Block Distinguished Service Professor of Medicine at the University of Chicago, described his work as Chief of Staff at the University of Chicago Hospitals and Clinics from 1971–1976. “I required excellence from my colleagues. They had to be on time, they had to be involved, and they had to follow-up on the outcome of the clinical situation.” Donald Berwick, a former pediatrician, has spearheaded the modern quality movement. Berwick has maintained that, to fix medicine, we need to measure ourselves and be more open about what we are doing. Harking back to principles enunciated by Codman a century ago, Berwick has argued that we need to compare the performance of doctors and hospitals and must give the patient access to the data. The thought is that openness will drive improvement. Quality of health care remains remarkably uneven. Robert Brook, Professor of Medicine and Health Services, University of California, Los Angeles, and one of the nation’s most innovative and respected health researchers, has observed that, “thousands of studies have focused on quality of health care throughout the Western world, and virtually all of them have shown that the level of quality of care provided to the average person leaves a great deal to be desired and, perhaps more importantly, that the variation in quality of care by physician or hospital is immense.” This notion of variation was described in a provocative article entitled “The bell curve: what happens when patients find out how good their doctors really are?” in The New Yorker by staff writer and surgeon Atul Gawande. Gawande notes that a plot of outcomes resembles a bell curve, with some providers achieving remarkably good results, some achieving poor results, and most in the “great undistinguished middle.” He argues that we need to identify best practice—those physicians and institutions with outstanding results—and emulate their methods. There has been much talk about paying for quality. The US Congress has discussed the idea, and insurers Aetna and Blue Cross and Blue Shield are introducing it. In the United Kingdom, family physicians have entered into a contract with the government to provide additional payments for high quality. With this step, the UK National Health Service has exceeded anything attempted in the United States, the previous leader in the quality improvement initiative. In 2004, the Institute of Medicine convened the First Annual Crossing the Quality Chasm Summit: A Focus on Communities (National Academies Press, 2004). The organizers hoped that the report of the summit would activate, coordinate, and integrate quality efforts. The report set forth 6 quality aims for health care improvement. The health care system should be: • Safe: avoiding injuries to patients from the care that is intended to help them; • Effective: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit; • Patient centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions; • Timely: reducing waits and occasionally harmful delays for both those who receive and those who give care; • Efficient: avoiding waste, in particular waste of equipment, supplies, ideas, and energy; and • Equitable: providing care that does not vary in quality because of personal characteristics such as sex, ethnicity, geographic location, and socioeconomic status. We have made tremendous advances in the science and technology of medicine. Unfortunately, the science and technology have been applied unevenly and outcomes have been disconcertingly variable. We need to take aggressive steps to reduce variation and to shift the points on the bell curve toward excellence. We need to resist averageness. Our patients deserve nothing less.
  • Most doctors are attracted to medicine because they look forward to curing disease. But all things considered, most patients would prefer never to contract a disease in the first place — or, if they cannot avoid an illness, they prefer that it be caught early and stamped out before it causes them any harm. To accomplish this, procedures are performed on patients without specific complaints, to identify and modify risk factors to avoid the onset of disease, or to find disease early in its course so that by intervening patients can remain well. Such activity is referred to as health maintenance or the periodic health examination.
  • Background &amp; Aims: Fructose consumption is increasing, and its malabsorption causes common GI symptoms. Because its absorption capacity is poorly understood, there is no standard method of assessing fructose absorption. We performed a dose-response study of fructose absorption in healthy subjects to develop a breath test to distinguish normal from abnormal fructose absorption capacity. Methods: In a double-blind study, 20 healthy subjects received 10% solutions of 15, 25, and 50 g of fructose and 33% solution of 50-g fructose on 4 separate days at weekly intervals. Breath samples were assessed for hydrogen (H2) and methane (CH4) during a period of 5 hours, and symptoms were recorded. Results: No subject tested positive with 15 g. Two (10%) tested positive with 25 g fructose but were asymptomatic. Sixteen (80%) tested positive with 50 g (10% solution), and 11 (55%) had symptoms. Breath H2 was elevated in: 13 (65%), CH4 in 1 (5%), and both in 2 (10%). Twelve (60%) tested positive with 50 g (33% solution), and 9 (45%) experienced symptoms. The area under the curve for H2 and CH4 was higher ( P &lt; .01) with 50 g compared with lower doses. There were no gender differences. Conclusions: Healthy subjects have the capacity to absorb up to 25 g fructose, whereas many exhibit malabsorption and intolerance with 50 g fructose. Hence, we recommend 25 g as the dose for testing subjects with suspected fructose malabsorption. Breath samples measured for H2 and CH4 concentration at 30-minute intervals and for 3 hours will detect most subjects with fructose malabsorption.
  • H2 and CH4 concentration (area under the curve in mm3) after ingestion of different doses of fructose (mean +/- standard error of the mean). Background &amp; Aims: Fructose consumption is increasing, and its malabsorption causes common GI symptoms. Because its absorption capacity is poorly understood, there is no standard method of assessing fructose absorption. We performed a dose-response study of fructose absorption in healthy subjects to develop a breath test to distinguish normal from abnormal fructose absorption capacity. Methods: In a double-blind study, 20 healthy subjects received 10% solutions of 15, 25, and 50 g of fructose and 33% solution of 50-g fructose on 4 separate days at weekly intervals. Breath samples were assessed for hydrogen (H2) and methane (CH4) during a period of 5 hours, and symptoms were recorded. Results: No subject tested positive with 15 g. Two (10%) tested positive with 25 g fructose but were asymptomatic. Sixteen (80%) tested positive with 50 g (10% solution), and 11 (55%) had symptoms. Breath H2 was elevated in: 13 (65%), CH4 in 1 (5%), and both in 2 (10%). Twelve (60%) tested positive with 50 g (33% solution), and 9 (45%) experienced symptoms. The area under the curve for H2 and CH4 was higher ( P &lt; .01) with 50 g compared with lower doses. There were no gender differences. Conclusions: Healthy subjects have the capacity to absorb up to 25 g fructose, whereas many exhibit malabsorption and intolerance with 50 g fructose. Hence, we recommend 25 g as the dose for testing subjects with suspected fructose malabsorption. Breath samples measured for H2 and CH4 concentration at 30-minute intervals and for 3 hours will detect most subjects with fructose malabsorption.
  • Background &amp; Aims: Fructose consumption is increasing, and its malabsorption causes common GI symptoms. Because its absorption capacity is poorly understood, there is no standard method of assessing fructose absorption. We performed a dose-response study of fructose absorption in healthy subjects to develop a breath test to distinguish normal from abnormal fructose absorption capacity. Methods: In a double-blind study, 20 healthy subjects received 10% solutions of 15, 25, and 50 g of fructose and 33% solution of 50-g fructose on 4 separate days at weekly intervals. Breath samples were assessed for hydrogen (H2) and methane (CH4) during a period of 5 hours, and symptoms were recorded. Results: No subject tested positive with 15 g. Two (10%) tested positive with 25 g fructose but were asymptomatic. Sixteen (80%) tested positive with 50 g (10% solution), and 11 (55%) had symptoms. Breath H2 was elevated in: 13 (65%), CH4 in 1 (5%), and both in 2 (10%). Twelve (60%) tested positive with 50 g (33% solution), and 9 (45%) experienced symptoms. The area under the curve for H2 and CH4 was higher ( P &lt; .01) with 50 g compared with lower doses. There were no gender differences. Conclusions: Healthy subjects have the capacity to absorb up to 25 g fructose, whereas many exhibit malabsorption and intolerance with 50 g fructose. Hence, we recommend 25 g as the dose for testing subjects with suspected fructose malabsorption. Breath samples measured for H2 and CH4 concentration at 30-minute intervals and for 3 hours will detect most subjects with fructose malabsorption.
  • Figure. Brain Areas Involved in the Regulation of Food Intake and Schematic Representation of Their Interactions in the Proposed Model The regulation of food intake in humans involves 3 hierarchical levels of control: cognition, homeostasis, and reward. Information on nutritional status is transmitted from the periphery to lower brain centers by neural and humoral signals. Indirect evidence suggests that peripheral mediators may also act on the cerebral cortex (dotted line). Extensive interconnectivity between these regulatory pathways allows precise and integrated control of food intake according to internal and external factors. These interactions are complex and may be inhibitory or facilitatory. Homeostatic and reward circuits (reflexive eating mode) tend to favor food intake. Brain areas involved in cognition (reflective eating mode), especially the right prefrontal cortex (PFC), tend to decrease food intake. Under normal circumstances, reflective areas can override and suppress reflexive areas (thick arrows). When activity of the right PFC is diminished, however, cognitive control of food intake decreases, favoring obesogenic habits.
  • The prospective, controlled Swedish Obese Subjects study enrolled 4047 subjects who either underwent bariatric surgery or received conventional treatment The results of follow-up for up to 15 years suggest that bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality Figure 1. Mean Percent Weight Change during a 15-Year Period in the Control Group and the Surgery Group, According to the Method of Bariatric Surgery. I bars denote 95% confidence intervals. Figure 2. Unadjusted Cumulative Mortality. The hazard ratio for subjects who underwent bariatric surgery, as compared with control subjects, was 0.76 (95% confidence interval, 0.59 to 0.99; P=0.04), with 129 deaths in the control group and 101 in the surgery group. Bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality In this issue of the Journal, two articles — by Sjöström et al.1 and Adams et al.2 — may provide the missing link between intentional weight loss and lives saved for obese patients. For the past two decades, we have been living through an epidemic of obesity.3,4 The prevalence of obesity has more than doubled in adults and has risen by a factor of more than 3 in children. This escalation in obesity is a time bomb for the future risk of diabetes and other illnesses and for the attendant costs.5 With the increasing use of surgery to treat massively overweight patients in the 1980s, the National Institutes of Health (NIH) convened a Consensus Conference, which proposed that bariatric surgery should be considered for persons with a body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) of more than 40 or of more than 35 in patients with coexisting illnesses.6 The conference group also concluded that bariatric surgery was appropriate only if other forms of treatment had failed. These opinions have been the primary guidelines for surgical intervention since they were published in 1991.6 The results of the studies by Sjöström et al. and Adams et al. may be taken to suggest that these criteria need to be reexamined. The National Heart, Lung, and Blood Institute3 and the World Health Organization4 document that weight loss reduces many of the risk factors for increased death and disease that so often accompany obesity. After weight loss, incident type 2 diabetes in persons with prediabetic conditions is reduced, hypertension and dyslipidemia can be treated or controlled more easily, the quantity of visceral fat decreases, and the quality of life improves. What has been missing from the equation is a demonstration that improvement in these risk factors translates into a longer life. Although we know that being overweight shortens life expectancy, some epidemiologic studies have suggested that weight loss may even worsen life expectancy. However, these studies are confounded by an inability to determine whether weight loss was intentional or unintentional — and we have known for more than 2500 years that unintentional weight loss is often ominous. Therefore, the studies by Sjöström et al. and Adams et al. showing that weight loss lowers the rate of death are most welcome. Two earlier studies by Flum and Dellinger7 and by Christou et al.8 using cross-sectional methods suggested that bariatric surgery improved long-term survival. Sjöström and Adams and their colleagues address this issue differently. Sjöström et al. conducted a prospective, controlled study of bariatric surgery, called the Swedish Obese Subjects (SOS) study, in which overweight patients wishing surgery were matched with equally obese patients not desiring surgery (Table 1). Men with a BMI of 34 or more and women with BMI of 38 or more were eligible, although these values were below those eventually recommended by guidelines of the NIH’s Consensus Conference. At 10 years, weight losses ranged from 14 to 25% among subjects who had undergone one of three surgical procedures, as compared with roughly 2% among control subjects. In the surgery group, there was a significant reduction in the adjusted hazard ratio for death (29%) after an average follow-up of 10.9 years, with a 99.9% ascertainment rate. Adams et al. conducted a retrospective cohort study with controls obtained from driver’s license records that were matched to patients who had undergone gastric-bypass surgery. In this study, deaths from all causes were reduced by 40%, from diabetes by 92%, from coronary artery disease by 56%, and from cancer by 60%. Surprisingly, deaths in the first year were essentially the same in the surgery group and the control group, a finding that contrasts with that of Sjöström et al., who reported that early deaths (defined as occurring within 90 days after surgery) were higher in the surgery group (Table 1). This difference needs further exploration. The reduction of mortality from diabetes and cancer are particularly noteworthy. Several caveats are needed. During the period in which these two studies were carried out, laparoscopic techniques largely replaced open operative techniques, allowing for a more rapid postoperative recovery, less surgical stress, and reduced mortality. Thus, future death rates associated with bariatric surgery should be lower than those reported by either Sjöström et al. or Adams et al. The lowest surgical mortality is seen among surgeons who have performed more than 50 operations and preferably more than 100 operations. This would suggest that the centers doing these procedures should provide optimal training and maintain health care facilities specifically for overweight patients. As noted above, obesity is a strong predictor for the risk of diabetes. Weight loss in patients with prediabetic conditions will delay or prevent the development of diabetes.9 A clinical trial involving patients with diabetes, called Look AHEAD (Action for Health in Diabetes; ClinicalTrials.gov number, NCT00017953), is testing whether weight loss by nonsurgical means can reduce mortality.10 We now have data to show that bariatric surgery reduces the risk of diabetes. In a 2004 study, Sjöström et al.11 reported a graded reduction in the incidence of diabetes after bariatric surgery. In patients who lost more than 12% of their body weight, diabetes did not develop during a 2-year period. Pories et al.12 suggested that bariatric surgery may be one of the best procedures for treating type 2 diabetes. A recent study by O’Brien et al.13 showed that weight loss after the laparoscopic insertion of an inflatable gastric band was more durable than that after nonsurgical treatment and that the rate of diabetes was reduced. However, the patients in that study had BMIs ranging from 30.0 to 34.9, which is below the NIH’s guidelines.6 Has the time come to reconsider BMI guidelines for bariatric surgery? In addition to the improvement in the risk of diabetes, the reduction in deaths from cancer2 may also argue in this direction. Sjöström et al. and Adams et al. show that weight loss saves lives in obese patients. Thus, the question as to whether intentional weight loss improves life span has been answered, and the answer appears to be a resounding yes. Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357:741-52. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med 2007;357:753-61. National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults — the evidence report. Obes Res 1998;6:Suppl 2: 51S-209S. [Erratum, Obes Res 1998;6:464.] Obesity: preventing and managing the global epidemic: report of a WHO consultation. World Health Organ Tech Rep Ser 2000;894:1-253. Bray GA. Obesity: a time bomb to be defused. Lancet 1998; 352:160-1. Consensus Development Conference Panel. NIH conference: gastrointestinal surgery for severe obesity. Ann Intern Med 1991;115:956-61. Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: a population-based analysis. J Am Coll Surg 2004; 199:543-51. Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg 2004;240:416-23. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403. Ryan DH, Espeland MA, Foster GD, et al. Look AHEAD (Action for Health in Diabetes): design and methods for a clinical trial of weight loss for the prevention of cardiovascular disease in type 2 diabetes. Control Clin Trials 2003;24: 610-28. Sjöström L, Londroos A-K, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351:2683-93. Pories WJ, MacDonald KG, Flickinger EG, et al. Is type II diabetes mellitus (NIDDM) a surgical disease? Ann Surg 1992; 215:633-42. O’Brien PE, Dixon JB, Laurie C, et al. Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: a randomized trial. Ann Intern Med 2006;144:625-33.
  • Figure 2. Unadjusted Cumulative Mortality. The hazard ratio for subjects who underwent bariatric surgery, as compared with control subjects, was 0.76 (95% confidence interval, 0.59 to 0.99; P=0.04), with 129 deaths in the control group and 101 in the surgery group. The prospective, controlled Swedish Obese Subjects study enrolled 4047 subjects who either underwent bariatric surgery or received conventional treatment The results of follow-up for up to 15 years suggest that bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality Bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality
  • Figure 2. Survival According to BMI in the Surgery Group and the Control Group. The body-mass index (BMI) is the weight in kilograms divided by the square of the height in meters. This study examined long-term total mortality after gastric bypass surgery in severely obese subjects, as compared with severely obese controls who did not have surgery Mortality was significantly reduced in subjects in the surgery group, particularly death from diabetes, heart disease, and cancer However, the risk of non-disease-related death (including accidents and suicide) was higher in the surgery group than in the control group Gastric bypass surgery appears to reduce long-term mortality in severely obese patients CONCLUSION : Long-term total mortality after gastric bypass surgery was significantly reduced, particularly deaths from diabetes, heart disease, and cancer However, the rate of death from causes other than disease was higher in the surgery group than in the control group
  • Effect of Onsite Dietitian Counseling on Weight Loss and Lipid Levels in an Outpatient Physician Office Francine K. Welty, MD, PhD*, Melita M. Nasca, PhD, Natalie S. Lew, BA, Sue Gregoire, MSN, and Yuheng Ruan, MD We examined the effect of an outpatient office-based diet and exercise counseling program on weight loss and lipid levels with an onsite dietitian who sees patients at the same visit with the physician and is fully reimbursable. Eighty overweight or obese patients (average age 55 12 years, baseline body mass index 30.1 6.4 kg/m2) with &gt; 1 cardiovascular risk factor (86%) or coronary heart disease (14%) were counseled to exercise 30 minutes/day and eat a modified Dietary Approaches to Stop Hypertension (DASH) diet (saturated fat &lt;7%, polyunsaturated fat to 10%, monounsaturated fat to 18%, low in glycemic index and sodium and high in fiber, low-fat dairy products, fruits, and vegetables). Weight, body mass index, lipid levels, and blood pressure were measured at 1 concurrent follow-up visit with the dietitian and physician and &gt; 1 additional follow-up with the physician. Maximum weight lost was an average of 5.6% (10.8 lb) at a mean follow-up of 1.75 years. Sixty-four (81%) of these patients maintained significant weight loss (average weight loss 5.3%) at a mean follow-up of 2.6 years. Average decrease in low-density lipoprotein cholesterol was 9.3%, average decrease in triglycerides was 34%, and average increase in high-density lipoprotein cholesterol was 9.6%. Systolic blood pressure was lowered from 129 to 126 mm Hg (p 0.21) and diastolic blood pressure from 79 to 75 mm Hg (p 0.003). In conclusion, having a dietitian counsel patients concurrently with a physician in the outpatient setting is effective in achieving and maintaining weight loss and is fully reimbursable. © 2007 Elsevier Inc. All rights reserved. (Am J Cardiol 2007;100:73–75)
  • Large Proportion of Americans experiment with CAM. Allopathic practitioners often dismiss CAM b/c of a belief that there is no sound scientific evidence that established utility Not widely appreciated, there are thousands of RCT in CAM that, after excluding prayer, more than a third of Americans have used one or more of these interventions.1 May 10, 2007The Daily Breeze reports that localite Bryan Williams (no relation) has sued Pinkberry and its founder Hwekyung &amp;quot;Shelly&amp;quot; Hwang for passing off the tasty treat as yogurt when in fact it&apos;s nothing of the sort. According to Williams&apos; suit, the Pinkberry dessert is nothing more than a powder-based product mixed with water or milk that is &amp;quot;sold in this adulterated state without notice to consumers of its ingredients.&amp;quot; Pinkberry is marketed as frozen yogurt &amp;quot;to deceive the public and to profit from that deception,&amp;quot; the suit states. The suit requests that Pinkberry stop marketing its product as frozen yogurt. Pinkberry may also be required to pay a fine if found guilty of passing off non-yo as fro-yo. · Lawsuit alleges trendy Pinkberry product isn&apos;t actually frozen yogurt [Daily Breeze] &amp;quot;32-year-old Korean woman whose small business has become successful beyond all reasonable expectations.&amp;quot; A large proportion of the American population avails itself of a variety of complementary and alternative medicine (CAM) interventions. Allopathic practitioners often dismiss CAM because of distrust or a belief that there is no sound scientific evidence that has established its utility. However, although not widely appreciated, there are thousands of randomized controlled trials (RCTs) that have addressed the efficacy of CAM. Allopathic medical practitioners base their advice and interventions on what they believe to be sound laboratory and clinical science. Many of them dismiss complementary and alternative medicine (CAM), believing that those practitioners are charlatans and/or that there is inadequate scientific evidence. However, CAM practices are becoming more widely used; a recent survey of a representative US population indicated that, after excluding prayer, more than a third of the respondents have used one or more of these interventions.1 1. Barnes P, Powell-Griner E, McFann K, Nahin R. Complementary and alternative medicine use among adults: United States, 2002. Advance data from vital and health statistics: no. 343. Hyattsville, MD: National Center for Health Statistics, 2004. Although the randomization process removes many of the confounding differences between study and control arms, conclusions from RCTs can be influenced by a number of methodologic shortcomings. These include type I or type II errors, randomization breakdown, the use of surrogate end points, defective randomization allocation or concealment (eg, quasirandomization), failure to account for all subjects, publication bias, and lack of blinding. RCTs in which investigators have used careful methodologic rigor (studies with “high quality”) usually find lower estimates of the treatment effect.4 CAM primarily focuses on symptoms, so RCTs of CAM usually measure subjective outcomes. Blinding usually needs to be an essential component of the study design.
  • Literal definition – good for life Accepted definition Joint FAO/WHO Working Group Report on Drafting Guidelines for the Evaluation of Probiotics in Food London, Ontario, Canada, April 30 and May 1, 2002 . 8 4. Recommendations 1. Adoption of the definition of probiotics as ‘Live microorganisms which when administered in adequate amounts confer a health benefit on the host’. Prebiotics are a category of functional food , defined as: Non-digestible food ingredients that beneficially affect the host by selectively stimulating the growth and/or activity of one or a limited number of bacteria in the colon, and thus improve host health . [1] Most potential prebiotics are carbohydrates (such as oligosaccharides ), but the definition does not exclude the use of non-carbohydrates as prebiotics. The definition does not emphasize a specific bacterial group. Often, however, it is assumed that a prebiotic should increase the number and/or activity of bifidobacteria and lactic acid bacteria , as these groups of bacteria are claimed to have several beneficial effects on the host. A product that stimulates (or claims to stimulate) bifidobacteria is considered a bifidogenic factor. Some prebiotics may thus also act as a bifidogenic factor and vice versa, but the two concepts are not identical. [2] Typical dietary sources of prebiotics are soybeans , Jerusalem artichokes (which contain inulin ), raw oats , unrefined wheat and unrefined barley . Some of the oligosaccharides that naturally occur in breast milk are believed to play an important role in the development of a healthy immune system in infants, but these are not consiedred prebiotics, as they do not act through the intestinal microflora. Prebiotic oligosaccharides may be added to processed foods . Some prebiotics that are used in this manner are fructooligosaccharides (FOS), xylooligosaccharides (XOS), and galactooligosaccharides (GOS). In petfood also Manno-olligosaccharides are being used. Fermentation: a process in which an agent causes an organic substance to break down into simpler substances; especially, the anaerobic breakdown of sugar into alcohol Treyzon definition Probiotics is a term that means “for life” and defined as “live microorganisms that beneficially affect the host by improving the balance of the intestinal microflora”. It is commonly used to refer to “good” bacteria that one has to have in the body in order to maintain a healthy immune system. There are over 400 different known species of bacteria that inhabit the normal bowel -- excluding viruses, yeasts, and parasites. To put it another way, there are 20 times more bacteria in the body than there are cells AND more than the total number of people that ever lived on Earth. Therefore, having the right kind of bacteria in the gut is very important since the intestinal tract is home to some 100 trillion microorganisms, but only a few of them are friendly. DEFINING PROBIOTICS Probiotics are defined as “live microorganisms that when administered in adequate amounts confer a health benefit on the host” (1). It is believed by many that the ideal probiotic should remain viable at the level of the intestine and should adhere to the intestinal epithelium to confer a significant health benefit. Some evidence supports the importance of viability in human studies, with viable bacteria having greater immunologic effects than nonviable bacteria and killed bacteria being associated with adverse effects in some instances (2, 3). Some of the best characterized probiotics have also been shown to adhere strongly to intestinal epithelium in both in vitro and in vivo studies (4). Probiotics must also be resistant to gastric acid digestion and to bile salts to reach the intestinal intact, and they should be nonpathogenic. Most probiotics are strains of Bifidobacterium or Lactobacillus species. Some are derived from the intestinal microbiota of healthy humans, and others are nonhuman strains used in the fermentation of dairy products. Species from other bacterial genera such as Streptococcus, Bacillus , and Enterococcus have also been used as probiotics, but there are concerns surrounding the safety of such probiotics because these genera contain many pathogenic species, particularly Enterococcus (1). Nonbacterial microorganisms such as yeasts from the genus Saccharomyces have also been used as probiotics for many years. - From Safety Peper Boyle Robins Kang History Probiotics was first conceptualized by the Russian Nobel Prize winner and father of modern immunology, Elie Metchnikoff, at the beginning of the 20th century. He believed that the fermenting bacteria in milk products consumed by Bulgarian peasants were responsible for their longevity and good health. Recent research is now catching up with what he already knew. The actual word was first used by Lilly and Stillwell in 1965 as a contrast to the word “antibiotics”. By the 1970s, “probiotics” was being used in the sense that we know it today. The use of live microorganisms in the diet has a long history and is one of the oldest methods for producing and preserving food. Soured milks and such cultured dairy products as kefir, koumiss, leben, and dahi were often used therapeutically before the existence of microorganisms was recognized. Such dairy products are mentioned in the Bible and the sacred books of Hinduism. Nutraceuticals The term ‘nutraceutical’ initially arose by combining ‘nutrition’ and ‘pharmaceutical’, and was defined as a food or part of a food that provided medical or health benefits. The concept has evolved and now generally refers to dietary supplements that contain a concentrated form of a bioactive substance originally derived from a food [3]. These supplements tend to deliver the bioactive compounds in isolation and in dosages that exceed what could be naturally obtained from foods. However, attempts to purify and study bioactive compounds in isolation to identify modes of action has led in many instances to disappointing, and sometimes opposite, effects to what might have been expected from studies of whole plant extracts. It would appear that in many situations the efficacy of a combination of plant phytochemicals far exceeds the sum of the isolated plant components.
  • Figure 1. Comparison of the effects of placebo, L. salivarius UCC4331 and B. infantis 35624 on a composite score of IBS symptoms.
  • Figure 5. Comparison of PBMC IL-10/IL-12 ratios at baseline and following therapy with placebo, L. salivarius UCC4331 and B. infantis 35624 with that of a normal control period.
  • McFarland, Lynne V. Meta-Analysis of Probiotics for the Prevention of Antibiotic Associated Diarrhea and the Treatment of Clostridium difficile Disease. The American Journal of Gastroenterology   101  (4), 812-822. Forest Plot of six randomized controlled trials of probiotics for the treatment of Clostridium difficile disease showing crude and pooled risk ratios. SB = Saccharomyces boulardii ; LGG = Lactobacillus rhamnosus GG; LP = Lactobacillus plantarum 299v; LA = Lactobacillus acidophilus ; BB = Bifidobacterium bifidum.
  • Even Obesity is beginning to be seen as a Brain-Gut disorder with a peripheral inflammatory component , involving alterations in the intestinal flora and possibly altered signaling of these microorganisms to epithelial cells and neurons within the gut wall. Gordon and Ruth Ley, a member of his lab, compared the gut bacteria of fat and skinny mice by testing mice that had a gene for obesity -- and their siblings that lacked the gene. It turned out that the obese mice had a smaller proportion of a kind of bacteria known as Bacteroidetes. Next, Ley looked at twelve obese people. The results, she says, were &amp;quot;just like the mice.&amp;quot; And as the 12 people lost weight over a year, their gut populations changed, becoming more and more like those in skinny mice. The issue, then was to determine which came first: the fat, or the bacteria. To find out, the lab took mice that had never been exposed to any bacteria, whose guts were totally germ-free. Half of them got bacteria taken from skinny mice. The other half got bacteria from fat mice. Both groups put on body fat. But the mice that received bacteria from obese donors gained more fat over the course of the experiment.
  • compared the gut bacteria of fat and skinny mice by testing mice that had a gene for obesity -- and their siblings that lacked the gene. obese mice had a smaller proportion of a kind of bacteria known as Bacteroidetes. They had relatively more fermicutes Next, Ley looked at twelve obese people. results were &amp;quot;just like the mice.&amp;quot; And as the 12 people lost weight over a year, their gut populations changed, becoming more and more like those in skinny mice. which came first: the fat, or the bacteria. To find out, the lab took mice that had never been exposed to any bacteria, whose guts were totally germ-free. Half of them got bacteria taken from skinny mice. The other half got bacteria from fat mice. Both groups put on body fat. But the mice that received bacteria from obese donors gained more fat over the course of the experiment.
  • Why do I not label her as IBS: Sometimes I am wrong It sets of alarms: “ I have a syndrome” Raises insurance premiums Focus on illness, as opposed to health See her in a multi-disciplinary digestive health clinic Irritable Bowel Syndrome - At least 3 months, with onset at least 6 months previously of recurrent abdominal pain or discomfort** associated with 2 or more of the following: Improvement with defecation; and/or Onset associated with a change in frequency of stool; and/or Onset associated with a change in form (appearance) of stool **Discomfort means an uncomfortable sensation not described as pain.
  • Bloating is cardinal symptom of IBS Unpredictability is next most important symptom. Chronic No weight loss Mild case, and very common, good QOL Seeking reassurance Very common case Focus on Health and Wellness Focus on individualized nature of symptoms Irritable Bowel Syndrome - At least 3 months, with onset at least 6 months previously of recurrent abdominal pain or discomfort** associated with 2 or more of the following: Improvement with defecation; and/or Onset associated with a change in frequency of stool; and/or Onset associated with a change in form (appearance) of stool **Discomfort means an uncomfortable sensation not described as pain.
  • Sounds like post infectious IBS: The ones that got N/V syndrome develop non-ulcer dyspepsia The ones that got diarrhea develop IBS Docusate does not seem to help; would encourage to come of ; strength of evidence Grade b (insufficient) Unemployment soon (try not to giver her a pre-existing condition) for no reason Compliment her on her great weight! Do I need labs? Not really; but they make me feel good that she is not sick
  • Wide spectrum of “normal” bowel habits What is gas and what are gas syndromes Concern for cancer Flatulogenic foods include healthy foods like cruciferous vegetables, legumes, carbonated beverages.
  • With progress in the science of prevention, current recommendations on health maintenance are quite different from those of the past. The challenge on us today is to figure out how to integrate preventive medicine principles and findings in order to achieve rationale modes of living.
  • Breakfast Symposium PowerPoint

    1. 1. Building Demand for California Dried Plums 2007-2008 Public Relations Recommendations June 28, 2007
    2. 2. Case Study <ul><li>Mrs. K: 32 y/o AAF executive at her PMD’s office </li></ul><ul><li>Feels “bloated”, gassy, infrequent stools </li></ul><ul><li>Lower abdominal cramps </li></ul><ul><li>Improved with BM’s (approx 3/week) </li></ul><ul><li>Occurs unpredictably, for last 7 months </li></ul><ul><li>Lasts for few days, then goes away </li></ul><ul><li>No interference w/ daily activities </li></ul><ul><li>Worried it might be “something serious” </li></ul>
    3. 3. Case Study continued <ul><li>Mrs. K: History and Physical </li></ul><ul><li>PMH: “food poisoning” one year ago </li></ul><ul><li>PSH: none </li></ul><ul><li>MEDS: colace qd </li></ul><ul><li>FH: mother has “minor depression” </li></ul><ul><li>SH: married, highly active, no T/E/D </li></ul><ul><li>Physical exam: normal; BMI = 24 </li></ul><ul><li>Labs: no anemia, ESR & CRP normal </li></ul>
    4. 4. DIGESTIVE HEALTH: THE RD’s PERSPECTIVE Leslie Bonci,MPH,RD,LDN,CSSD Director of Sports Nutrition University of Pittsburgh Medical Center
    5. 5. WHAT ARE WE HEARING? <ul><li>Rock hard abs </li></ul><ul><li>Commercials for various GI medications </li></ul><ul><li>Increased product availability- OTC/supplements </li></ul><ul><li>Diarrhea/Constipation are dinner table conversation </li></ul><ul><li>Detox </li></ul><ul><li>Colon cleansing </li></ul>
    6. 6. THE FACTS <ul><li>Eating can be a trigger for gut problems </li></ul><ul><ul><li>Good digestive health is the ability to digest, absorb and utilize nutrients </li></ul></ul><ul><li>It is not just about the food, but also the eating habits: </li></ul><ul><ul><li>Timing </li></ul></ul><ul><ul><li>Quantity </li></ul></ul><ul><ul><li>Where one eats </li></ul></ul><ul><ul><li>How one eats </li></ul></ul>
    7. 7. GETTING TO GOOD DIGESTIVE HEALTH <ul><li>Achieving/maintaining an appropriate weight </li></ul><ul><li>Eating a diet that is balanced, varied, and individualized to address digestive concerns </li></ul><ul><li>Stress reduction </li></ul><ul><li>Physical activity </li></ul>
    8. 8. LIFESTYLE INFLUENCERS <ul><li>Stress </li></ul><ul><li>Irregular schedule </li></ul><ul><li>Travel’s effect on food choices </li></ul><ul><li>Busy lives </li></ul>
    9. 9. BARRIERS <ul><li>Patients are not always forthcoming with symptoms/complaints </li></ul><ul><li>Patients may try to self-treat </li></ul><ul><li>Power of suggestion </li></ul><ul><li>Sensitive subject </li></ul><ul><li>Food safety concerns </li></ul>
    10. 10. TREATING DIGESTIVE DISORDERS WITH DIET <ul><li>Not black and white </li></ul><ul><li>No guarantee that symptoms will abate </li></ul><ul><li>May have to experiment over several months </li></ul><ul><li>Outcomes may be more subjective than objective </li></ul>
    11. 11. DIETS THAT CAN AFFECT THE GUT <ul><li>High protein/high fat </li></ul><ul><ul><li>Low-carb products </li></ul></ul><ul><li>High carbohydrate </li></ul><ul><ul><li>High fiber </li></ul></ul><ul><li>Fad diets </li></ul><ul><ul><li>Cabbage soup/food combining </li></ul></ul>
    12. 12. SUPPLEMENTS THAT AFFECT THE GUT <ul><li>Vitamin Mineral supplements </li></ul><ul><ul><li>Mega dose Vitamin C </li></ul></ul><ul><ul><li>Potassium supplements </li></ul></ul><ul><ul><li>Calcium </li></ul></ul><ul><ul><li>Iron supplements </li></ul></ul><ul><ul><li>Large doses of Magnesium </li></ul></ul><ul><li>“Energy” Drinks </li></ul><ul><li>Flaxseed/Flaxseed oil </li></ul>
    13. 13. OTHER POTENTIAL OFFENDERS <ul><li>Echinacea </li></ul><ul><li>Chitosan </li></ul><ul><li>Dieter’s Tea </li></ul><ul><li>Glucosamine </li></ul><ul><li>Fish oil capsules </li></ul>
    14. 14. THINGS TO KEEP IN MIND <ul><li>There is not ONE eating plan </li></ul><ul><li>Need to customize and individualize eating </li></ul><ul><li>Need to make changes gradually </li></ul><ul><li>Need to monitor eating to discover potential food and habit stressors, as well as foods that are well tolerated </li></ul>
    15. 15. WHAT TO TELL PATIENTS <ul><li>Make meal times relaxed </li></ul><ul><li>Take time to eat </li></ul><ul><li>Allow time for food to digest </li></ul><ul><li>Eat at regular intervals </li></ul><ul><li>Eat smaller amounts at any given eating episode </li></ul><ul><li>Take small bites </li></ul><ul><li>Focus on eating, not everything else </li></ul>
    16. 16. WHAT SHOULD THEY DO? <ul><li>Keep a food/symptom diary listing : </li></ul><ul><ul><li>Foods eaten </li></ul></ul><ul><ul><li>Quantity </li></ul></ul><ul><ul><li>Time consumed </li></ul></ul><ul><li>Document outcomes: </li></ul><ul><ul><li>Symptom relief </li></ul></ul><ul><ul><li>Decrease in symptom frequency </li></ul></ul><ul><ul><li>Better sleep patterns </li></ul></ul><ul><ul><li>Improved energy </li></ul></ul><ul><ul><li>Different bowel patterns </li></ul></ul>
    17. 17. FOCUS ON FUNCTIONAL FOODS <ul><li>Yogurt- probiotics </li></ul><ul><li>Dried plums- fiber/sorbitol </li></ul><ul><li>Oats- beta-glucan,prebiotics </li></ul><ul><li>Orange juice, eggs, peanut butter, spreads- Omega-3 enhanced foods </li></ul>
    18. 18. TRAVEL GUIDELINES <ul><li>Bottled water on planes </li></ul><ul><li>Travel with “safe” foods- packets of oatmeal, nuts, dried fruits </li></ul><ul><li>www.cdc.gov/travel </li></ul><ul><li>List of food concerns if traveling to other countries </li></ul><ul><li>Travel with bouillon cubes , sports drink powder </li></ul><ul><li>Wash hands frequently, or use wipes </li></ul>
    19. 19. GOOD GUT TRAVEL KIT <ul><li>Nausea </li></ul><ul><ul><ul><li>Sports drink </li></ul></ul></ul><ul><ul><ul><li>Candied gingerroot </li></ul></ul></ul><ul><li>Constipation </li></ul><ul><ul><ul><li>Ground flaxseed </li></ul></ul></ul><ul><ul><ul><li>Dried plums/fig bars </li></ul></ul></ul><ul><li>IBS/Abdominal cramps </li></ul><ul><ul><ul><li>Chamomile tea </li></ul></ul></ul><ul><li>Diarrhea </li></ul><ul><ul><ul><li>Raspberry tea/Blackberry root bark tea </li></ul></ul></ul><ul><ul><ul><li>Sure-Jel or Certo </li></ul></ul></ul><ul><ul><ul><li>Carob powder </li></ul></ul></ul>
    20. 20. FINAL WORDS <ul><li>The emphasis needs to be on what patients can have- NOT what they can’t!!! </li></ul>
    21. 21. DIET RECOMMENDATIONS FOR MRS K <ul><li>Ask about recent change in diet </li></ul><ul><li>Food diary to ascertain potential offenders: bloat and gas causing foods/beverages </li></ul><ul><li>Discuss food habits- eating on the go, or sitting down to meals </li></ul><ul><li>Ask about supplement use </li></ul><ul><li>Ask about exercise routine </li></ul><ul><li>Discuss ways to GRADUALLY add fiber to the diet, along with adequate fluids </li></ul>
    22. 22. CONTACT <ul><li>Leslie Bonci, MPH, RD </li></ul><ul><li>Phone (412) 432-3674 </li></ul><ul><li>e-mail: [email_address] </li></ul><ul><li>American Dietetic Association’s Guide to Better Digestion! </li></ul>
    23. 23. Identifying and Achieving Digestive Health – A Look to the Future <ul><li>Leo Treyzon M.D. </li></ul><ul><li>Divisions of </li></ul><ul><li>Digestive Diseases & </li></ul><ul><li>Clinical Nutrition </li></ul><ul><li>David Geffen School of Medicine at UCLA </li></ul>
    24. 24. Disclosures <ul><li>NIH Training Grant </li></ul><ul><li>UCLA STAR Program </li></ul><ul><li>Annenberg GI Fellowship Award </li></ul><ul><li>UCLA Center for Human Nutrition </li></ul><ul><li>Digestive Health Organization and CDPB </li></ul>
    25. 25. Why is this an important topic? <ul><li>Unpredictable, uncomfortable and embarrassing </li></ul><ul><li>Large economic burden </li></ul><ul><li>Next frontier in health care is prevention </li></ul>
    26. 26. Hard to Define <ul><li>I can’t describe it, but… “I know when I see it” </li></ul><ul><ul><li>Justice Stewart, Ohio Supreme Court </li></ul></ul>Jacobellis v. Ohio, 378 U.S. 184, 197 (1964)
    27. 27. Defining Digestive Health <ul><li>“ 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.” </li></ul>American Gastroenterology Association
    28. 28. Definition – Digestive Health <ul><li>Ability to digest, absorb and utilize nutrients </li></ul><ul><li>Eliminate waste products </li></ul><ul><li>Optimizes vitality, and resilience </li></ul><ul><li>Appropriate weight is central theme </li></ul><ul><li>Don't regularly experience bothersome digestive symptoms </li></ul><ul><li>This state of well-being is achieved by: </li></ul><ul><ul><li>consuming a nutritious diet </li></ul></ul><ul><ul><li>minimizing emotional stressors </li></ul></ul><ul><ul><li>embracing physical activity </li></ul></ul><ul><li>Oriented to the prevention of chronic disease. </li></ul>
    29. 29. Other Approaches to Health <ul><li>Bio-Medical – the body as machine; disease oriented </li></ul><ul><li>Behavioral – health as energy – lifestyle </li></ul><ul><li>Bio-psycho-social – attempts to address deficiencies of behavioral model within biomedical context </li></ul><ul><li>Socio-environmental – a means to realize aspirations and change environments </li></ul>
    30. 30. Strengths of Digestive Health Approach <ul><li>Individualized to the person </li></ul><ul><li>Creates energy and balance in self </li></ul><ul><li>Focus on individual responsibility </li></ul><ul><li>Focus on lifestyle change for health and disease prevention </li></ul><ul><li>Spiritual connection to natural environment </li></ul>
    31. 32. Leading GI Symptoms Prompting U.S. Outpatient Clinic Visits in 2002 Shaheen NJ et al . Am J Gastroenter 2006. National Ambulatory Medical Care Survey 2002. 15 14 13 12 11 10 9 Rank 8 7 6 5 4 3 2 1 Rank 0.9 Dyspepsia 0.55 0.75 0.76 0.79 0.81 0.87 0.89 # of Visits (Millions) Appetite Decrease Lower Abdominal Pain Dysphagia Abdominal Distension Melena Anorectal Symptoms Other GI Symptoms (unspecified) GI Symptom 1.4 Heartburn 1.5 Rectal Bleeding 1.8 Constipation 2.1 Nausea 2.6 Vomiting 3.7 Diarrhea 11.8 Abdominal pain, cramps, spasms # of Visits (Millions) GI Symptom
    32. 33. Physician Diagnoses for GI Disorders in Outpatient Clinic Visits Shaheen NJ et al . Am J Gastroenter 2006. National Ambulatory Medical Care Survey 2002. 1.23 Hernia, noninguinal 10 1.24 Hepatitis C infection 9 8 7 6 5 4 3 2 1 Rank 1.49 Diverticular Disease 1.54 Hemorrhoids 2.06 Irritable Bowel Syndrome 2.29 Dyspepsia, Gastritis 2.56 Constipation 3.32 Gastroenteritis 4.17 Abdominal Pain 5.51 GERD Number of Visits (Millions) Diagnosis
    33. 34. Physician Visits per Year (GI and non-GI) Drossman DA, et al., Dig Dis Sci 1993; 38:1569 MD Visits Per Year IBS Normal 0 1 2 3 4 5 Complaints 6 Non-GI GI
    34. 35. Drossman DA, et al., Dig Dis Sci 1993; 38:1569 Work or School Absences IBS Normal 0 2 4 6 8 10 12 14 Days per Year
    35. 36. Beyond the economic costs… QOL matters too!
    36. 37. Barriers toward Digestive Health Promotion <ul><li>Medical culture oriented towards cure </li></ul><ul><ul><li>Doctors’ preference vs. patients’ preference </li></ul></ul><ul><ul><li>ER and House vs. “The Preventionist” </li></ul></ul><ul><li>If you cannot avoid an illness, at least catch it early and prevent it from causing harm. </li></ul><ul><ul><ul><li>Identification of risk factors </li></ul></ul></ul><ul><ul><ul><li>Modification of risk factors early in course </li></ul></ul></ul><ul><ul><ul><li>“ Periodic Health Examination” </li></ul></ul></ul>
    37. 38. Where is Digestive Health Accomplished? <ul><li>Health Provider Level </li></ul><ul><ul><li>learning how to screen effectively </li></ul></ul><ul><ul><li>counseling effectively (integrative health approach) </li></ul></ul><ul><li>Societal Level </li></ul><ul><ul><li>public education </li></ul></ul><ul><ul><li>regulations oriented toward healthy lifestyle </li></ul></ul><ul><ul><li>national prevention guidelines </li></ul></ul><ul><li>Patient Level </li></ul><ul><ul><li>being inquisitive </li></ul></ul><ul><ul><li>taking interest in health </li></ul></ul>
    38. 39. What is new in Digestive Health research in 2007? <ul><li>Dietary fructose </li></ul><ul><li>Weight Disorders </li></ul><ul><ul><li>CNS role in eating behaviors </li></ul></ul><ul><ul><li>Weight Loss and Longevity </li></ul></ul><ul><ul><li>Doctor-Dietitian Duo </li></ul></ul><ul><ul><li>Gut ecology and Obesity </li></ul></ul><ul><li>Probiotics </li></ul>
    39. 40. Fructose Malabsorption in Normal Persons <ul><li>Dose-response study from which they developed a fructose malabsorption breath test . </li></ul><ul><li>20 persons got on 4 separate days: </li></ul><ul><ul><li>10% solution of 15 g, 25 g, or 50g fructose </li></ul></ul><ul><ul><li>33% solution 50 g fructose </li></ul></ul><ul><li>Analyzed H2 and CH4 over 5 hours </li></ul>Rao, S, et al. Clin Gastro and Hepatol 2007.
    40. 41. H2 and CH4 concentration after intake of different doses of fructose Rao, S, et al. Clin Gastro and Hepatol 2007.
    41. 42. Results <ul><li>No subject tested (+) with 15 g. No gender differences. </li></ul><ul><li>10% (+) with 25 g fructose but were asymptomatic. </li></ul><ul><li>50 g (10% solution) </li></ul><ul><ul><li>80% (+) breath test </li></ul></ul><ul><ul><ul><li>H2 - 65% </li></ul></ul></ul><ul><ul><ul><li>CH4 in 5% </li></ul></ul></ul><ul><ul><ul><li>Both H2 and CH4 10% </li></ul></ul></ul><ul><ul><li>55% had symptoms </li></ul></ul><ul><li>50 g (33% solution) </li></ul><ul><ul><li>60% (+) </li></ul></ul><ul><ul><li>45% experienced symptoms. </li></ul></ul>Rao, S, et al. Clin Gastro and Hepatol 2007.
    42. 43. Conclusions <ul><li>Healthy subjects absorb up to 25 g </li></ul><ul><li>Many exhibit malabsorption and intolerance with 50 g </li></ul><ul><li>For suspected malabsorption: 25 g should be test dose, and measure at 30 minute intervals for 3 hours </li></ul>Rao, S, et al. Clin Gastro and Hepatol 2007.
    43. 44. Alonso-Alonso, M. et al. JAMA 2007;297:1819-1822. Brain Areas Involved in the Regulation of Food Intake and Schematic Representation of Their Interactions
    44. 45. 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
    45. 46. Unadjusted Cumulative Mortality Sjostrom L et al. N Engl J Med 2007;357:741-752
    46. 47. Survival According to BMI in the Surgery Group and the Control Group Adams TD et al. N Engl J Med 2007;357:753-761
    47. 48. Effect of Onsite Dietitian (D) Counseling on Outpatient Weight Loss and Lipids in a Physician (MD) Office <ul><li>Intro : D sees patients at same visit w/ MD (fully reimbursable). </li></ul><ul><li>Intervention : D counsels on diet (DASH) + exercise (30 min/d). One f/u w MD and D. </li></ul><ul><li>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. </li></ul><ul><li>Conclusion : concurrent counseling is effective in achieving & maintaining WL & is reimbursable </li></ul>Welty, FK et al. Am J Cardiol 2007;100:73–75
    48. 49. Using Bugs as Drugs: How to be a Probioticist in 2007
    49. 50. Definitions <ul><li>Probiotic : </li></ul><ul><li>live microorganisms that when administered in adequate amounts confer a health benefit on the host </li></ul><ul><li>Prebiotic : </li></ul><ul><li>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 </li></ul><ul><li>Synbiotics : </li></ul><ul><li>combination nutritional supplements comprised of probiotics and prebiotics </li></ul><ul><li>Neutraceutical : </li></ul><ul><li>Original : food that provided medical or health benefit </li></ul><ul><li>Current : dietary supplements that contain a concentrated form of a bioactive substance originally derived from a food. </li></ul>FAO/WHO. Guidelines for the evaluation of probiotics in food. 2002
    50. 52. IL - 10:IL - 12 ratio ’ 250 150 50 0 100 200 300 B. infantis 35624 L. salvarius 4331 Placebo Healthy Volunteers 250 150 50 0 100 200 p=0.001 p=0.001 300 B. infantis 35624 L. salvarius 4331 Placebo Healthy Volunteers Pre treatment Post treatment Pre treatment Post treatment IL - 10:IL - 12 ratio ’ 250 150 50 0 100 200 p=0.001 300 B. infantis 35624 L. salvarius 4331 Placebo Healthy Volunteers Pre treatment Post treatment p=0.001 Pre treatment Post treatment O” Mahony et al. Gastroenterology 2005 (128)541 551.
    51. 53. C. Diff 6 Trials McFarland, LV. AJG 101 (4), 812-822. 2006.
    52. 55. Ley et al. Nature. 2006
    53. 56. The case of Mrs. K <ul><li>32 y/o executive with 2 months of bloating, gas, constipation </li></ul><ul><li>Most likely diagnosis: Bloating </li></ul><ul><li>What do others call this? </li></ul><ul><li>Why do I not label her as IBS? She fulfills criteria? </li></ul><ul><li>Where do I see her? </li></ul>
    54. 57. Mrs. K – 32 y/o AAF executive <ul><li>Feels “bloated”, gassy, infrequent stools </li></ul><ul><li>Lower abdominal cramps </li></ul><ul><li>Improved with BM’s (approx 3/week) </li></ul><ul><li>Occurs unpredictably, for last 7 months </li></ul><ul><li>Lasts for few days, then goes away </li></ul><ul><li>No interference w/ daily activities </li></ul><ul><li>Worried it might be “something serious” </li></ul>
    55. 58. Mrs. K: History and Physical <ul><li>PMH: “food poisoning” one year ago </li></ul><ul><li>PSH: none </li></ul><ul><li>MEDS: docusate qd </li></ul><ul><li>FH: mother has “minor depression” </li></ul><ul><li>SH: married, no T/E/D, unemployment soon </li></ul><ul><li>Physical exam: normal; BMI = 24 </li></ul><ul><li>Labs: Nl. CBC, Chem-10, ESR & CRP </li></ul>
    56. 59. How are we treating IBS? STRATEGY 1: Symptom based therapy Pain Bloating Diarrhea Constipation Courtesy of Pimentel, M.
    57. 60. STRATEGY 2: Hypothesis-based DYSMOTILITY ACUTE GASTROENTERITIS S I B O SEROTONIN IBS BRAIN-GUT AXIS Salmonella, E. coli, Campylobacter, … Agonist/Antagonist Courtesy of Pimentel, M.
    58. 61. What Next?
    59. 62. Digestive Health Approach <ul><li>Reassurance that its not serious </li></ul><ul><li>Symptom and food diary </li></ul><ul><li>Screen for lactose and fructose intolerance </li></ul><ul><li>Write a Dietary Rx: </li></ul><ul><li>Diet without flatulogenic foods </li></ul><ul><li>Slowly increase H20 and fiber content of foods over weeks (dried plums, apples, etc). </li></ul>
    60. 63. The Challenge of Digestive Health: <ul><li>&quot;Live sensibly — among a thousand people, only one dies a natural death, the rest succumb to irrational modes of living.“ </li></ul><ul><li>- Maimonides 1135-1204 A.D. </li></ul>
    61. 64. THE END

    ×