NATURAL WAYS TO NATURAL WAYS TO DIGESTIVE HEALTHDIGESTIVE HEALTH

• Stephen Holt, MD LLD (Hon.) ChB., PhD, DNM, DSc, FRCP (C) , MRCP (UK), FACP, FACG, FACN, FACAM, KSJ

• Distinguished Professor of Medicine (Emeritus)

• Scientific Advisor, Natural Clinician LLC

INTRODUCTIONINTRODUCTION

• Without efficient digestive function, general health cannot prevail

• A “rumble” in the guts produces a “rumble” in the mind and vice versa

• The most common digestive disorders are functional in origin

• Integrative Medicine cannot impact “plumbing problems” in the gut

FUNCTIONAL DIGESTIVE FUNCTIONAL DIGESTIVE DISORDERSDISORDERS

• Commonest cause of digestive upset

• A lack of harmony of digestive function (Claude Bernard)

• Involves the brains of the body and the “brains” of the gut

• The mind-body or body-mind

• Constitutes about 75% of all GI work

REGION OF GUT DISORDER

Mouth Bruxism

Rumination

Esophagus Globus-Sensation

Functional chest pain

Functional heartburn?

Functional dysphagia

Aerophagia

Stomach and duodenum

Non-ulcer dyspepsia

Small Intestines Irritable Bowel Syndrome

Large Intestines Irritable Bowel Syndrome

RED FLAG SYMPTOMSRED FLAG SYMPTOMS• Difficulty in swallowing

• Common first symptom of cancer of the

esophagus especially in adults.• Persistent, new

abdominal pain • Abdominal pain must be taken

seriously. It may signal serious diseases.

• Family history of bowel cancer, inflammation or polyps

• These diseases run in families.

• Blood in the stool or vomit

• Bleeding common among individuals with cancer or ulcers.

• Change in digestive function in people over the age of 40 years

• Most cancers in the gastrointestinal tract occur with advancing age.

• Systemic symptoms

• Weight loss, fever, joint disease etc.

COMMON ALTERNATIVE INTERVENTIONSCOMMON ALTERNATIVE INTERVENTIONS

• Nutritional Therapies, Nutraceuticals

• Purging for health (Colonic Therapies)• Special Food Combinations (Allergies)• Prebiotic and Probiotic Therapy• Specific Remedies of Natural Origin• Lifestyle Change• Digestive Enzymes• Gut Detoxification• Biopharmaceutical Concepts

THE MOUTH: NO MAN’S LANDTHE MOUTH: NO MAN’S LAND

• Dentists don’t speak to doctors and vice versa

• Revolving door phenomenon

• Poor oral health spells disease

• Bacterial translocation

• CVS, respiratory and gut disease

• Concept of oral biocleansing

GERD: ACID REFLUXGERD: ACID REFLUX

• Mismatch between symptoms and severity of esophagitis

• Endoscopy indicated in persistent symptoms or dysphagia

• Oxidative tissue damage contributes to Barrett’s metaplasia (pre-cancer)

• A peptic stricture may hide cancer• Dysphagia over the age of 45 years is

cancer until proven otherwise

GERD: ACID REFLUXGERD: ACID REFLUX• Obtrusive problems with many

unobtrusive issues

• Laryngitis, globus sensation, asthma and COPD

• Coexistence of obesity and Metabolic Syndrome X

• Adverse effects of medication (occult)

• Misdiagnosis

GERD MANAGEMENTGERD MANAGEMENT• Staged intervention strategies• Lifestyle changes, weight control,

beverages, sleep propped up, exercise and posture, drugs etc.

• Acid neutralization• Inhibition of acid secretion • Mucosal protection• Rebound phenomena

PUMPING ACIDPUMPING ACID

HOLISTIC NUTRACEUTICAL HOLISTIC NUTRACEUTICAL APPROACH TO GERDAPPROACH TO GERD

• Neutralize gastric acid: fava bean flour (USP standard), sodium bicarbonate (2% RDI, Na), Ca, Mg

• Natural inhibitors of the proton pump e.g. ellagic acid: c.f. H+/K+ ATP-ase

• Antioxidants: E, C, green tea, turmeric, beta carotene: REDOX balance

• Miscellaneous: mastic gum, lecithin, apple pectin, gastric mucin, Zn

EFFECTS OF ELLAGIC ACID REFERENCES

ANTI-CANCER EFFECTS:INHIBITION OF CARCINOGENICITY AND MUTAGENICITY

Ratnoff, O.D., Crum, J.D. (1964) J. Lab. Clin. Med. 63, 359; Bhargava, U.C., Westfall BA (1968) J. Pharm. Sci. 57, 1728

POWERFUL ANTIOXIDANT EFFECTS

Constantin A et al. “The dietary anti-cancer agent ellagic acid is a potent inhibitor of DNA topoisomerasie in Vitro.” Nutr. Cancer 23 (2): 121-30, 1995

REDUCTION OF BLOOD PRESSURE Fiedler, V., Hildebrand, G.H. (1954) Arznelmittel Forsh 4, 426

INHIBITION OF THROMBOXANE B2 SYNTHESIS

Kimura, Y., Okuda, H., Okuda, T., Arichi, S. (1986) Planta Med. 52, 337

INHIBITION OF ACID SECRETION BY THE STOMACH: BLOCKS GASTRIC PROTON PUMPS

Murakami, S., Kijima, H., Isobe, Y., Muramatsu, M., Aihara, H., Otomo, S., (1991), Planta Med. 57, 305-308

UNRESOLVED ISSUES IN ACID UNRESOLVED ISSUES IN ACID PEPTIC DISEASEPEPTIC DISEASE

• Holt S, “Over-the-counter Histamines H2-receptor Antagonists. How will they affect the treatment of acid-related diseases?” Drugs 47(1): 1-11, 1994

• Removal of acid defense promoting gut infection e.g. traveler's diarrhea

• Consequences of hypochlorhydria or achlorhydria• Promotion of gastric cancer? (nitrosamine)• Drug induced nutrient depletion e.g. Vit. B-12• Reinforcement of adverse lifestyle by symptom

reduction, with limited effects on the natural history or clinical course of the disease

SYMPTOMS AND SIGNS OF SYMPTOMS AND SIGNS OF HYPOCHLORHYDRIAHYPOCHLORHYDRIA

SYMPTOMS SIGNS

Bloating, belching, burning and flatulence immediately after meals

Itching around the rectum; weak, peeling and cracked fingernails; dilated blood vessels in the cheeks and nose

A sense of “fullness” after eating Acne

Indigestion, diarrhea or constipation Iron deficiency, calcium deficiency

Multiple food allergies Chronic intestinal parasites or abnormal flora

Nausea after taking supplements Undigested food in stool; chronic Candida infections; functional symptoms in upper digestive tract; gas, belching, bloating and dyspepsia

THE GASTRO DUODENUMTHE GASTRO DUODENUM

PEPTIC ULCER DISEASE

• Potent antisecretory drugs put surgeons out of work, but their legacy remains with post gastrectomy or post vagotomy complications (DDD)

• Helicobacter pylori is a miscreant

• Mind-body plays a role: Tidy, H, “The Incidence of Peptic Ulcer at St. Thomas’ Hospital” BMJ, 1, 319, 1945

PEPTIC ULCERPEPTIC ULCER

Dr. H Tidy stated in 1945, BMJ:

Psychoneurotic stimuli (mind) may pull the trigger (referring to peptic ulcer complications), but some other hand has previously loaded the gun.”

HELICOBACTER PYLORIHELICOBACTER PYLORI

• A bug that lies below the layers of gastric mucus in the antrum

• Switches on acid

• Damages tissue by major generation of free radicals and oxidative stress

• Peptic ulcer disability worse in substance abusers: oxidative stress

KEY CONCEPT: THE KEY CONCEPT: THE ANTIOXIDANT APPROACHANTIOXIDANT APPROACH

• The role of oxidative stress in the generation of acid peptic disease has been well defined but ignored as an important focus of therapeutic intervention

• Oxidative stress promotes tissue injury, inflammation, metaplasia and cancer in the upper digestive tract

• All individuals with acid peptic disease should receive REDOX balanced antioxidants

NSAID: PUBLIC HEALTH CONCERNSNSAID: PUBLIC HEALTH CONCERNS

• Cox inhibition: Cox 1 versus Cox 2 • Onerous side effect profile• Massive increase in prescription and OTC use• Holt S, et al. Nonsteroidal anti‑inflammatory

drugs and lower gastrointestinal bleeding. Dig Dis Sci 38:1619-1623, 1993.

• Holt S, et al. Gastric mucosal injury induced by anti-inflammatory drugs (NSAIDs). Southern Medical Journal 84, 3:355-360, 1991.

• Holt S, et al. Omeprazole: overview and opinion. Digestive Diseases and Sciences 36(4):385-93, 1991.

REDUCING THE BURDEN OF REDUCING THE BURDEN OF NSAID DAMAGENSAID DAMAGE

• Reduce NSAID dosage by topical bone and joint rubs with evidence-based dietary supplement strategy

• Synergistic formulation of chondroprotection, herbal Cox-2 inhibition, immune tolerance and specific anti-inflammatory agents

• Therapeutic tips: “delayed onset”

IRRITABLE BOWELS OR GUTSIRRITABLE BOWELS OR GUTS

• Visceral learning • About 25M Americans have “The IBS,

a condition that includes the presence of long lasting (>3m) or intermittent abnormalities of bowel habit, with or without lower abdominal pain or discomfort, not explained by causes involving any structural or metabolic changes” c.f. Functional Dyspepsia

MANAGEMENT OF IBSMANAGEMENT OF IBS• A perfect target for Integrative

Medicine• Controlled trials reinforce visceral

learning: body-mind approach, relaxation responses, self hypnosis

• A mixed bag of disorders: benefit of smooth muscle relaxation, fish oil, synergistic GI balancing formulae

• Back to Claude Bernard

COLON CLEANSINGCOLON CLEANSING

• Synergistic, gentle, herbal, water-retaining supplements which facilitate exodus of stool

• Lifestyle change, fiber etc.

• A role for colon hydrotherapy

• Must consider concepts of CDR

FIBER SUPPLEMENTSFIBER SUPPLEMENTS• Soluble and insoluble fibers• Fiber has predictable effects by

consideration of physicochemical properties e.g. bran vs. hydrocolloids

• Soluble fibers have intrinsic metabolic effects

• Fiber must interact with colonic bacteria to exert its many benefits

FIBER: THE GLYCEMIC INDEXFIBER: THE GLYCEMIC INDEX

• Calculations of the glycemic index of food are probably a waste of time.

• Understanding factors that control gastric emptying rate can result in inference about the glycemic index.

• Slowing gastric emptying slows glucose absorption – relevance in acute dosing

FIBER: THE GLYCEMIC INDEXFIBER: THE GLYCEMIC INDEX

Holt S, et al Effect of Gel Fiber… Lancet, March 24th, 1979.

MECHANISMS OF DIARRHEAMECHANISMS OF DIARRHEA

• Exudative diarrhea: infection, inflammation

• Osmotic diarrhea: lactose, magnesium

• Secretory diarrhea: cholera, hormones

• Diarrhea due to motor disturbances: IBS, post cholecystectomy

FOOD ADDITIVESFOOD ADDITIVES

• Recurrent skin rashes, urticaria, angiodema

• Respiratory disorders

• Attention deficit disorder

PROBIOTICSPROBIOTICSHUMAN FOOD SUPPLEMENTS ANIMAL FEED SUPPLEMENTS

• Lactobacillus acidophilus DDS-1 • Lactobacillus acidophilus DDS-1

• Lactobacillus brevis • Lactobacillus plantarum

• Lactobacillus bulgaricus • Lactobacillus casei

• Lactobacillus casei • Steptococcus faecium

• Lactobacillus casei spp Rhamnosus • Steptococcus lactis• Lactobacillus caucasius

• Lactobacillus plantarum

• Lactobacillus salivarrus

• Bifidobacterium bifidum

• Bifidobacterium longum

• Steptococcus faecium

PROBIOTICS: BENEFITSPROBIOTICS: BENEFITS• Assistance with digestion• Alleviation of digestive disorders, e.g., colitis, IBS, peptic ulcer.• Enhanced mineral absorptions, especially calcium.• Enhancement of the synthesis of several vitamins (especially

B complex).• Protection against pathogenic bacterial infections, e.g., E. coli

infection.• Reduction of symptoms of lactose intolerance; permits limited

reintroduction of dairy products.• Reduction of yeast overgrowth (Candidiasis); notable reduction

in vaginal thrush.• Improvement in immune function; “primes” the gut immune

system.• Anticancer effects, some good evidence.• Prevention of Helicobacter pylori infection and its association

with peptic ulcer, dyspepsia and gastric cancer.• Acne prevention (?)• Cholesterol reduction, modest and unpredictable.

THE CANDIDA CONTROVERSYTHE CANDIDA CONTROVERSY

• Candida albicans: innocuous gut inhabitant or pathogen

• Opportunistic organism with gliotoxin, which depresses immunity

• Combined use of prebiosis, probiosis, enzymes and detox

• Dietary change: sugar elimination

ORGANIC FOODORGANIC FOOD• Favored for enhanced nutrient

density and absence of organochemicals

• Pesticides and fertilizers are growth promoters and may contribute to body toxicity that promotes obesity TOXIC LIPOGENESIS

• Food contamination: strawberries, cherries, apricots, grapes etc.

• Economic disadvantages

PARASITESPARASITES• Clever organisms that are not “fooled

by a dose of salts”

• Effective management involves eradication. Most predictable by the use of drugs, cleansing inadequate?

• Herbal approaches are variable e.g. black walnut, grapefruit seed, wormwood, rosemary, thyme, marshmallow and citrus peel

LEAKY GUTS 1LEAKY GUTS 1• Damage to tight junctions in the

intestinal lining• “Chicken and Egg arguments”• Disease associations: drug usage,

autoimmune disease, gastrointestinal disease, skin disease, AIDS, etc.

• Causes: drugs (NSAID), infections, radiation therapy, trauma, TPN

• Dysbiosis: classic lack of harmony

LEAKY GUTS 2LEAKY GUTS 2

• Concepts of “CDR,” with focus on “R”• Glutamine, barrier protomorphogens • Soluble fiber, e.g. oat beta glucan• EPA, decrease leukotriene B4, TNF,

reduction in Type 2 prostaglandins• Flavonoids: Ginkgo, Quercetin, etc • Probiosis, prebiosis, enzymes, detox

CONCLUSIONCONCLUSION

• Without digestive health, general health will not prevail

• Practitioners of Integrative Medicine are focused on restoring digestive harmony as a premonitory to the management of all disease

• New advances in nutraceutical technology remain underexplored

• Think digestive health as a baseline