2. TAKING CONTROL: Keeping Your Gut Happy Jacqueline Wolf, M.D. Associate Professor of Medicine Harvard Medical School Beth Israel Deaconess Medical Center

3. What are the issues of the evening? Constipation Diarrhea Gas Colorectal cancer

4. 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.

5. 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.

6. What does the gut do? 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

7. 800-1000cc of fluid (26-33 ounces) 200cc of fluid (6-7 ounces) STOMACH SMALL INTESTINES COLON ILEUM RECTUM

8. 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 over- the-counter preparations. Occasional heartburn is common in many people.

9. 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

10. 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

11. 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

12. 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.

13. 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

14. Over-the-Counter Constipation Remedies Fiber supplements –Psyllium (Metamucil, Konsyl) –Methylcelluose (Citracel) –Guar (Benefiber) –Pectin –Flax seed –Calcium polycarbophil (Fibercon) –Inulin (Fiber choice) Lubricant (mineral oil) Stool softener (Colace, etc)

15. 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

16. 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.

17. 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.

18. 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

19. 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

20. Intestinal Flora (A Balanced Ecosystem) Pseudomonas Proteus Staphylococci Clostridia Enterococci E. coli Lactobacilli Streptococci Eubacteria Bifidobacteria Bacteroides Potentially Harmful Bacteria Cause diarrhea/constipation Cause infections Produce toxins Potentially Helpful Bacteria 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 From: Gibson GR. J Nutrition 1995; 125:1401-1412. Probiotics and Gut Health

21. Probiotics

22. L. casei L. casei Shirota L. johnsonii Probiotics L. casei L. reuteri L. rhamnosus GG B. lactis Bb12 Ganeden Lactobacillus

23. Are probiotics effective? NAMEPROBIOTIC STRAIN STUDIES AND RESULTS Dannon Activia Yogurt Contains gluten Bifidus regularis A similar type of bacteria speeds the stool through the colon in healthy women Culturelle Gluten free Lactobacillus GG 10 Billion CFUs Helps prevent diarrhea after antibiotics Align Gluten free 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.

24. Are probiotics effective? NAMEPROBIOTIC STRAIN STUDIES AND RESULTS VSL #3 Gluten free 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 Florastor Gluten 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.

25. Colorectal Cancer (CRC) The third most common cause of cancer in women and men (2 nd 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

26. The Warning Signs of Colorectal Cancer Change of stools –new constipation –narrowed stools Weight loss Bleeding from the rectum Abdominal pain

27. Probability of Developing Invasive CRC Cancer, US 2001-2003 Birth- 39 40-5960-7970-Birth to Death Male 1 in 13421 in 1071 in 601 in 20 1 in 17 Female 1 in 14691 in 1381 in 861 in 221 in 19 ACS, Surveillance Research 2007

28. 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

29. 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

30. 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

31. 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

32. Factors Affecting the Incidence of Colorectal Cancer in Women IncreaseNo changeDecrease Cigarette Smoking  35 years Fiber Aspirin  15-20 years Obesity- BMI  29kg/m 2 Vitamin E Multivitamin  15 years (? Folate) for colon cancer Cholecystectomy for proximal cancers Helicobacter pylori infection Higher calcium intake for distal colon cancer Hormone replacement therapy (early stage cancer) Physical activity Magnesium (colon not rectal cancer)

33. 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 !

34. Acknowledgements Monique S. Martin Kirsten Doyle Marsha L. Steinberg Siobhan Connolly

35. QUESTIONS?