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Copyright © 2015 All rights reserved.
Neither this document nor any part of it may be reproduced or transmitted in any form or
by any means including photocopying, email, fax, etc. without prior written
permission of the author.
Advanced Clinical Focus: Digestion and GI Health
presented by Josh Gitalis
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
What you will learn...
• The digestive process
• The 5 R’s of digestive healing
• Leaky gut syndrome
• Autoimmune disease
• Allergies
• IBD
• IBS
• Digestive healing diets
• Therapeutic foods
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
What you will not learn...
• Protocols
• One-size-fits-all
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
GI Facts
• Largest surface area that interacts with the environment
• Site where the needs of nutrient absorption and host defences collide
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
GI Facts
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
The Digestive Process
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
The Digestive Process
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Complex Ecological Network
• Proper pH
• Smooth muscle tone
• Stomach acid
• Pancreatic enzymes
• Bile
• GI Mucosa
• Microbiome
• Lifestyle
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
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
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Digestive Regulation
Digestion
Nervous System
Autonomic Nervous System
24+ Hormones
SNS PNS
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Soil, Air, Water, Sun Into You
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Soil Into You
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
The Cephalic Phase
• Conditioned reflex
• 20%-50% of gastric secretion and hormones
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
There Are No Teeth in Your Stomach
• Release of plant enzymes
• Salivary amylase
• Salivary lipase
• Nitrate-reducing bacteria
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
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.”
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Importance of Oral Flora
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Oral Microbiota and KissingRESEARCH Open Access
Shaping the oral microbiota through intimatekissingRemco 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 manyfactors, including the human genetic makeup, diet, age, surroundings, and sexual behavior. In this study, we investigatedthe effects of intimate kissing on the oral microbiota of 21 couples by self-administered questionnaires about their pastkissing behavior and by the evaluation of tongue and salivary microbiota samples in a controlled kissing experiment. Inaddition, we quantified the number of bacteria exchanged during intimate kissing by the use of marker bacteriaintroduced 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 oralmicrobiota composition compared to unrelated individuals, with by far most pronounced similarity for communitiesassociated with the tongue surface. An intimate kiss did not lead to a significant additional increase of the averagesimilarity of the oral microbiota between partners. However, clear correlations were observed between the similarityindices of the salivary microbiota of couples and self-reported kiss frequencies, and the reported time passed after thelatest kiss. In control experiments for bacterial transfer, we identified the probiotic Lactobacillus and Bifidobacteriummarker bacteria in most kiss receivers, corresponding to an average total bacterial transfer of 80 million bacteria perintimate kiss of 10 s.
Conclusions: This study indicates that a shared salivary microbiota requires a frequent and recent bacterial exchangeand is therefore most pronounced in couples with relatively high intimate kiss frequencies. The microbiota on thedorsal surface of the tongue is more similar among partners than unrelated individuals, but its similarity does notclearly correlate to kissing behavior, suggesting an important role for specific selection mechanisms resulting from ashared lifestyle, environment, or genetic factors from the host. Furthermore, our findings imply that some of thecollective bacteria among partners are only transiently present, while others have found a true niche on the tongue’ssurface allowing long-term colonization.
Keywords: Intimate kiss, Oral microbiota, Tongue, Saliva, Next generation sequencing, Streptococcus, Lactobacillus
BackgroundMouth-to-mouth contact has been observed in a widevariety of animals, including fish, birds, and primatesand serves a range of functions, including the assess-ment of physical abilities and the acquirement of food.However, intimate kissing involving full tongue contactand saliva exchange appears to be an adaptive courtshipbehavior unique to humankind and is common in over
90% of known cultures, as reported in [1] and referencesherein. Interestingly, the current explanations for thefunction of intimate kissing in humans include an im-portant role for the microbiota and viruses present inthe oral cavity, although to our knowledge, the effects ofintimate kissing on the oral microbiota have never beenstudied to date.A recent study on the importance of kissing in human
mating situations proposes that the first kiss serves as auseful mate-assessment function and the following formediation of feelings of attachment in long term rela-tionships, rather than the facilitation of sexual arousal[1]. Kissing may contribute in mate assessment andbonding via sampling of chemical taste cues in the saliva
* Correspondence: [email protected] Microbiology and Systems Biology, Utrechtseweg 48, 3704 HE Zeist,The Netherlands2Micropia, Natura Artis Magistra, Plantage Kerklaan 38-40, 1018 CZAmsterdam, The NetherlandsFull list of author information is available at the end of the article
© 2014 Kort et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.
Kort et al. Microbiome 2014, 2:41http://www.microbiomejournal.com/content/2/1/41
Kort et al. Microbiome 2014, 2:41
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Swallow Food
• Stomach expands
• Release of HCl (parietal)
• Release of intrinsic factor (parietal)
• Pepsinogen → pepsin (chief)
• Predigestion
• pH decreases
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Predigestion
60% of Carbohydrates30% of Protein10% of Fat
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
With Sufficient HCl
• Enzymes deactivated
• Tissues softened
• Microorganisms sterilized
• Food in stomach 30min - 2 hours
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
The Triad of Stomach Protection
1. Mucous
2. Bicarbonate
3. Blood
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
pH Decreases to 1.5-3
• Minerals ionized
• Pyloric sphincter relaxes
• Chyme into duodenum
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Minerals Ionized
KCl Ionized
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Minerals Ionized
KCl K+ + Cl-
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Minerals Ionized
KCl K+ + Cl-Stomach
Acid
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
pH Decreases to 1.5-3
• GB squirts bile into duodenum
• Pancreas secretes enzymes and bicarbonate
• Bicarbonate and bile neutralize chyme
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Gallbladder
• Bile:
• Bile salts
• Pigments (bilirubin)
• Cholesterol
• Phospholipids
• Thick greenish-yellow
• Formed by hepatocytes
• Emulsifies
• Stimulated by fat
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Pancreas
• Bicarbonate
• Amylases
• Lipases
• Proteases
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Small Intestine
• 15-20 feet
• 3-6 hour journey
• Almost all absorption
• GALT (A.K.A. MALT)
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Small Intestine
• Pancreatic enzymes
• Brush border enzymes
• Bile re-absorbed
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Small Intestine: Absorbed into Blood
• Minerals
• Water-soluble vitamins
• Amino acids
• SCFA
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Small Intestine: Absorbed into Lymph
• MCFA
• LCFA
• Fat-soluble vitamins
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Colon• 3-5 feet long, 2.5 inches thick
• No microvilli
• Goblet cells
• Fecal matter:
• Bacteria
• Fibre
• Intestinal secretions
• Cellular debris
• Bile salts
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
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
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Lipski. Digestive Wellness: 4th Edition. 2012. pp. 19
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Transit Time
• Ideal = 18-24 hours
• Avg. = 72 hours
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
FibreEast Africans • 100 g of Fibre • 18-24 hours
transit time
North Americans • 25 g of Fibre • 72 hours transit time
Jensen, Bernard. Dr. Jensen’s Guide to Better Bowel Care. Avery: 1999.
The “5 R’s”
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Digestive Healing
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Diet Functional Foods
SupplementsLifestyle
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Factors to Consider
• Symptom control
• Modified diet
• Heal the gut
• Reintroduce and rebalance
Diet Functional Foods
SupplementsLifestyle
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
1. Remove
2. Replace
3. Reinoculate
4. Repair
5. Rebalance
The 5 R’s of Digestive Healing
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Remove: What?
• Pathogens
• Allergens/sensitivities
• Irritants/toxins
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Remove: How?
• Antimicrobials:
• Pharmaceuticals
• Neutraceuticals
• pH
• Starve
• Crowd out
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Remove: Antimicrobials
• Garlic
• Oregano oil
• Grapefruit seed extract
• Olive leaf
• Berberine (goldenseal, oregon grape)
• Black Walnut Hull
• Plant oils (thyme, oregano, peppermint)
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
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
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Remove: Antimicrobials
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Alkaline Diet• Meat, eggs
• Coffee
• Grains
• Nuts
• Dairy
• Oils
• Sugar
• Alcohol
• Drugs and chemicals
• Fruit/veg, sea salt
• Organic chicken breast
• Organic eggs
• Herbal tea
• Millet
• Sprouted nuts, seeds
• Organic yoghurt
• Apple cider vin.
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Remove: Starve
• Eliminate sugar and alcohol
• Eliminate grains
• Eliminate monosaccharides,disaccharides, polysaccharides
• Eliminate FODMAPs
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Replace
• Digestive factors:
• Water
• Hydrochloric acid
• Enzymes
• Bile
• Fibre
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Replace: Water
• Symptoms:
• Dry skin, lips
• Thirst
• Constipation
• Yellow pee
• 1 oz. per Kg of body weight
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Hydrochloric Acid
• Beginning of the digestive cascade
• Ionizes minerals
• Activates pepsin
• Sterilizes (immune)
• 50% over 60
• 85% over 80
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Hypochlorhydria
• Protein putrefaction
• Carbohydrate fermentation
• Formation of Sulfur compounds
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Hypochlorhydria: Clinical Cues
• Bloating, burping, burning and flatulence immediately after meals
• Fullness
• Feeling as though food sits for hours
• Indigestion, diarrhea, or constipation
• Food allergies
• Nausea after taking supplements
• Itching around rectum
• Weak nails
• Dilated blood vessels in cheeks
Indigestion, Antacids, Achlorhydria and H. Pylori. American Journal of Natural Medicine. (Jan-Feb 1997): 11-16
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Hypochlorhydria: Clinical Cues
• Acne
• Iron deficiency
• Chronic parasite/infection
• Undigested food in stool
• Chronic candida
• Upper GI gas
Indigestion, Antacids, Achlorhydria and H. Pylori. American Journal of Natural Medicine. (Jan-Feb 1997): 11-16
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Misdiagnosis?
But that sounds like too much
stomach acid?!
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Hypochlorhydria: Disease Assoc.
• Addison’s
• Asthma
• Celiac
• Autoimmune
• Hives
• Dermatitis
• Diabetes
• Eczema
• Gallbladder disease
• Graves
• Hepatitis
• Thyroid issues
• Lupus
• Myasthenia gravis
• Osteoporosis
• Pernicious anemia
• Psoriasis
• Rheumatoid arthritis
• Rosacea
• Sjogren’s syndrome
• Thyrotoxicosis
• VitiligoIndigestion, Antacids, Achlorhydria and H. Pylori. American Journal of Natural Medicine. (Jan-Feb 1997): 11-16
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Heidelberg pH Capsule Test
Normal Heidelberg gastrogram Achlorhydric gastrogram
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Replace: HCl
• Stomach makes 60-70 grains of HCl per meal
• 1 grain = 60mg
• 1 capsule = ~10 grains
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Replace: HCl
• Rest and Digest
• Stomach acid repletion protocol
• Bitters
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Decrease HCl Requirement
• Lemon juice or ACV
• Smaller meals
• Limit mealtime fluid
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Replace: Enzymes1413121110987654321
pH Scale Alkaline
Acid
Pancreatic enzymes
Mouth pH and resting stomach
HCl and pepsin
Food Enzymes
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Digestive Stimulation from SpicesPancreatic Amylases
Lipase Activity Disaccharides At least one
disaccharaseAlkaline
phosphatase•Ginger •Curcumin
•Curcumin •Coriander (nearly 300%) •Onion
•Ginger •Fennel •Cumin •Curcumin •Capsaicin (cayenne) •Piperine (black pepper)
Increased: •Onion •White coriander
Decreased: •Coriander •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?
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Digestive Stimulation from Herbs
• Globe artichoke
• Dandelion root
• Gentian
• Chamomile
• Turmeric
• Ginger
Ailment Pharmacol Ther 18 (2003): 1099-105.
Fitoterapia 75.7–8 (2004): 760–3.
Current Therapeutic Research 1981;29:525-536.
Mol Med Report. 2010 Nov 1;3(6):895-901.
J Altern Complement Med 10.6 (2004): 1015–18.
Dig Dis Sci 50.10 (2005): 1889–97.
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Replace: Bile Salts
• Secretes 700ml/day
• Functions:
• Emulsifies fat
• Cholesterol removal
• Toxin removal
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
• Cholestasis
• “Sludgy” bile
• Removal of gallbladder
Replace: Bile Salts
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Replace: Bile Salts
• Insufficiency Signs:
• Incomplete digestion/absorption of fats
• Steatorrhea
• Diarrhea
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
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
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Reinoculate
• Probiotics
• Prebiotics
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Microbial Individuality
The composition of the microbiota can shape a healthy immune response or predispose to disease.
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
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.”
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Reinoculate
• 2-5 lbs of bacteria in colon
• Prefer slightly alkaline environment
• Most pathogens anaerobic
• Most abundant species:
• Lactobacillus acidophilus
• Bifidobacterium bifidum
• Immune stimulation
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Clinical Nutrition: A Functional Approach: 2nd Edition. 2004. pp 206
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Reinoculate
• Natural antibiotics
• GALT
• Balance upset by:
• Ax and other Rx
• Alcohol
• Stress
• S.A.D.
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Probiotics
1. Either symbiotic or pathogenic
2. Help with absorption of nutrients
3. Break down polysaccharides
4. Produce SCFAs - feed flora downstream (butyrate feeds bifidobacteria)
5. Influence the brain
6. Educate the immune system
7. Ensure proper detoxification
8. Oral flora - nitrates to NO
9. Dysbiotic microbes suppress HCl
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Transfer of DNA
• Japanese can break down nori carbohydrate
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Probiotics: Mechanism of Action
Inhibits Pathogenic Bacteria
Improve Epithelial Function ↑ Immunoregulation
↓ Luminal pH Bacteriocidal proteins Colonization resistance ↓ Epithelial binding ↓ Epithelial invasion ↑ beta defensins
↑ SCFA (butyrate) ↑ Healing ↑ Mucous ↑ Apoptosis ↑ Barrier integrity ↑ HSP 25, 72
↑ IL-10, TGFb ↓ THF, IL-12 ↓ T cell proliferation ↑ Apoptosis TH1 cells ↑ sIgA ↓ NFkB
Sartor RB. J Clin Gastro. 2007;41:S37-S43.
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Probiotics - Competition
1. Competitive nutrient consumption
2. Epithelial cell receptor interaction
3. Excretion of antimicrobial substances
4. Interaction with the immune system
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
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.
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
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
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
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.
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Reinoculate
• Kimchi
• Sauerkraut
• Kombucha
• Yoghurt
• Kefir
• Pickles
• Miso
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
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
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
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 pathogensSartor RB. Curr Opin Gastroenterol. 2003, 19:358-365.
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
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
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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ADVANCED CLINICAL FOCUS
Repair
• Anti-inflammatories
• Digestive healing nutrients
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Repair
• Multi vitamin/mineral
• Protein
• Vitamin A and D
• Zinc (Carnosine)
• L-Glutamine
• EFAs
• Quercetin
• Botanical anti-inflammatories
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Vitamin D• Vitamin D deficiency is a
world-wide epidemic,1 2 3
with recent estimates indicating greater than 50% of the global population is at risk.4
• A high prevalence of vitamin D deficiency has been found across all age groups in all populations studied in 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.
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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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:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Vitamin D“Vitamin D...favours less Inflammation.”
Kidney International, Vol. 68 (2005), pp 1973-1981.
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Zinc Carnosine
“Regarding intestinal permeability, Zinc Carnosine caused an approximate threefold increase in gut integrity and repair.” Gut. 2007 Feb;56(2):168-75
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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ADVANCED CLINICAL FOCUS
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:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
• Preferential fuel • Vital for mucosal growth,
structure, and function • Deficiency = small bowel
atrophy • Maintains sIgA levels • #1 prescription for ulcers
in Asia
L-Glutamine
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
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
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
L-Glutamine
“[L-Glutamine] decreases villous atrophy, increases jejunal weight, and decreases intestinal permeability.” Alternative Medicine Review Volume 6, Number 4 2001
Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Essential Fatty Acids
Omega-3
• Fish, walnuts, flax, chia, eggs
• Anti-inflammatory
Omega-6
• Corn, safflower, red meat, cottonseed
• Anti-inflammatory or pro-inflammatory
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Essential Fatty Acids• Omega 3 converts into
EPA and DHA
• EPA = anti-inflammatory
• DHA = structure
Omega 3 (Flax)
EPA (Fish)
DHA (Fish)PG3 (Anti-inflammatory)
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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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:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Cell membrane
Phospholipase A2
Arachadonic Acid
Cyclooxygenase Lipooxygenase
Leukotrienes SRS-A
Prostaglandin 2 series
Thromboxane A2
Pharmaceutical modulation of Inflammation
Indomethacin Aspirin Ibuprofen Sulfasalazine
X
Cortisone X
X Colchicine
SulfasalazineX
Mullin GE, et al, Expert Review of Gastroenterology and Hepatology, April 2008
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Botanical Modulation of Inflammation
Mullin GE, et al, Expert Review of Gastroenterology and Hepatology, April 2008
Cell membrane
Phospholipase A2
Arachadonic Acid
Cyclooxygenase Lipooxygenase
Leukotrienes SRS-A
Prostaglandin 2 series
Thromboxane A2
Indomethacin Aspirin Ibuprofen Sulfasalazine
X
Cortisone X
X Colchicine
SulfasalazineXQuercetin Liquorice root
Quercetin Ginger Turmeric Bromelain White Willow Bark
Quercetin Turmeric Onion Garlic Boswellia
Potentiates cortisol: Liquorice root Turmeric
X X
XX
Ginger
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Turmeric
• Active component: Curcumin
• Anti-inflammatory
• Inhibits leukotriene formation
• Inhibits platelet aggregation
• Promotion of fibrinolysis
• Inhibition of neutrophil inflammatory process
• Stabilization of lysosomal membranes
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Turmeric MechanismHumira,
Remicade
Erbitux, Erlotinib, Geftinib
AsacolBharat B. et al. 2006
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
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
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Quercetin
• Inhibits mast cell and basophil degranulation
• Inhibits phospholipase A2 and lipoxygenase
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Rebalance
• Diet
• Balancing the ANS
• Stress
• Sleep
• Exercise
• Connection
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
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
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
The Gut-Brain Axis• Vagus nerve
• Signalling to and from the digestive tract
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Vagus Nerve Stimulation
• Gargling
• Singing loudly
• Gagging
• Coffee enemas
• Deep breathing
Kharrazian, Datis. Why My Brain Isn’t Working. 2013.
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Rebalance: Perception
Stimulus
Rest/Digest Stop/Think (PNS)
Fight/Flight/Fright (SNS)
Stress Hormones
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Body-Mind and DigestionRest and Digest Stop and Think
(Parasympathetic Nervous System)
or
Fright, Flight or Fight
(Sympathetic Nervous System)
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
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:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
• Deep breathing/meditation
• Heart rate variability
• Epsom salt baths
• Manual therapies
• Walking, yoga
• Nature
• CBT
• Adaptogens
• Less international travel
• Light therapy
Rebalance
Current Opinion in Gastroenterology. 2006;22(2):128-135
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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• Remove needs to take place first
• The other R’s can occur sequentially or together
• All R’s must be accounted for
The 5 R’s Guidelines
Leaky Gut Syndrome
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Tight Junctions
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
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Tight Junctions
Advanced Clinical Focus:Digestion and GI HealthDigestion
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Leaky Gut Syndrome - Causes• Dysbiosis
• Allergies
• Infections, parasites
• Drugs - NSAIDs, BCP, steroids radiation
• Alcohol
• Putrefying food
• Stress
• Environmental contaminants
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
The Viscous CycleGI Irritant
Leaky Gut
Allergy, Sensitivity, Microbe
Damage to GI
Malabsorption
Inflammation
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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ADVANCED CLINICAL FOCUS
GlutenEinkorn14 Chromosomes
Dwarf42 Chromosomes
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Celiac: 2x Every 15 years
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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1. Gluten induces release of zonulin2. Zonulin causes permeability3. Gluten into blood4. Immune mobilization5. Inflammation6. Antigenic memory
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Non-Celiac Gluten Sensitivity (NCGS)
“Increased intestinal permeability after gliadin exposure occurs in all individuals.”
Nutrients 2015, 7, 1565-1576.
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Gluten-Related Illness
Non-Celiac Gluten Sensitivity
No KnownReaction
CeliacDisease
• Bone and Joint pain• Osteoporosis• Leg numbness• Muscle Cramps• Unexplained anemia• Migraines
• Bone and Joint pain
• Osteoporosis• Leg numbness• Muscle
Cramps• Unexplained
anemia• Migraines• Behavioural
changes
• Amenorrhea• Infertility• Delayed
growth• Thyroiditis• Tooth
discolouration• Seizures• Dementia• Hepatitis
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
Gluten-Related Illness
Non-Celiac Gluten Sensitivity
No KnownReaction
CeliacDisease
• Bone and Joint pain• Osteoporosis• Leg numbness• Muscle Cramps• Unexplained anemia• Migraines
• Bone and Joint pain
• Osteoporosis• Leg numbness• Muscle
Cramps• Unexplained
anemia• Migraines• Behavioural
changes
• Amenorrhea• Infertility• Delayed
growth• Thyroiditis• Tooth
discolouration• Seizures• Dementia• Hepatitis
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Cross-Reactivity
Autoimmune Disease
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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ADVANCED CLINICAL FOCUS
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
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ADVANCED CLINICAL FOCUS
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
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Why Does The Body Attack Itself?
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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Autoimmune Disease
Genetics Environmental Trigger Gut Permeability
Nat Clin Prac Gastro & Hep, Sept 2005, Vol2;No.9
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ADVANCED CLINICAL FOCUS
2. Genetics
1. Trigger
3. Leaky gut
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Genes or Environment?
Arq. Gastroenterol. vol.46 no.1 São Paulo Jan./Mar. 2009
1986-2005: ↑ of 15-24x
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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Epigenetics
January, 2011
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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
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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Increase of Allergies 1990-2001
BMJ 2003;327:1142
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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
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Mechanism of GI Allergy
Mechanism
Immune-Mediated (“GI Allergy”)
Non-Immune-Mediated (“GI Intolerance”)
Holgate, Church and Lichtenstein: Allergy 3rd edition © 2006 Elsevier Ltd.
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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Mechanism of GI Allergy
Mechanism
Immune-Mediated (“GI Allergy”)
Non-Immune-Mediated (“GI Intolerance”)
IgE-Mediated Reactions
Other Immune Reactions
Holgate, Church and Lichtenstein: Allergy 3rd edition © 2006 Elsevier Ltd.
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Mechanism of GI Allergy
Mechanism
Immune-Mediated (“GI Allergy”)
Non-Immune-Mediated (“GI Intolerance”)
IgE-Mediated Reactions
Other Immune Reactions
Immune Complexes
T-Cell Mediated
IgA Mediated
Late Phase
Immediate Phase
Holgate, Church and Lichtenstein: Allergy 3rd edition © 2006 Elsevier Ltd.
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Mechanism of GI Allergy
Mechanism
Immune-Mediated (“GI Allergy”)
Non-Immune-Mediated (“GI Intolerance”)
IgE-Mediated Reactions
Other Immune Reactions
Toxic (occurring in any individual)
Non-Toxic (individual susceptibility)
Immune Complexes
T-Cell Mediated
IgA Mediated
Late Phase
Immediate Phase
Holgate, Church and Lichtenstein: Allergy 3rd edition © 2006 Elsevier Ltd.
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Mechanism of GI Allergy
Mechanism
Immune-Mediated (“GI Allergy”)
Non-Immune-Mediated (“GI Intolerance”)
IgE-Mediated Reactions
Other Immune Reactions
Toxic (occurring in any individual)
Non-Toxic (individual susceptibility)
Enzymatic (e.g. lactose intolerance)
Pharmacologic (e.g. vasoactive
amines)
Others (e.g. additive
intolerance)
Immune Complexes
T-Cell Mediated
IgA Mediated
Late Phase
Immediate Phase
Holgate, Church and Lichtenstein: Allergy 3rd edition © 2006 Elsevier Ltd.
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ADVANCED CLINICAL FOCUS
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
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Lactose Intolerance
Mahan LK, Escott-Stump S. Food Nutrition and Diet Therapy. Philedelphia, Pa: W.B.Saunders. 1996:625-626
Descent
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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The Immunoglobulin Isotypes
Allergology International 2007; 56: 349-361
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ADVANCED CLINICAL FOCUS
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 AnyPatient Awareness Always Rarely
Persistence of Ab Lifelong Months after elimination
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
The Immunoglobulin Isotypes
Class Features Major Activity
IgG
Transplacental23 Day half life circulating2-3 months mast cell half life
Protects tissues
IgE
Attaches to mast cellsContact with allergen causes release of histamine, etc.2.3 Day half-life14 Day mast cell half-life
Extreme sensitivityGatekeeper for IgAAnti-parasitic
IgATwo Forms:Serum - MonomerSecretions - Dimer
Protects mucousClears absorbed food
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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Immunoglobulins and Location
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& GI Health
ADVANCED CLINICAL FOCUS
Allergy/Hypersensitivity Testing
IgE IgG, IgG4
SerumSerumSkin Testing
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
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
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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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.
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Mullin, Swift, Lipski, Turnbull, Rampertab. Nutr Clin Pract 2010; 25; 192
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ADVANCED CLINICAL FOCUS
Conditions Helped by IgG Testing
• Atopic conditions Awazuhara, H. et al. (1997), el Rafei, A. et al. (1989), Nakagawa, T. et al. (1992), Hofman, T. (1995), Jenmalm, M.C. et al. (2000)
• Migraine headaches Alpay, K. et al. (2010), Mitchell, N. 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)
• Epilepsy Egger, J. et al. (1989)
• Glomerulonephritis Van der Woude, F.J. et al. (1983)
• ADHD Pelsser, L.M. et al. (2011)
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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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.
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What To Do: Prevention
• Vaginal birth versus C-section
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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
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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What To Do: Prevention
• Breastfeeding
• Maternal fish oils/probiotics
• Prebiotics/probiotics for both
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What To Do: PreventionRESEARCH ARTICLE Open Access
Perinatal probiotic supplementation in theprevention of allergy related disease: 6 yearfollow up of a randomised controlled trialMelanie 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 preventionof atopic dermatitis (AD) in early childhood, although the long term effects of probiotics on AD and otherallergic diseases is less certain. We have previously reported a significant reduction in the cumulativeincidence of AD at 2 years after maternal probiotic supplementation. In this study we present the effectsof perinatal probiotics given to women from a general population on allergy related diseases in their offspringat 6 years.
Methods: Four hundred and fifteen pregnant women were randomised to receive probiotic or placebo milk ina double-blinded trial from 36 week gestation until 3 months postpartum. Probiotic milk contained Lactobacillusrhamnosos GG, L. acidophilus La-5 and Bifidobacterium animalis subsp. lactis Bb-12. At 6 years, children werere-assessed for AD, atopic sensitisation, asthma and allergic rhinoconjunctivitis (ARC).
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 theprobiotic group compared to the placebo group (OR 0.64, 95 % CI 0.39-1.07, p = 0.086; NNT = 10). This findingwas statistically significantly in the complete case analysis (OR 0.48, 95 % CI 0.25-0.92, p = 0.027, NNT = 6). Theprevalence of asthma and atopic sensitisation, and the cumulative incidence of ARC were not significantlyaffected by the probiotic regime at 6 years of age.
Conclusions: Maternal probiotic ingestion alone may be sufficient for long term reduction in the cumulativeincidence of AD, but not other allergy related diseases.
Trial registration: ClinicalTrials.gov identifier: NCT00159523
Keywords: Allergy, Asthma, Atopic dermatitis, Paediatrics, Prevention, Probiotics, Rhinitis
BackgroundAtopic dermatitis (AD), asthma and allergic rhinocon-junctivitis (ARC) are a major cause of chronic disease inchildhood. A revised version of the “hygiene hypothesis”suggests that the pattern of colonisation and the diver-sity of the intestinal microbiota may be an importantfactor in the increased prevalence of these diseases
observed over the past several decades [1–3]. Subse-quently, probiotics have been investigated in the preven-tion and treatment of allergy related diseases [3–8], withthe strongest evidence emerging for the primary preven-tion of atopic dermatitis [3–5]. Throughout this paperwe refer AD, asthma and ARC as “allergy related dis-eases”, recognising that not all presentations of theseconditions are related to a classic IgE-mediated inflam-matory process.Randomised controlled trials (RCTs) testing probiotics
in the prevention of childhood allergy related disease areheterogeneous and have used a variety of bacterial strains,administration regimes and varying ages of follow-up.
* Correspondence: [email protected] of Public Health and General Practice, Faculty of Medicine,Norwegian University of Science and Technology (NTNU), Postboks 8905,MTFS, 7491, Trondheim, NorwayFull list of author information is available at the end of the article
© 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 et al. BMC Dermatology (2015) 15:13 DOI 10.1186/s12895-015-0030-1
“Maternal probiotic ingestion alone may be sufficient for long term reduction in the cumulative incidence of atopic dermatitis…”
Simpson MR, et al. BMC Dermatol. 2015; 15:13
Advanced Clinical Focus:Digestion and GI HealthDigestion
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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.
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“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.”
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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
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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
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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
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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
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Irritable Bowel Syndrome
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5 People Diagnosed With IBS
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5 Different Causes
Cause 3Cause 2Cause 1 Cause 4 Cause 5
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5 Different Causes
Cause 3Cause 2Cause 1 Cause 4 Cause 5
• Antidepressants • Antispasmodics • Laxatives • Antidiarrheals
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Cochrane Review of 40 StudiesThe evidence for drug therapies is
weak and there is no clear evidence of benefit for
antidepressants or bulking agents.
The Cochrane Library. N.p., n.d. Web. 08 June 2014.
Drug
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Placebo More Effective
Drug effects are smaller than the placebo effect in most
randomized trials.
Spiller R. Clinical Update: irritable bowel syndrome. Lancet. 2007;369:1586-1588.
>Placebo Drug
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“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.
?
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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
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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:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
IBS Symptoms
? ?
??
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Iatrogenesis
• Incorrect diagnosis
• Symptom overlap
• Unnecessary surgeries: cholecystectomy, hysterectomy, appendectomy, back surgery
Gastroenterol Clin North Am. 2005;34:189-204
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
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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)
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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.
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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.
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FODMAPs and IBS
F ermentable
O ligo
D i M ono-saccharides
A nd
P olyolsGibson PR, Shepard SJ, 2005
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
FODMAPs and IBS
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FODMAPs and IBS
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Low FODMAPs Improve IBS
Jour of Gastroenterol and Hepatol. 25 (2010) 1366-1373.
“Dietary FODMAPs induce … gastrointestinal and systemic symptoms experienced by patients with IBS.”
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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.
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Antibiotics and Gut Flora
Altern Med Rev. 2004;9:180-197
No Effect
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Antibiotics, Gut Flora, and Probiotics
Red area = AxBlue line = MicrobiomeRed line = SB with AxGreen line = SB after AxBlack dotted = SB during and after
(SB = Saccharomyces Boulardii)
Clin Exp Gastroenterol. 2015; 11:237-255.
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Jama. 2004. Vol. 292 No. 7
“The gastrointestinal immune effects of SIBO provide a unifying framework for understanding frequent
observations in IBS…”
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Distribution of Bacteria
Lin, H.C. JAMA 2004;292:852-858
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SIBO and IBS
• SIBO often found in IBS (78% in one study)
Am J Gastroenterol. 2000;95:3503-3506.
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Treating SIBO
Glob Adv in Health and Med. May 2014;3:3 pp 16-25
Response rate:Rifaximin 34% vs Herbal Therapy 46%
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Treating SIBO
Glob Adv in Health and Med. May 2014;3:3 pp 16-25
Herbal therapies:• Candibactin-AR and Candibactin-BR (Metagenics)•FC-Cidal and Dysbiocide (Biotics)
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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%)
Common Parasites
Courtesy of Dr. Patrick Hannaway
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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
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Symptoms persist 3 years after treatment.
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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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Bifidobacterium, Lactobacillus, Placebo in IBS Over 8 Weeks
Gastroenterology. 2005;128(3):541-551
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Peppermint Oil
• Natural antispasmodic
• C. Albicans
• Note: Relaxes LES
J Gastroenterol 1997;32:765-68
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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
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Stress and IBS
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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
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IBD: Theories of Etiology
Genetic
Infection Immunologic
Psychosomatic Diet
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Genes or Environment?
Arq. Gastroenterol. vol.46 no.1 São Paulo Jan./Mar. 2009
1986-2005: ↑ of 15-24x
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Diet: What Don’t We Know?
• The best diet for IBD
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Not knowing the
right thing
doesn't necessarily mean
we don’t know
the wrong thing.
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• 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
Clinical Implications of Diet on IBD
Integrated Healthcare Practitioners. June/July 2014, p. 55
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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-3Thornton 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
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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
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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
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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
• Control of Crohn’s enhanced by sucrose eliminationMatsui et al., 1990; Martini & Brandes, 1976; Thurton, Emmet, & Heaton, 1979; Mayberry, Rhodfes, & Newcombe
Heaton, Thornton, & Emmet, 1979
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FODMAPs and Crohn’s
F ermentable
O ligo
D i M ono-saccharides
A nd
P olyolsGibson PR, Shepard SJ, 2005
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
ADVANCED CLINICAL FOCUS
FODMAPs and Crohn’s
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FODMAPs and Crohn’s
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Low Sulfur Diet in Ulcerative C.
• Protein = ↑ sulfide in colon
• Protein (esp. meat), total sulfur and sulfates influence relapse
• Some evidence for low sulfur dietRoediger, 1998
Jowett et al., 2004
Magee, Richardson, Hughes, & Cummings, 2000
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Crohn’s Disease: Exclusion Diets
78 Patients ✗Eliminate✓ Maintain
Riordan et al., 1993
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Crohn’s Disease: Exclusion Diets
Percentage in remission (%)
0
17.5
35
52.5
70
6 Months 2 Years
Steroids Diet
70%
34%38%
21%
Riordan et al., 1993
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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%/yearAlun Jones, Workman, & Freeman, 1985
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Crohn’s Disease and Yeast
• Many CD patients have AB to Baker’s/Brewer’s yeast
• Increases TNF-alpha
Barnes et al., 1990
Konrad et al., 2004
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IBD and Deficiencies
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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
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Alimentary Pharmacology & Therapeutics Volume 32, Issue 3 pages 377- 383, 11 MAY 2010
• 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
Clinical Trial: Vitamin D3 treatment in Crohn’s disease
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335
Advanced Clinical Focus:Digestion and GI HealthDigestion
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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
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
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
Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335
Advanced Clinical Focus:Digestion and GI HealthDigestion
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Fish Oils and IBD:Animal Studies
• 6/6 mice models of ulcerative colitis showed protection from injury and healing with omega-3 fatty acids.
Proc Natl Acad Sci U S A. 2006;103(30):11276-11281. Clin Nutr. 2006;25(3):466-476. 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.
Fish Oil Placebo
Protection UC
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
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Ulcerative Colitis - Summary• 9 randomized controlled trials
• 4.7 g EPA/DHA/day (Average)
• Duration 35 weeks (Average)
Two or more:
• Reduce ulceration
• Reduce overall disease
• Reduce drug use
• Reduce relapse
• Increase remission
Advanced Clinical Focus:Digestion and GI HealthDigestion
& GI Health
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Cell membrane
Phospholipase A2
Arachadonic Acid
Cyclooxygenase Lipooxygenase
Leukotrienes SRS-A
Prostaglandin 2 series
Thromboxane A2
Pharmaceutical modulation of Inflammation
Indomethacin Aspirin Ibuprofen Sulfasalazine
X
Cortisone X
X Colchicine
SulfasalazineX
Mullin GE, et al, Expert Review of Gastroenterology and Hepatology, April 2008
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Botanical Modulation of Inflammation
Mullin GE, et al, Expert Review of Gastroenterology and Hepatology, April 2008
Cell membrane
Phospholipase A2
Arachadonic Acid
Cyclooxygenase Lipooxygenase
Leukotrienes SRS-A
Prostaglandin 2 series
Thromboxane A2
Indomethacin Aspirin Ibuprofen Sulfasalazine
X
Cortisone X
X Colchicine
SulfasalazineXQuercetin Liquorice root
Quercetin Ginger Turmeric Bromelain White Willow Bark
Quercetin Turmeric Onion Garlic Boswellia
Potentiates cortisol: Liquorice root Turmeric
X X
XX
Ginger
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
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Turmeric
“Studies involving curcumin to date in the field of IBD have been consistently positive.” Nutrition in Clinical Practice 23:49-62, Feb 2008
Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335
Advanced Clinical Focus:Digestion and GI HealthDigestion
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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:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
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 cfu of bacteria daily for six weeks.
• Treatment of patients with mild to 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.
53%
24%
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
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• 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
Psychological Stress and IBD
Mawdsley J E, Rampton D S Gut 2005;54:1481-1491
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Psychological Stress and IBD
Mawdsley J E, Rampton D S Gut 2005;54:1481-1491
Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335
Advanced Clinical Focus:Digestion and GI HealthDigestion
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Psychological Stress and IBD
• Meditation
• Light Exercise
• Yoga
• Acupuncture, massage, bodywork
• Nature walks
• Music
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Digestive Healing Diets
Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Diets For GI Healing
• Gluten-Free/Casein-Free
• SCD Diet
• FODMAP
• Low Sulphur Diet
• Comprehensive Elimination Diet
• Anti-Fungal Diet
• Anti-Inflammatory Diet
• Restoration Diet
• Palaeolithic Diet (Autoimmune)
• GAPS Diet
Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335
Advanced Clinical Focus:Digestion and GI HealthDigestion
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Diets For GI Healing
What do these all have in common?
Elimination No processed foods No refined sugar Good fats
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Digestive Healing Foods
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Functional Foods
Advanced Clinical Focus:Digestion and GI HealthDigestion
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Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
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Fibre: Friend or Foe?
Advanced Clinical Focus:Digestion and GI HealthDigestion
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FibreEast Africans • 100 g of Fibre • 18-24 hours
transit time
North Americans • 25 g of Fibre • 72 hours transit time
Jensen, Bernard. Dr. Jensen’s Guide to Better Bowel Care. Avery: 1999.
Advanced Clinical Focus:Digestion and GI HealthDigestion
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Relax, sir. The hair in your soup provides fibre.
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
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FibreSoluble Fibre:
• Soothing • Partially and Completely
Fermented: • Short Chain Fatty Acids • Gases
Insoluble Fibre: • Not fermented • Speeds transit time • Adds bulk
Advanced Clinical Focus:Digestion and GI HealthDigestion
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Mucilaginous Foods/Herbs
• Slippery elm powder
• Marshmallow root
• Flax seed
• Chia seed
• Aloe vera
• Okra
Advanced Clinical Focus:Digestion and GI HealthDigestion
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Bone Broths
• Gelatin
• Free amino acids
• Calcium
• Glycinate
• Proline
• Phosphorus
• Hyaluronic acid
• Chondroitin sulfate
• Magnesium
• Potassium
• Sulfate
• Fluoride
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
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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:Digestion and GI HealthDigestion
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Therapeutic Diet/Food Summary
• Choose the appropriate diet (GET/RID)
• Eliminate problematic foods
• Choose therapeutic foods
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Factors to Consider
• Symptom control
• Modified diet
• Heal the gut
• Reintroduce and rebalance
Diet Functional Foods
SupplementsLifestyle
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved
Advanced Clinical Focus:Digestion and GI HealthDigestion
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ADVANCED CLINICAL FOCUS
Current
EvidencePatient’s
Story
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Personalized
Advanced Clinical Focus:Digestion and GI HealthDigestion
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Applied Knowledge Is Power.
Copyright © 2015 ● Josh Gitalis Ba(H), RNCP/ROHP, CNP ● All Rights Reserved