ACF-Digestion and GI Health 1

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Advanced Clinical Focus: Digestion and GI Health

presented by Josh Gitalis

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health What you will learn...

• The digestive process • IBS

• The 5 R’s of digestive • Digestive healing diets healing • Therapeutic foods • Leaky gut syndrome

• Autoimmune disease

• Allergies

• IBD

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health What you will not learn...

• Protocols

• One-size-ﬁts-all

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health GI Facts

• Largest surface area that interacts with the environment

• Site where the needs of nutrient absorption and host defences collide

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health GI Facts

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health The Digestive Process

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Complex Ecological Network

• Proper pH • Microbiome

• Smooth muscle tone • Lifestyle

• Stomach acid

• Pancreatic enzymes

• Bile

• GI Mucosa

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Components

• Digestion: break down of foodstuff in progressively smaller units

• Absorption: food across membrane

• Assimilation: converting food into cells

• Elimination: removing metabolic waste and byproducts

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Digestive Regulation

Digestion

Nervous System 24+ Hormones Autonomic Nervous System

SNS PNS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Soil, Air, Water, Sun Into You

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Soil Into You

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health The Cephalic Phase

• Conditioned reﬂex

• 20%-50% of gastric secretion and hormones

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health There Are No Teeth in Your Stomach

• Release of plant enzymes

• Salivary amylase

• Salivary lipase

• Nitrate-reducing bacteria

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Importance of Oral Flora

• Gastroprotective and blood pressure lowering effect of nitrates.

Bacteria in the mouth convert nitrates into nitrite then bioactive circulating nitric oxide.

“Excessive use of antiseptic mouthwashes may attenuate the bioactivity of dietary nitrate.”

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Importance of Oral Flora

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Oral Microbiota and Kissing

Kort et al. Microbiome 2014, 2:41 http://www.microbiomejournal.com/content/2/1/41

RESEARCH Open Access Shaping the oral microbiota through intimate kissing Remco Kort1,2,3*, Martien Caspers1, Astrid van de Graaf2, Wim van Egmond2, Bart Keijser1 and Guus Roeselers1

Abstract Background: The variation of microbial communities associated with the human body can be the cause of many factors, including the human genetic makeup, diet, age, surroundings, and sexual behavior. In this study, we investigated the effects of intimate kissing on the oral microbiota of 21 couples by self-administered questionnaires about their past kissing behavior and by the evaluation of tongue and salivary microbiota samples in a controlled kissing experiment. In addition, we quantified the number of bacteria exchanged during intimate kissing by the use of marker bacteria introduced through the intake of a probiotic yoghurt drink by one of the partners prior to a second intimate kiss. Results: Similarity indices of microbial communities show that average partners have a more similar oral microbiota composition compared to unrelated individuals, with by far most pronounced similarity for communities associated with the tongue surface. An intimate kiss did not lead to a significant additional increase of the average similarity of the oral microbiota between partners. However, clear correlations were observed between the similarity indices of the salivary microbiota of couples and self-reported kiss frequencies, and the reported time passed after the latest kiss. In control experiments for bacterial transfer, we identified the probiotic Lactobacillus and Bifidobacterium marker bacteria in most kiss receivers, corresponding to an average total bacterial transfer of 80 million bacteria per intimate kiss of 10 s. Conclusions: This study indicates that a shared salivary microbiota requires a frequent and recent bacterial exchange and is therefore most pronounced in couples with relatively high intimate kiss frequencies. The microbiota on the dorsal surface of the tongue is more similar among partners than unrelated individuals, but its similarity does not clearly correlate to kissing behavior, suggesting an important role for specific selection mechanisms resulting from a shared lifestyle, environment, or genetic factors from the host. Furthermore, our findings imply that some of the collective bacteria among partners are only transiently present, while others have found a true niche on the tongue’s surface allowing long-term colonization. Keywords: Intimate kiss, Oral microbiota, Tongue, Saliva, Next generation sequencing, Streptococcus, Lactobacillus

Background 90% of known cultures, as reported in [1] and references Mouth-to-mouth contact has been observed in a wide herein. Interestingly, the current explanations for the variety of animals, including fish, birds, and primates function of intimate kissing in humans include an im- and serves a range of functions, including the assess- portant role for the microbiota and viruses present in ment of physical abilities and the acquirement of food. the oral cavity, although to our knowledge, the effects of However, intimate kissing involving full tongue contact intimate kissing on the oral microbiota have never been and saliva exchange appears to be an adaptive courtship studied to date. behavior unique to humankind and is common in over A recent study on the importance of kissing in human mating situations proposes that the first kiss serves as a useful mate-assessment function and the following for * Correspondence: [email protected] 1TNO Microbiology and Systems Biology, Utrechtseweg 48, 3704 HE Zeist, mediation of feelings of attachment in long term rela- The Netherlands tionships, rather than the facilitation of sexual arousal 2 Micropia, Natura Artis Magistra, Plantage Kerklaan 38-40, 1018 CZ [1]. Kissing may contribute in mate assessment and Amsterdam, The Netherlands Full list of author information is available at the end of the article bonding via sampling of chemical taste cues in the saliva

© 2014 Kort et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, Kort et al. Microbiome 2014, 2:41 unless otherwise stated.

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Swallow Food

• Stomach expands

• Release of HCl (parietal)

• Release of intrinsic factor (parietal)

• Pepsinogen → pepsin (chief)

• Predigestion

• pH decreases

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Predigestion

60% of Carbohydrates 30% of Protein 10% of Fat

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health With Sufﬁcient HCl

• Enzymes deactivated

• Tissues softened

• Microorganisms sterilized

• Food in stomach 30min - 2 hours

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health The Triad of Stomach Protection

1. Mucous

2. Bicarbonate

3. Blood

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health pH Decreases to 1.5-3

• Minerals ionized

• Pyloric sphincter relaxes

• Chyme into duodenum

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Minerals Ionized

KCl Ionized

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Minerals Ionized

KCl K+ + Cl-

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Minerals Ionized

Stomach Acid KCl K+ + Cl-

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health pH Decreases to 1.5-3

• GB squirts bile into duodenum

• Pancreas secretes enzymes and bicarbonate

• Bicarbonate and bile neutralize chyme

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Gallbladder

• Bile: • Formed by hepatocytes • Bile salts • Emulsiﬁes • Pigments (bilirubin) • Stimulated by fat • Cholesterol

• Phospholipids

• Thick greenish-yellow

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Pancreas

• Bicarbonate

• Amylases

• Lipases

• Proteases

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Small Intestine

• 15-20 feet

• 3-6 hour journey

• Almost all absorption

• GALT (A.K.A. MALT)

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Small Intestine

• Pancreatic enzymes

• Brush border enzymes

• Bile re-absorbed

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Small Intestine: Absorbed into Blood

• Minerals

• Water-soluble vitamins

• Amino acids

• SCFA

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Small Intestine: Absorbed into Lymph

• MCFA

• LCFA

• Fat-soluble vitamins

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Colon

• 3-5 feet long, 2.5 inches thick

• No microvilli

• Goblet cells

• Fecal matter:

• Bacteria

• Fibre

• Intestinal secretions

• Cellular debris

• Bile salts

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Colon

• Bacteria make vitamin K and some B- vitamins

• “Bad” bacteria metabolize end products

• With ﬁbre and water, wastes eliminated

• Food particles

• Metabolic waste

• Bacteria

• Water absorbed

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

Lipski. Digestive Wellness: 4th Edition. 2012. pp. 19

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Transit Time

• Ideal = 18-24 hours

• Avg. = 72 hours

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Fibre East Africans North Americans • 100 g of Fibre • 25 g of Fibre • 18-24 hours • 72 hours transit time transit time

Jensen, Bernard. Dr. Jensen’s Guide to Better Bowel Care. Avery: 1999.

The “5 R’s”

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Digestive Healing

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

Diet Functional Foods

Lifestyle Supplements

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Factors to Consider

• Symptom control

• Modiﬁed diet Functional Diet Foods • Heal the gut

• Reintroduce and rebalance Lifestyle Supplements

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health The 5 R’s of Digestive Healing

1. Remove

2. Replace

3. Reinoculate

4. Repair

5. Rebalance

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Remove: What?

• Pathogens

• Allergens/sensitivities

• Irritants/toxins

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Remove: How?

• Antimicrobials:

• Pharmaceuticals

• Neutraceuticals

• pH

• Starve

• Crowd out

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Remove: Antimicrobials

• Garlic

• Oregano oil

• Grapefruit seed extract

• Olive leaf

• Berberine (goldenseal, oregon grape)

• Black Walnut Hull

• Plant oils (thyme, oregano, peppermint)

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Remove: Antimicrobials

• Oregano oil caps, 200mg TID

• Thyme, standardized thymol, 100-200 mg TID

• Goldenseal, standardized berberine, 200-400 mg TID

• Artemisia/Chinese Wormwood 1-3 g TID

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Remove: Antimicrobials

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Alkaline Diet

• Meat, eggs • Fruit/veg, sea salt

• Coffee • Organic chicken breast • Grains • Organic eggs • Nuts • Herbal tea • Dairy • Millet • Oils • Sprouted nuts, seeds • Sugar • Organic yoghurt • Alcohol • Apple cider vin. • Drugs and chemicals

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Remove: Starve

• Eliminate sugar and alcohol

• Eliminate grains

• Eliminate monosaccharides,disaccharides, polysaccharides

• Eliminate FODMAPs

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Replace

• Digestive factors:

• Water

• Hydrochloric acid

• Enzymes

• Bile

• Fibre

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Replace: Water

• Symptoms:

• Dry skin, lips

• Thirst

• Constipation

• Yellow pee

• 1 oz. per Kg of body weight

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Hydrochloric Acid

• Beginning of the digestive cascade

• Ionizes minerals

• Activates pepsin

• Sterilizes (immune)

• 50% over 60

• 85% over 80

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Hypochlorhydria

• Protein putrefaction

• Carbohydrate fermentation

• Formation of Sulfur compounds

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Hypochlorhydria: Clinical Cues

• Bloating, burping, • Food allergies burning and ﬂatulence immediately after meals • Nausea after taking supplements • Fullness • Itching around rectum • Feeling as though food sits for hours • Weak nails

• Indigestion, diarrhea, or • Dilated blood vessels in constipation cheeks

Indigestion, Antacids, Achlorhydria and H. Pylori. American Journal of Natural Medicine. (Jan-Feb 1997): 11-16

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Hypochlorhydria: Clinical Cues

• Acne • Upper GI gas

• Iron deﬁciency

• Chronic parasite/ infection

• Undigested food in stool

• Chronic candida

Indigestion, Antacids, Achlorhydria and H. Pylori. American Journal of Natural Medicine. (Jan-Feb 1997): 11-16

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Misdiagnosis?

But that sounds like too much stomach acid?!

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Hypochlorhydria: Disease Assoc.

• Addison’s • Gallbladder • Pernicious anemia disease • Asthma • Psoriasis • Graves • Celiac • Rheumatoid • Hepatitis arthritis • Autoimmune • Thyroid issues • Rosacea • Hives • Lupus • Sjogren’s • Dermatitis syndrome • Myasthenia gravis • Diabetes • Thyrotoxicosis • Osteoporosis • Eczema • Vitiligo Indigestion, Antacids, Achlorhydria and H. Pylori. American Journal of Natural Medicine. (Jan-Feb 1997): 11-16

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Heidelberg pH Capsule Test

Normal Heidelberg gastrogram Achlorhydric gastrogram

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Replace: HCl

• Stomach makes 60-70 grains of HCl per meal

• 1 grain = 60mg

• 1 capsule = ~10 grains

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Replace: HCl

• Rest and Digest

• Stomach acid repletion protocol

• Bitters

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Decrease HCl Requirement

• Lemon juice or ACV

• Smaller meals

• Limit mealtime ﬂuid

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Replace: Enzymes pH Scale 14 Alkaline 13 12 11 10 9 Pancreatic enzymes 8 7 Food Mouth pH and resting stomach 6 5 Enzymes HCl and pepsin 4 3 2 1 Acid

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Digestive Stimulation from Spices

Pancreatic Lipase At least one Alkaline Disaccharides Amylases Activity disaccharase phosphatase •Ginger •Curcumin •Coriander •Ginger Increased: •Curcumin (nearly 300%) •Fennel •Onion •Onion •Cumin •White •Curcumin coriander •Capsaicin (cayenne) Decreased: •Piperine •Coriander (black pepper) •Fenugreek •Mint •Mustard Adapted from Platel & Srinivasan, 2004; Indian J Med Res, 119, 167-179. Review Article: Digestive stimulant • action of spices: A myth or reality?

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Digestive Stimulation from Herbs

• Globe artichoke Ailment Pharmacol Ther 18 (2003): 1099-105. • Dandelion root Fitoterapia 75.7–8 (2004): 760–3. • Gentian Current Therapeutic Research 1981;29:525-536. • Chamomile Mol Med Report. 2010 Nov 1;3(6):895-901. • Turmeric J Altern Complement Med 10.6 (2004): 1015–18. • Ginger Dig Dis Sci 50.10 (2005): 1889–97.

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Replace: Bile Salts

• Secretes 700ml/day

• Functions:

• Emulsiﬁes fat

• Cholesterol removal

• Toxin removal

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Replace: Bile Salts

• Cholestasis

• “Sludgy” bile

• Removal of gallbladder

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Replace: Bile Salts

• Insufﬁciency Signs:

• Incomplete digestion/absorption of fats

• Steatorrhea

• Diarrhea

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Replace: Bile Salts

• Cholagogues/Choleretics → agents that promote the ﬂow of bile from the gallbladder or production of bile from the liver

• Bile salts

• Dandelion root

• Globe artichoke

• Taurine

• Wormwood

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Reinoculate

• Probiotics

• Prebiotics

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Microbial Individuality

The composition of the microbiota can shape a healthy immune response or predispose to disease.

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Microbial Individuality

“The mammalian gut microbiota interact extensively with the host through metabolic exchange and co-metabolism of substrates…appropriates consideration of individual human gut microbiome activities will be a necessary part of future personalized health-care paradigms.”

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Reinoculate

• 2-5 lbs of bacteria in colon

• Prefer slightly alkaline environment

• Most pathogens anaerobic

• Most abundant species:

• Lactobacillus acidophilus

• Biﬁdobacterium biﬁdum

• Immune stimulation

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

Clinical Nutrition: A Functional Approach: 2nd Edition. 2004. pp 206

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Reinoculate

• Natural antibiotics

• GALT

• Balance upset by:

• Ax and other Rx

• Alcohol

• Stress

• S.A.D.

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Probiotics

1. Either symbiotic or 5. Influence the brain pathogenic 6. Educate the immune 2. Help with absorption of system nutrients 7. Ensure proper 3. Break down detoxification polysaccharides 8. Oral flora - nitrates to NO 4. Produce SCFAs - feed flora downstream (butyrate 9. Dysbiotic microbes feeds bifidobacteria) suppress HCl

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Transfer of DNA

• Japanese can break down nori carbohydrate

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Probiotics: Mechanism of Action

Inhibits Pathogenic Improve Epithelial ↑ Immunoregulation Bacteria Function

↓ Luminal pH ↑ SCFA (butyrate) ↑ IL-10, TGFb Bacteriocidal proteins ↑ Healing ↓ THF, IL-12 Colonization resistance ↑ Mucous ↓ T cell proliferation ↓ Epithelial binding ↑ Apoptosis ↑ Apoptosis TH1 cells ↓ Epithelial invasion ↑ Barrier integrity ↑ sIgA ↑ beta defensins ↑ HSP 25, 72 ↓ NFkB

Sartor RB. J Clin Gastro. 2007;41:S37-S43.

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

Probiotics - Competition

1. Competitive nutrient consumption

2. Epithelial cell receptor interaction

3. Excretion of antimicrobial substances

4. Interaction with the immune system

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Dysbiosis

• Dysbiosis is the condition of having microbial imbalances on or within the body.

• Dysbiosis is most prominent in the digestive tract or on skin but can also occur on any exposed surface or mucous membrane such as vagina, lungs, nose, sinuses, ears, nails, or eyes.

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Dysbiosis: History

• Concept consolidated by Metchnikoff in 1908

• 1376 Medline articles indexed by “dysbiosis” (as of Oct. 2015)

• Other related terms:

• Dysbacteriosis

• Autointoxication

• SIBO

• Mucosal colonization

• Subclinical infection

• Some controversy still exists in the medical literature

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Dysbiosis

• Dysbiosis is not so much about the microbe as it is about the effect of that microbe on a susceptible host; i.e. it is about the relationship between host and microbe.

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Reinoculate

• Kimchi • Miso

• Sauerkraut

• Kombucha

• Yoghurt

• Keﬁr

• Pickles

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Reinoculate

• Prebiotics → non-digestible food ingredients that stimulate the growth and health of good bacteria

• Inulin: onions, chicory root, dandelions

• Oligosaccharides: artichokes, leeks, asparagus

• Beta-glucan: seaweed, oats, barley

• Pectin: apples, apricots

• Resistant starch: bananas, potatoes, beans

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health FOS and Biﬁdobacteria

• At least 4g/day to ↑ B.B. with a dose -response noted

• Biﬁdobacteria:

• Form SCFA

• B-vitamins

• Restores ﬂora after Ax

• Inhibit growth of pathogens

Sartor RB. Curr Opin Gastroenterol. 2003, 19:358-365.

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Inulin: Clinical Use

• Constipation

• 40g/day for 19 days increased BB and produced soft stools

Kleesen B, et al. AJCN. 1997 May;65(5):1397-402

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Repair

• Anti-inﬂammatories

• Digestive healing nutrients

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Repair

• Multi vitamin/mineral

• Protein

• Vitamin A and D

• Zinc (Carnosine)

• L-Glutamine

• EFAs

• Quercetin

• Botanical anti-inﬂammatories

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Vitamin D

• Vitamin D deﬁciency is a • A high prevalence of

world-wide epidemic,1 2 3 vitamin D deﬁciency has with recent estimates been found across all indicating greater than age groups in all 50% of the global populations studied in

population is at risk.4 countries around the

globe. 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 1. Prentice, A. Vitamin D deficiency: a global perspective. Nutr Rev. 2008 Oct; 66 (10 Suppl 2): S153-64. 2. Pettifor, J. M. Vitamin D &/or calcium deficiency rickets in infants & children: a global perspective. Indian J Med Res. 2008 Mar; 127 (3): 245-9. 3. Holick, M. F. Chen, T. C. Vitamin D deficiency: a worldwide problem with health consequences. Am J Clin Nutr. 2008 Apr; 87 (4): 1080S-6S. 4. University of California Riverside More Than Half the World’s Population Gets Insufficient Amounts of Vitamin D, Says UC Riverside Biochemist. 15 July 2010; 5. Science Daily Millions Of U.S. Children Low In Vitamin D. 3 Aug 2009; 6. Schwalfenberg, G. K. Genuis, S. J. Hiltz, M. N. Addressing vitamin D deficiency in Canada: a public health innovation whose time has come. Public Health. 2010 Jun; 124 (6): 350-9. 7. Kuriacose, R. Olive, K. E. Prevalence of vitamin D deficiency and insufficiency in northeast Tennessee. South Med J. 2008 Sep; 101 (9): 906-9. 8. Bandeira, F. Griz, L. Dreyer, P. Eufrazino, C. Bandeira, C. Freese, E. Vitamin D deficiency: A global perspective. Arq Bras Endocrinol Metabol. 2006 Aug; 50 (4): 640-6. 9. Ardestani, P. M. Salek, M. Keshteli, A. H. Nejadnik, H. Amini, M. Hosseini, S. M. Rafati, H. Kelishadi, R. Hashemipour, M. Vitamin D status of 6- to 7-year-old children living in Isfahan, Iran. Endokrynol Pol. 2010 Jul-Aug; 61 (4): 377-82. 10. Bener, A. Al-Ali, M. Hoffmann, G. F. Vitamin D deficiency in healthy children in a sunny country: associated factors. Int J Food Sci Nutr. 2009; 60 Suppl 560-70. 11. Teale, G. R. Cunningham, C. E. Vitamin D deficiency is common among pregnant women in rural Victoria. Aust N Z J Obstet Gynaecol. 2010 Jun; 50 (3): 259-61. 12. Harinarayan, C. V. Joshi, S. R. Vitamin D status in India--its implications and remedial measures. J Assoc Physicians India. 2009 Jan; 5740-8. 13. Andersen, R. Molgaard, C. Skovgaard, L. T. Brot, C. Cashman, K. D. Chabros, E. Charzewska, J. Flynn, A. Jakobsen, J. Karkkainen, M. Kiely, M. Lamberg-Allardt, C. Moreiras, O. Natri, A. M. O'Brien, M. Rogalska-Niedzwiedz, M. Ovesen, L. Teenage girls and elderly women living in northern Europe have low winter vitamin D status. Eur J Clin Nutr. 2005 Apr; 59 (4): 533-41. 14. Rodriguez Sangrador, M. Beltran de Miguel, B. Quintanilla Murillas, L. Cuadrado Vives, C. Moreiras Tuny, O. [The contribution of diet and sun exposure to the nutritional status of vitamin D in elderly Spanish women: the five countries study (OPTIFORD Project)]. Nutr Hosp. 2008 Nov-Dec; 23 (6): 567-76. 15. Bhattoa, H. P. Bettembuk, P. Ganacharya, S. Balogh, A. Prevalence and seasonal variation of hypovitaminosis D and its relationship to bone metabolism in community dwelling postmenopausal Hungarian women. Osteoporos Int. 2004 Jun; 15 (6): 447-51. 16. Allali, F. El Aichaoui, S. Khazani, H. Benyahia, B. Saoud, B. El Kabbaj, S. Bahiri, R. Abouqal, R. Hajjaj-Hassouni, N. High prevalence of hypovitaminosis D in Morocco: relationship to lifestyle, physical performance, bone markers, and bone mineral density. Semin Arthritis Rheum. 2009 Jun; 38 (6): 444-51. 17. Du, X. Greenfield, H. Fraser, D. R. Ge, K. Trube, A. Wang, Y. Vitamin D deficiency and associated factors in adolescent girls in Beijing. Am J Clin Nutr. 2001 Oct; 74 (4): 494-500. 18. Peters, B. S. dos Santos, L. C. Fisberg, M. Wood, R. J. Martini, L. A. Prevalence of vitamin D insufficiency in Brazilian adolescents. Ann Nutr Metab. 2009; 54 (1): 15-21. 19. Judkins, A. Eagleton, C. Vitamin D deficiency in pregnant New Zealand women. N Z Med J. 2006; 119 (1241): U2144.

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Vitamin D

“[Vitamin D] markedly enhanced tight junctions by increasing junction protein expression and preserved the structural integrity of tight junctions.”

Am J Physiol Gastrointest Liver Physiol, 2008 Jan;294(1):G208-160

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Vitamin D

“Vitamin D...favours less Inﬂammation.”

Kidney International, Vol. 68 (2005), pp 1973-1981.

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Zinc Carnosine

“Regarding intestinal permeability, Zinc Carnosine caused an approximate threefold increase in gut integrity and repair.”

Gut. 2007 Feb;56(2):168-75

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Zinc Carnosine

• Relieves gastric discomfort such as occasional heartburn and indigestion, upset stomach, mild nausea, bloating, belching, and burping

• Promotes healthy gastric bacterial balance

• Provides antioxidant protection for gastric mucosal cells • Helps maintain the integrity of the protective gastric mucosal lining by supporting healthy mucus secretion

• Gastro-supportive beneﬁts demonstrated in over 20 published studies

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health L-Glutamine

• Preferential fuel • Vital for mucosal growth, structure, and function • Deﬁciency = small bowel atrophy • Maintains sIgA levels • #1 prescription for ulcers in Asia

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health L-Glutamine

“The gastrointestinal tract is by far the greatest user of glutamine in the body, as [the intestinal cells] use glutamine as their principal metabolic fuel.”

Alternative Medicine Review Volume 6, Number 4 2001

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health L-Glutamine

“[L-Glutamine] decreases villous atrophy, increases jejunal weight, and decreases intestinal permeability.”

Alternative Medicine Review Volume 6, Number 4 2001

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Essential Fatty Acids

Omega-3 Omega-6

• Fish, walnuts, ﬂax, • Corn, safﬂower, red chia, eggs meat, cottonseed

• Anti-inflammatory • Anti-inflammatory or pro-inflammatory

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Essential Fatty Acids

• Omega 3 converts into EPA and DHA

• EPA = anti-inﬂammatory Omega 3 (Flax)

• DHA = structure EPA (Fish)

PG3 (Anti-inﬂammatory) DHA (Fish)

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Essential Fatty Acids

“EPA appears to exert much of its anti-inflammatory benefit by suppressing [pro-inflammatory] activation...thus reducing elaboration of pro-inflammatory mediators.”

Nutritional Perspectives, Vol. 28, no. 1, 1-16

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Pharmaceutical modulation of Inﬂammation Cell membrane

Cortisone X Phospholipase A2 X Sulfasalazine

Indomethacin Arachadonic Acid Aspirin Ibuprofen X Cyclooxygenase Lipooxygenase Sulfasalazine X Colchicine Prostaglandin Thromboxane Leukotrienes 2 series A2 SRS-A

Mullin GE, et al, Expert Review of Gastroenterology and Hepatology, April 2008

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Botanical Modulation of Inﬂammation Cell membrane

Cortisone XX Phospholipase A2 X X Sulfasalazine Quercetin Potentiates cortisol: Liquorice root Liquorice root Turmeric Indomethacin Arachadonic Acid Aspirin Ibuprofen XX Cyclooxygenase Lipooxygenase Sulfasalazine Ginger X X Colchicine Quercetin Quercetin Ginger Prostaglandin Thromboxane Leukotrienes Turmeric Turmeric 2 series A2 SRS-A Onion Bromelain Garlic White Willow Bark Boswellia

Mullin GE, et al, Expert Review of Gastroenterology and Hepatology, April 2008

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Turmeric

• Active component: Curcumin

• Anti-inﬂammatory

• Inhibits leukotriene formation

• Inhibits platelet aggregation

• Promotion of ﬁbrinolysis

• Inhibition of neutrophil inﬂammatory process

• Stabilization of lysosomal membranes

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Turmeric Mechanism Humira, Remicade

Erbitux, Erlotinib, Geftinib

Asacol Bharat B. et al. 2006

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Turmeric

“Turmeric,...or its component curcumin, has shown surprisingly beneﬁcial effects in experimental studies of acute and chronic diseases characterized by an exaggerated inﬂammatory reaction. There is ample evidence to support its clinical use, both as a prevention and a treatment.”

J of Par and Ent Nut Vol. 30,no.1,2006,45-51

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Quercetin

• Inhibits mast cell and basophil degranulation

• Inhibits phospholipase A2 and lipoxygenase

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Rebalance

• Diet

• Balancing the ANS

• Stress

• Sleep

• Exercise

• Connection

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health The Second Brain

• The gut has more nerve endings than the spine !

• 90% of all serotonin is made in the gut

• 40-50% of total NE occurs in mesenteric organs

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health The Gut-Brain Axis

• Vagus nerve

• Signalling to and from the digestive tract

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Vagus Nerve Stimulation

• Gargling

• Singing loudly

• Gagging

• Coffee enemas

• Deep breathing

Kharrazian, Datis. Why My Brain Isn’t Working. 2013.

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Rebalance: Perception

Stimulus

Rest/Digest Fight/Flight/Fright Stop/Think (PNS) (SNS)

Stress Hormones

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Body-Mind and Digestion

Rest and Digest Stop and Think (Parasympathetic Nervous System)

Fright, Flight or Fight (Sympathetic Nervous System)

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Stress Causes Changes

• Suppresses lactobacilli, biﬁdobacteria, and sIgA

• Catecholamines stim. gram- organisms (yersinia, pseudomonas)

• Anger or fear increases Bacteroides fragilis

Develepmental Psychology 1999;35;2:146-155

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Rebalance

• Deep breathing/ • Nature meditation • CBT • Heart rate variability • Adaptogens

• Epsom salt baths • Less international travel • Manual therapies • Light therapy • Walking, yoga

Current Opinion in Gastroenterology. 2006;22(2):128-135

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health The 5 R’s Guidelines

• Remove needs to take place ﬁrst

• The other R’s can occur sequentially or together

• All R’s must be accounted for

Leaky Gut Syndrome

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Tight Junctions

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Leaky Gut Syndrome - Causes

• Dysbiosis

• Allergies

• Infections, parasites

• Drugs - NSAIDs, BCP, steroids radiation

• Alcohol

• Putrefying food

• Stress

• Environmental contaminants

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health The Viscous Cycle GI Irritant

Allergy, Damage to GI Sensitivity, Microbe Inﬂammation

Malabsorption Leaky Gut

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Gluten

Einkorn Dwarf 14 Chromosomes 42 Chromosomes

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Celiac: 2x Every 15 years

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

1. Gluten induces release of zonulin 2. Zonulin causes permeability 3. Gluten into blood 4. Immune mobilization 5. Inﬂammation 6. Antigenic memory

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Non-Celiac Gluten Sensitivity (NCGS)

“Increased intestinal permeability after gliadin exposure occurs in all individuals.”

Nutrients 2015, 7, 1565-1576.

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Gluten-Related Illness

No Known Non-Celiac Celiac Reaction Gluten Sensitivity Disease

• Bone and Joint pain • Bone and • Amenorrhea • Osteoporosis Joint pain • Infertility • Leg numbness • Osteoporosis • Delayed • Muscle Cramps • Leg numbness growth • Unexplained anemia • Muscle • Thyroiditis • Migraines Cramps • Tooth • Unexplained discolouration anemia • Seizures • Migraines • Dementia • Behavioural • Hepatitis changes

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Gluten-Related Illness

No Known Non-Celiac Celiac Reaction Gluten Sensitivity Disease

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Cross-Reactivity

Autoimmune Disease

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health What Is Autoimmune Disease?

• An inappropriate immune response of the body against substances and tissues normally present in the body.

http://en.wikipedia.org/wiki/Autoimmune_disease

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

More then 40 autoimmune conditions have been identiﬁed, including such common examples as type 1 diabetes, rheumatoid arthritis, and celiac disease. Together they constitute the 3rd leading cause of sickness and death after heart disease and cancer. Scientiﬁc American, March 2007

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Why Does The Body Attack Itself?

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Autoimmune Disease

Genetics Environmental Trigger Gut Permeability

Nat Clin Prac Gastro & Hep, Sept 2005, Vol2;No.9

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

1. Trigger

2. Genetics

3. Leaky gut

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Genes or Environment?

1986-2005: ↑ of 15-24x

Arq. Gastroenterol. vol.46 no.1 São Paulo Jan./Mar. 2009

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Epigenetics

January, 2011

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Leaky Gut Syndrome

“The autoimmune process can be arrested if the interplay between genes and environmental triggers is prevented by re- establishing intestinal barrier function.” Nut Clin Prac Gastro & Hep. Sept 2005 Vol. 2 No.9

Genes Environment

You

“Phenotype”

Allergies and Sensitivities

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Increase of Allergies 1990-2001

BMJ 2003;327:1142

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Allergies Deﬁned

• Allergy (type 1 hypersensitivity): IgE-mediated response

• Sensitivity/Intolerance: IgG-mediated, enzyme deﬁciency

• “Not all symptoms of allergic response can be ascribed to IgE.” Annals Allergy. 1987;59(2):110-17

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Mechanism of GI Allergy

Mechanism

Immune-Mediated Non-Immune-Mediated (“GI Allergy”) (“GI Intolerance”)

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Mechanism of GI Allergy

Mechanism

Immune-Mediated Non-Immune-Mediated (“GI Allergy”) (“GI Intolerance”)

IgE-Mediated Other Immune Reactions Reactions

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Mechanism of GI Allergy

Mechanism

Immune-Mediated Non-Immune-Mediated (“GI Allergy”) (“GI Intolerance”)

IgE-Mediated Other Immune Reactions Reactions

Immediate Late IgA T-Cell Immune Phase Phase Mediated Mediated Complexes

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Mechanism of GI Allergy

Mechanism

Immune-Mediated Non-Immune-Mediated (“GI Allergy”) (“GI Intolerance”)

IgE-Mediated Other Immune Toxic (occurring Non-Toxic (individual Reactions Reactions in any individual) susceptibility)

Immediate Late IgA T-Cell Immune Phase Phase Mediated Mediated Complexes

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Mechanism of GI Allergy

Mechanism

Immune-Mediated Non-Immune-Mediated (“GI Allergy”) (“GI Intolerance”)

IgE-Mediated Other Immune Toxic (occurring Non-Toxic (individual Reactions Reactions in any individual) susceptibility)

Enzymatic Pharmacologic Others (e.g. Immediate Late IgA T-Cell Immune (e.g. lactose (e.g. vasoactive additive Phase Phase Mediated Mediated Complexes intolerance) amines) intolerance)

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Food Additives and Allergies

Additive Use Reaction

Sulﬁtes Preservative Asthma, anaphylaxis

MSG Flavour enhancer Chinese restaurant syndrome, asthma, urticaria

Aspartame Sweetener Urticaria

Tartrazine Food dye Urticaria, asthma, hyperactivity in children

Other food dyes Dyes Hyperactivity, urticaria

BHA/BHT Preservative Urticaria

Parabens Preservative Urticaria

Benzoates Preservative Urticaria

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Lactose Intolerance

Descent

Mahan LK, Escott-Stump S. Food Nutrition and Diet Therapy. Philedelphia, Pa: W.B.Saunders. 1996:625-626

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health The Immunoglobulin Isotypes

Allergology International 2007; 56: 349-361

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Symptom Characteristics: IgE vs IgG

IgE “Allergy” IgG “Sensitivity” Onset Rapid Delayed Duration Brief-hours Prolonged (days) Mechanism Mast cell Circulating complexes Quantity of Food Tiny Tiny, dose dependent Food Any Any Patient Always Rarely Awareness Persistence of Ab Lifelong Months after elimination

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health The Immunoglobulin Isotypes

Class Features Major Activity

Transplacental Protects tissues 23 Day half life circulating IgG 2-3 months mast cell half life

Attaches to mast cells Extreme sensitivity Contact with allergen causes release of Gatekeeper for IgA IgE histamine, etc. Anti-parasitic 2.3 Day half-life 14 Day mast cell half-life Two Forms: Protects mucous IgA Serum - Monomer Clears absorbed food Secretions - Dimer

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Immunoglobulins and Location

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

Allergy/Hypersensitivity Testing

IgE IgG, IgG4

Skin Testing Serum Serum

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Role of Skin Tests

If an IgE-mediated disorder is likely:

• Negative skin prick test is 95% predictive.

• Positive skin tests predict reaction 40% of the time.

• Size of reaction is important; > 8 mm is 95% predictive when supported by history.

Clark AT, Ewan PW. Interpretation of tests for nut allergy in one thousand patients in relation to allergy or tolerance. Clin Exp Allergy 33:1041-1045, 2003

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health IgG Food Allergy Testing

• Good diagnostic tool with some patients

• Used to determine modiﬁed elimination diet in patients with IBS

• Groups eliminating real foods (vs sham) were 30% improved

Atkinson W. Sheldon TA, Shaath N, Whorwell PJ. Food elimination based upon IgG antibodies in irritable bowel syndrome: a randomized controlled trial. Gut. 2004;53:1459-64.

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

Mullin, Swift, Lipski, Turnbull, Rampertab. Nutr Clin Pract 2010; 25; 192

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Conditions Helped by IgG Testing

• Atopic conditions Awazuhara, H. • Epilepsy Egger, J. et al. (1989) et al. (1997), el Rafei, A. et al. (1989), Nakagawa, T. et al. (1992), Hofman, T. (1995), Jenmalm, M.C. et al. (2000)

• Glomerulonephritis Van der Woude, F.J. et al. (1983) • Migraine headaches Alpay, K. et al. (2010), Mitchell, N. et al. (2011)

• ADHD Pelsser, L.M. et al. (2011) • Cystic ﬁbrosis Lucarelli, S. et al. (1994)

• IBS Zar, S. et al. (2005), Atkinson, W. et al. (2004), Drisko, J. et al. (2006)

• Crohn’s Bentz, S. et al. (2010)

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Testing

• “Single entity testing is incomplete” (i.e. IgE, IgG)

Brandtzaeg P. Current understanding of gastrointestinal immunoregulation and its relation to food allergy. Ann N Y Acad Sci. 2002;964:13-45.

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health What To Do: Prevention

• Vaginal birth versus C-section

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Allergies in Infancy

• Infants gut = leaky

• IgA, IgM, IgE, IgD, IgD in breast milk

• 146K - 970k daltons

• Casein: 121.7K daltons

• Glutenin: 150k daltons

Clinical Nutrition: A Functional Approach: 2nd Edition. 2004. pp 202-203

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health What To Do: Prevention

• Breastfeeding

• Maternal ﬁsh oils/ probiotics

• Prebiotics/probiotics for both

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health What To Do: Prevention

Simpson et al. BMC Dermatology (2015) 15:13 DOI 10.1186/s12895-015-0030-1

RESEARCHARTICLE Open Access Perinatal probiotic supplementation in the prevention of allergy related disease: 6 year follow up of a randomised controlled trial Melanie Rae Simpson1*, Christian Kvikne Dotterud1,2, Ola Storrø1, Roar Johnsen1 and Torbjørn Øien1

Abstract Background: Perinatal probiotics supplementation has been shown to be effective in the primary prevention of atopic dermatitis (AD) in early childhood, although the long term effects of probiotics on AD and other allergic diseases is less certain. We have previously reported a significant reduction in the cumulative incidence of AD at 2 years after maternal probiotic supplementation. In this study we present the effects of perinatal probiotics given to women from a general population on allergy related diseases in their offspring “Maternalat 6 years. probiotic ingestion alone may be Methods: Four hundred and fifteen pregnant women were randomised to receive probiotic or placebo milk in adouble-blindedtrialfrom36weekgestationuntil3monthspostpartum.ProbioticmilkcontainedLactobacillus rhamnosos GG, L. acidophilus La-5 and Bifidobacterium animalis subsp. lactis Bb-12. At 6 years, children were suﬃcientre-assessed for for AD, atopiclong sensitisation, asttermhma and allergic rhinoconjunctivitisreduction (ARC). in the Results: At 6 years, 81 and 82 children were assessed for AD in the probiotic and placebo groups, respectively. In a multiple imputation analysis, there was as trend towards a lower cumulative incidence of AD in the cumulativeprobiotic group comparedincidence to the placebo group (OR 0.64,of 95 % CIatopic 0.39-1.07, p =0.086;NNT=10).Thisfinding was statistically significantly in the complete case analysis (OR 0.48, 95 % CI 0.25-0.92, p =0.027,NNT=6).The prevalence of asthma and atopic sensitisation, and the cumulative incidence of ARC were not significantly dermatitis…”affected by the probiotic regime at 6 years of age. Conclusions: Maternal probiotic ingestion alone may be sufficient for long term reduction in the cumulative incidence of AD, but not other allergy related diseases. Trial registration: ClinicalTrials.gov identifier: NCT00159523 Keywords: Allergy, Asthma, Atopic dermatitis, Paediatrics, Prevention, Probiotics, Rhinitis

Background observed over the past several decades [1–3]. Subse- Atopic dermatitis (AD), asthma and allergic rhinocon- quently, probiotics have been investigated in the preven- junctivitis (ARC) are a major cause of chronic disease in tion and treatment of allergy related diseases [3–8], with childhood. A revised version of the “hygiene hypothesis” the strongest evidence emerging for the primary preven- suggests that the pattern of colonisation and the diver- tion of atopic dermatitis [3–5]. Throughout this paper sity of the intestinal microbiota may be an important we refer AD, asthma and ARC as “allergy related dis- factor in the increased prevalence of these diseases eases”, recognising that not all presentations of these conditions are related to a classic IgE-mediated inflammatory process. * Correspondence: [email protected] Randomised controlled trials (RCTs) testing probiotics 1 Department of Public Health and General Practice, Faculty of Medicine, in the prevention of childhood allergy related disease are Norwegian University of Science and Technology (NTNU), Postboks 8905, MTFS, 7491, Trondheim, Norway heterogeneous and have used a variety of bacterial strains, Full list of author information is available at the end of the article administration regimes and varying ages of follow-up.

© 2015 Simpson et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Simpson MR, et al. BMC Dermatol. 2015; 15:13

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Allergies in Infancy

• Allergy reactions to foods are much more common in the ﬁrst few years of life

• Formula feeding associated with increased prevalence of allergy and asthma

Zeiger RS. Dietary aspects of food allergy prevention in infants and children. J Ped Gastro Nutr. 2000;30:S77-S86. Kelly D, Coutts AGP. Early nutrition and the development of immune function in the neonate. Proc Nutr Soc. 2000;59:177-85.

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

“In this review, we describe the importance of properly balanced intestinal permeability in oral tolerance induction and address the processes involved in damaging the intestinal barrier in the sensitized epithelium and during allergic reactions. We conclude by speculating on the eﬀect of increased intestinal permeability on the onset of sensitization towards dietary antigens.”

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Gastric Acidity and Allergy

• The gatekeeping function of the stomach in the sensitization and effector phase of food allergy

Untersmayr, E and Jensen-Jarolim, E. The role of protein digestibility and antacids on food allergy outcomes. J Allergy Clin Immunol. 2008 June; 121(6):1301-1310

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Gastric Enzymes

• Reduced allergenicity of melon allergens after incubation with gastric enzymes

Untersmayr, E and Jensen-Jarolim, E. The role of protein digestibility and antacids on food allergy outcomes. J Allergy Clin Immunol. 2008 June; 121(6):1301-1310

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

Affects of PPIs on Allergenicity of Proteins

• Gastric digestion substantially decreases the potential of food proteins to bind IgE, which increases the threshold dose of allergens required to elicit symptoms in patients with food allergy

• Double-blind, placebo-controlled, food challenges in these patients with ﬁsh allergy resulted in a 10-30 fold higher tolerated allergen dose if the ﬁsh proteins were previously subjected to in vitro gastric digestion

• Thus, anti-ulcer agents impeding gastric protein digestion have a major effect on the sensitization and effector phase of food allergy

Untersmayr, E and Jensen-Jarolim, E. The role of protein digestibility and antacids on food allergy outcomes. J Allergy Clin Immunol. 2008 June; 121(6):1301-1310

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Allergy Summary

• No one test accounts for all allergies

• IgE and IgG testing both have clinical beneﬁts: they are tools

• Prevention is key

• Comprehensive elimination diet = gold standard

• Healing the gut is critical

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health 5 People Diagnosed With IBS

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health 5 Different Causes

Cause 1 Cause 2 Cause 3 Cause 4 Cause 5

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health 5 Different Causes

Cause 1 Cause 2 Cause 3 Cause 4 Cause 5

• Antidepressants • Antispasmodics • Laxatives • Antidiarrheals

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Cochrane Review of 40 Studies

The evidence for drug therapies is weak and there is no clear evidence of beneﬁt for antidepressants or bulking agents.

Drug

The Cochrane Library. N.p., n.d. Web. 08 June 2014.

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Placebo More Effective

Drug effects are smaller than the placebo effect in most randomized trials.

Placebo > Drug

Spiller R. Clinical Update: irritable bowel syndrome. Lancet. 2007;369:1586-1588.

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health “Unmet Needs” “There are signiﬁcant unmet needs including lack of familiarity with irritable bowel syndrome, difﬁculties in diagnosis and lack of effective treatments for the multiple symptoms of the disorder.” ?

Dig Liver Dis. 2006 Oct;38(10):717-23. Epub 2006 Jun 27.

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Who Is Affected?

• 10-15% in North America

• 0.8-28% world-wide

• Mostly women

• Upper-socioeconomic groups

Am J Gastroenterol. 2002;97:S1-5 Best Pract Res Clin Gastroenterol. 2004;18 Gastroenterol Clin North Am. 2005;34:189-204

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Rome III Criteria: IBS Diagnosis

• 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 BM

• Change in freq. of BM

• Change in form of stool

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

? ?

IBS Symptoms

? ?

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Iatrogenesis

• Incorrect diagnosis

• Symptom overlap

• Unnecessary surgeries: cholecystectomy, hysterectomy, appendectomy, back surgery

Gastroenterol Clin North Am. 2005;34:189-204

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Food As Trigger

• Food is the #1 trigger

• Increased rate of positive skin-prick

• Food elimination based on IgG

Eur J Clin Nutr. 2006;60:667-672. World J Gastroenterol. 2006;12:2382-2387. Zar, S. et al. (2005) Atkinson, W. et al. (2004) Drisko, J. et al. (2006)

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health IBS: A Randomized Control Trial IgG Food Allergy Testing • Diagnostic tool

• Determine modiﬁed elimination diet

• Groups eliminating real foods (vs sham) were 30% improved

Gut. 2004;53:1459-64.

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Gluten and IBS

• “The clinical presentation of gluten sensitivity is a combination of IBS-like symptoms…”

Nat Rev Gastroenterol Hepatol. May 2012;9(5):295-299.

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health FODMAPs and IBS

F ermentable

O ligo

D i

M ono-saccharides

A nd

P olyols

Gibson PR, Shepard SJ, 2005

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health FODMAPs and IBS

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Low FODMAPs Improve IBS

“Dietary FODMAPs induce … gastrointestinal and systemic symptoms experienced by patients with IBS.”

Jour of Gastroenterol and Hepatol. 25 (2010) 1366-1373.

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Antibiotics

• Upset gut ﬂora

• Predisposes to IBS

Gut. 2006;55:182-190. Am J Gastroenterology. 2002;97:104-108. Eur J Gastroenterol Hepatol. 1998;10:59-62.

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Antibiotics and Gut Flora

No Effect

Altern Med Rev. 2004;9:180-197

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Antibiotics, Gut Flora, and Probiotics

Red area = Ax Blue line = Microbiome Red line = SB with Ax Green line = SB after Ax Black dotted = SB during and after

(SB = Saccharomyces Boulardii)

Clin Exp Gastroenterol. 2015; 11:237-255.

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

“The gastrointestinal immune eﬀects of SIBO provide a unifying framework for understanding frequent observations in IBS…”

Jama. 2004. Vol. 292 No. 7

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Distribution of Bacteria

Lin, H.C. JAMA 2004;292:852-858

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health SIBO and IBS

• SIBO often found in IBS (78% in one study)

Am J Gastroenterol. 2000;95:3503-3506.

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Treating SIBO

Response rate: Rifaximin 34% vs Herbal Therapy 46%

Glob Adv in Health and Med. May 2014;3:3 pp 16-25

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Treating SIBO

Herbal therapies: • Candibactin-AR and Candibactin-BR (Metagenics) •FC-Cidal and Dysbiocide (Biotics)

Glob Adv in Health and Med. May 2014;3:3 pp 16-25

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Common Parasites

23% positive for parasite (3,223/13,857)

• Blastocystis hominis (12.5%)

• Dietamoeba fragilis (3.8%)

• Entamoeba spp. (3.4%)

• Endolimax nana (2.2%)

• Giardia lamblia (0.7%)

Courtesy of Dr. Patrick Hannaway

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Role of Blastocystis Hominis

4x more frequent in those with IBS

B. Hominis treated = resolution in 80%

Am J. Torop. Med. Hyg. 7094), 2004, pp.383-385

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

Symptoms persist 3 years after treatment.

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Gut In Balance

• “...the mucosa [is] directly exposed to the external environment and taxed with antigenic loads consisting of commensal bacteria, dietary antigens, and viruses at far greater quantities on a daily basis than the systemic immune system sees in a lifetime.”

• 99% of the time, the job of the immune system is to NOT respond! ✗

Mayer L. Mucosal Immunity. Pediatrics 2003;111:1595-1600.

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Biﬁdobacterium, Lactobacillus, Placebo in IBS Over 8 Weeks

Gastroenterology. 2005;128(3):541-551

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Peppermint Oil

• Natural antispasmodic

• C. Albicans

• Note: Relaxes LES

J Gastroenterol 1997;32:765-68

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Peppermint Oil

ECPO (%) Placebo (%)

Abdominal Pain 79 43

Abdominal distension 83 29

Stool frequency 83 33

Stomach rumble 73 31

Flatulence 79 22.5

J Gastroenterol 1997;32:765-68

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Stress and IBS

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Stress as Trigger

• Life events increase symptoms

• General stress

• Disease stress

Gut. 1998;43:256-261. Nurs Res. 2007;56:399-406. J Psychosom Res. 1998;44:537-545.

Inﬂammatory Bowel Disease

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health IBD: Theories of Etiology

Genetic

Infection Immunologic

Psychosomatic Diet

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Genes or Environment?

1986-2005: ↑ of 15-24x

Arq. Gastroenterol. vol.46 no.1 São Paulo Jan./Mar. 2009

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Diet: What Don’t We Know?

• The best diet for IBD

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

Not knowing the right thing doesn't necessarily mean we don’t know the wrong thing.

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Clinical Implications of Diet on IBD

• Gluten: Increases intestinal permeability

• Fibre: High ﬁbre beneﬁcial

• FODMAPs: May worsen symptoms

• Dairy: Increases incidence

• Meat: Mainly red and processed

• PUFAs: Omega-3s are protective

Integrated Healthcare Practitioners. June/July 2014, p. 55

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health IBD and Diet: What we know...

• Formula feeding

• “SAD” diet

• Reﬁned sugar (Study: 122g/day vs 65g/day)

• Food allergies: wheat and dairy

• Reduced intake of omega-3

Thornton JR, Emmett PM, Heaton KW. Br Med J 1979;279:762-764. Jones VA et al. Lancet. 1985 Jul 27;2(8448):177-80. Shoda R, Matsueda K, Yamato S, Umeda N. Am J Clin Nutr 1996;63:741-745 Cashman KD, Shanahan F. Eur J Gastroenterol Hepatol. 2003;15:607-613 O’Sullivan M, O’Morain C. Best Pract Res Clin Gastroenterol. 2006;20:561-573

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Formula Feeding and IBD

• Less likely to have been breastfed = higher risk of IBD

• Breastfeeding:

• Protects against enteric infection

• Develops GI immune system

• Delays antigenic exposure

Cashman & Shanahan, 2003 O’Sullivan & O’Morain, 2006

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Cow’s Milk Allergy and IBD

• Implicated as antecedent precursor to IBD

• Association between allergic asthma, rhinitis, and the subsequent development of IBD (particularly UC)

Cashman & Shanahan, 2003 Glassman, Newman, Berezin, & Gryboski, 1990 Ceyhan, Karakurt, Cevik, & Sungur, 2003 D’Arienzo et al.2002 Weng, Liu, Barcellos, Allison, & Herrington, 2007

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Speciﬁc Carbohydrate Diet

• Eliminate: Grain, Lactose, Sucrose

• More effective for Crohn’s

• Meat, ﬁsh, eggs, most vegetables, fruits, nut ﬂours, aged cheese, homemade yoghurt, honey

• High sucrose predisposes to Crohn’s Matsui et al., 1990; Martini & Brandes, 1976; Thurton, Emmet, & Heaton, 1979; Mayberry, Rhodfes, & Newcombe • Control of Crohn’s enhanced by sucrose elimination Heaton, Thornton, & Emmet, 1979

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health FODMAPs and Crohn’s

F ermentable

O ligo

D i

M ono-saccharides

A nd

P olyols

Gibson PR, Shepard SJ, 2005

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DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health FODMAPs and Crohn’s

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Low Sulfur Diet in Ulcerative C.

• Protein = ↑ sulﬁde in colon Magee, Richardson, Hughes, & Cummings, 2000 • Protein (esp. meat), total sulfur and sulfates inﬂuence relapse Jowett et al., 2004 • Some evidence for low sulfur diet Roediger, 1998

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Crohn’s Disease: Exclusion Diets 78 Patients ✗

Maintain Eliminate

✓ Riordan et al., 1993

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Crohn’s Disease: Exclusion Diets

Steroids Diet

70 70%

52.5 Percentage in remission (%) 35 38% 34%

17.5 21%

0 6 Months 2 Years Riordan et al., 1993

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Crohn’s Disease: Exclusion Diets

• Exclusion diet:

• 1 meat (lamb or chicken), 1 starch (rice or potatoes), 1 fruit, 1 vegetable

• Provocation

• Most common allergens: wheat, cow’s dairy, corn, yeast, tomatoes, citrus, eggs, and cruciferous veg.

• Maintenance

• Result: Relapse of under 10%/year Alun Jones, Workman, & Freeman, 1985

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Crohn’s Disease and Yeast

• Many CD patients have AB to Baker’s/Brewer’s yeast Barnes et al., 1990

• Increases TNF-alpha Konrad et al., 2004

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health IBD and Deﬁciencies

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Vitamin D

“Vitamin D deﬁciency may compromise the mucosal barrier, leading to increased susceptibility to mucosal damage and increased risk of IBD.”

Am J Physiol Gastrointest Liver Physiol, 2008 Jan;294(1):G208-16

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Clinical Trial: Vitamin D3 treatment in Crohn’s disease • Patients received 1200iu/day

• Blood levels started at 69 nmol/L and went to 96 nmol/L at 3 months

• Vitamin D group: 13% relapse

• Placebo: 29% relapse

Alimentary Pharmacology & Therapeutics Volume 32, Issue 3 pages 377- 383, 11 MAY 2010

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Zinc

• Approximately 45% of those with Crohn’s = deﬁcient

• Disease activity correlated with zinc deﬁciency

J Physiol Gastrointest Liver Physiol, 2008 Jan;294(1):G208-160

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Essential Fatty Acids

“When ...evaluating the role of fish oil in the treatment of ulcerative colitis, 3 of 3 studies showed statistically significant improvement in the study group that received fish oil supplementation.”

Nutrition in Clinical Practice 23:9, Feb 2008

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Fish Oils and IBD:Animal Studies

• 6/6 mice models of ulcerative colitis showed protection from injury and healing with omega-3 fatty acids.

Fish Oil Placebo

Proc Natl Acad Sci U S A. 2006;103(30):11276-11281. Clin Nutr. 2006;25(3):466-476. Protection UC Nutrition. 2006;22(3):275-282. World J Gastroenterol. 2005;11(47):7466-7472. Proc Natl Acad Sci U S A. 2005;102(21):7671-7676. Inﬂamm Bowel Dis. 2005;11(4):340-349.

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Ulcerative Colitis - Summary • 9 randomized controlled trials Two or more:

• 4.7 g EPA/DHA/day (Average) • Reduce ulceration

• Duration 35 weeks (Average) • Reduce overall disease

• Reduce drug use

• Reduce relapse

• Increase remission

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Pharmaceutical modulation of Inﬂammation Cell membrane

Cortisone X Phospholipase A2 X Sulfasalazine

Indomethacin Arachadonic Acid Aspirin Ibuprofen X Cyclooxygenase Lipooxygenase Sulfasalazine X Colchicine Prostaglandin Thromboxane Leukotrienes 2 series A2 SRS-A

Mullin GE, et al, Expert Review of Gastroenterology and Hepatology, April 2008

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Botanical Modulation of Inﬂammation Cell membrane

Mullin GE, et al, Expert Review of Gastroenterology and Hepatology, April 2008

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Turmeric

“Studies involving curcumin to date in the ﬁeld of IBD have been consistently positive.”

Nutrition in Clinical Practice 23:49-62, Feb 2008

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Quercetin

• “We suggest that the addition of polyphenols (quercetin)...would improve outcomes of patients with IBD...”

Gut 56:426-436, Mar 2007

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Induction of Remission in Ulcerative Colitis with High-Dose Probiotics

• 34 patients with active UC (non- responsive to conventional treatment), were given 3.6 trillion 53% cfu of bacteria daily for six weeks.

• Treatment of patients with mild to 24% moderate UC resulted in a combined induction of remission/ response rate of 77% -- with no adverse events.

• Bacterial species in the probiotic product were detected at the target site. Am J Gastroenterol. 2005;100:1539-1546.

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Psychological Stress and IBD

• Chronic stress, adverse life events, and depression can cause a relapse in patients with IBD

• HPA function, gut ﬂora, mast cell activation, and CRF mediate the effect of stress on inﬂammation in IBD

• The symptoms of IBD may be exacerbated by the effects of stress on gut motility and ﬂuid secretion

• There is a need for further studies of the potential beneﬁts of stress reduction therapy in IBD

Mawdsley J E, Rampton D S Gut 2005;54:1481-1491

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Psychological Stress and IBD

Mawdsley J E, Rampton D S Gut 2005;54:1481-1491

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Psychological Stress and IBD

• Meditation

• Light Exercise

• Yoga

• Acupuncture, massage, bodywork

• Nature walks

• Music

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Diets For GI Healing

• Gluten-Free/Casein- • Anti-Fungal Diet Free • Anti-Inﬂammatory Diet • SCD Diet • Restoration Diet • FODMAP • Palaeolithic Diet • Low Sulphur Diet (Autoimmune)

• Comprehensive • GAPS Diet Elimination Diet

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Diets For GI Healing

What do these all have in common?

Elimination No processed foods No reﬁned sugar Good fats

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Functional Foods

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Fibre: Friend or Foe?

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Fibre East Africans North Americans • 100 g of Fibre • 25 g of Fibre • 18-24 hours • 72 hours transit time transit time

Jensen, Bernard. Dr. Jensen’s Guide to Better Bowel Care. Avery: 1999.

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

Relax, sir. The hair in your soup provides ﬁbre.

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Fibre

Soluble Fibre: Insoluble Fibre: • Soothing • Not fermented • Partially and Completely • Speeds transit time Fermented: • Adds bulk • Short Chain Fatty Acids • Gases

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Mucilaginous Foods/Herbs

• Slippery elm powder

• Marshmallow root

• Flax seed

• Chia seed

• Aloe vera

• Okra

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Bone Broths

• Gelatin • Hyaluronic acid

• Free amino acids • Chondroitin sulfate

• Calcium • Magnesium

• Glycinate • Potassium

• Proline • Sulfate

• Phosphorus • Fluoride

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Cabbage Juice

• Original research: Cheney 1949-1952

• 66% improvement within 4 days

• 80% symptom-free within 1 week

• Replicable

• Dosage: 1 quart fresh, green cabbage juice in divided doses for 7-10 days

Cheney, G. (1952) "Vitamin U therapy of peptic ulcer." California Medicine, 77:4, 248-252

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Therapeutic Diet/Food Summary

• Choose the appropriate diet (GET/RID)

• Eliminate problematic foods

• Choose therapeutic foods

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health Factors to Consider

• Symptom control

• Modiﬁed diet Functional Diet Foods • Heal the gut

• Reintroduce and rebalance Lifestyle Supplements

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

Current Patient’s Evidence Story

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

Personalized

ADVANCED CLINICAL FOCUS

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

Applied Knowledge Is Power.

DigestionAdvanced Clinical Focus: &Digestion GI Health and GI Health

Thank you!

evidence-based clinical nutrition and integrative healthcare