Building Demand for California Dried Plums

2007-2008 Public Relations Recommendations

June 28, 2007

2

Case Study

Mrs. K: 32 y/o AAF executive at her PMD’s office

• Feels “bloated”, gassy, infrequent stools• Lower abdominal cramps • Improved with BM’s (approx 3/week)• Occurs unpredictably, for last 7 months• Lasts for few days, then goes away• No interference w/ daily activities• Worried it might be “something serious”

3

Case Study continued

Mrs. K: History and Physical

• PMH: “food poisoning” one year ago• PSH: none• MEDS: colace qd• FH: mother has “minor depression”• SH: married, highly active, no T/E/D• Physical exam: normal; BMI = 24• Labs: no anemia, ESR & CRP normal

DIGESTIVE HEALTH: DIGESTIVE HEALTH: THE RD’s PERSPECTIVETHE RD’s PERSPECTIVE

Leslie Bonci,MPH,RD,LDN,CSSDLeslie Bonci,MPH,RD,LDN,CSSD

Director of Sports NutritionDirector of Sports Nutrition

University of Pittsburgh Medical CenterUniversity of Pittsburgh Medical Center

55

WHAT ARE WE HEARING?WHAT ARE WE HEARING?

• Rock hard abs• Commercials for various GI medications• Increased product availability- OTC/supplements• Diarrhea/Constipation are dinner table

conversation• Detox• Colon cleansing

66

THE FACTSTHE FACTS

• Eating can be a trigger for gut problemsGood digestive health is the ability to digest, absorb and utilize nutrients

• It is not just about the food, but also the eating habits:– Timing– Quantity– Where one eats– How one eats

77

GETTING TO GOOD DIGESTIVE GETTING TO GOOD DIGESTIVE HEALTHHEALTH

• Achieving/maintaining an appropriate weight

• Eating a diet that is balanced, varied, and individualized to address digestive concerns

• Stress reduction

• Physical activity

88

LIFESTYLE INFLUENCERSLIFESTYLE INFLUENCERS

• Stress

• Irregular schedule

• Travel’s effect on food choices

• Busy lives

99

BARRIERSBARRIERS

• Patients are not always forthcoming with symptoms/complaints

• Patients may try to self-treat

• Power of suggestion

• Sensitive subject

• Food safety concerns

1010

TREATING DIGESTIVE TREATING DIGESTIVE DISORDERS WITH DIETDISORDERS WITH DIET

• Not black and white

• No guarantee that symptoms will abate

• May have to experiment over several months

• Outcomes may be more subjective than objective

1111

DIETS THAT CAN AFFECT THE DIETS THAT CAN AFFECT THE GUTGUT

• High protein/high fat– Low-carb products

• High carbohydrate– High fiber

• Fad diets– Cabbage soup/food combining

1212

SUPPLEMENTS THAT AFFECT SUPPLEMENTS THAT AFFECT THE GUTTHE GUT

• Vitamin Mineral supplements– Mega dose Vitamin C – Potassium supplements – Calcium– Iron supplements– Large doses of Magnesium

• “Energy” Drinks

• Flaxseed/Flaxseed oil

1313

OTHER POTENTIAL OFFENDERSOTHER POTENTIAL OFFENDERS

• Echinacea

• Chitosan

• Dieter’s Tea

• Glucosamine

• Fish oil capsules

1414

THINGS TO KEEP IN MINDTHINGS TO KEEP IN MIND

• There is not ONE eating plan

• Need to customize and individualize eating

• Need to make changes gradually

• Need to monitor eating to discover potential food and habit stressors, as well as foods that are well tolerated

1515

WHAT TO TELL PATIENTSWHAT TO TELL PATIENTS

• Make meal times relaxed• Take time to eat• Allow time for food to digest• Eat at regular intervals• Eat smaller amounts at any given eating

episode• Take small bites• Focus on eating, not everything else

1616

WHAT SHOULD THEY DO?WHAT SHOULD THEY DO?

• Keep a food/symptom diary listing :– Foods eaten– Quantity– Time consumed

• Document outcomes:– Symptom relief– Decrease in symptom frequency– Better sleep patterns– Improved energy– Different bowel patterns

1717

FOCUS ON FUNCTIONAL FOODSFOCUS ON FUNCTIONAL FOODS

• Yogurt- probiotics

• Dried plums- fiber/sorbitol

• Oats- beta-glucan,prebiotics

• Orange juice, eggs, peanut butter, spreads- Omega-3 enhanced foods

1818

TRAVEL GUIDELINESTRAVEL GUIDELINES

• Bottled water on planes• Travel with “safe” foods- packets of oatmeal,

nuts, dried fruits• www.cdc.gov/travel• List of food concerns if traveling to other

countries• Travel with bouillon cubes, sports drink powder• Wash hands frequently, or use wipes

1919

GOOD GUT TRAVEL KITGOOD GUT TRAVEL KIT

• Nausea• Sports drink • Candied gingerroot

• Constipation• Ground flaxseed • Dried plums/fig bars

• IBS/Abdominal cramps• Chamomile tea

• Diarrhea• Raspberry tea/Blackberry root bark tea • Sure-Jel or Certo• Carob powder

2020

FINAL WORDSFINAL WORDS

• The emphasis needs to be on what patients can have- NOT what they can’t!!!

2121

DIET RECOMMENDATIONS FOR DIET RECOMMENDATIONS FOR MRS KMRS K

• Ask about recent change in diet• Food diary to ascertain potential offenders: bloat

and gas causing foods/beverages• Discuss food habits- eating on the go, or sitting

down to meals• Ask about supplement use• Ask about exercise routine• Discuss ways to GRADUALLY add fiber to the

diet, along with adequate fluids

2222

CONTACTCONTACT

• Leslie Bonci, MPH, RD

• Phone (412) 432-3674

• e-mail: boncilj@upmc.edu

• American Dietetic Association’s Guide to Better Digestion!

23

Identifying and Achieving Digestive Health – A Look to the Future

UCLASpecialty

Training andAdvancedResearchProgram

Leo Treyzon M.D.

Divisions of

Digestive Diseases &

Clinical Nutrition

David Geffen School of Medicine at UCLA

24

Disclosures

1. NIH Training Grant

2. UCLA STAR Program

3. Annenberg GI Fellowship Award

4. UCLA Center for Human Nutrition

5. Digestive Health Organization and CDPB

25

Why is this an important topic?

• Unpredictable, uncomfortable and embarrassing

• Large economic burden

• Next frontier in health care is prevention

26

Hard to Define

I can’t describe it, but… “I know when I see it”

– Justice Stewart, Ohio Supreme Court

Jacobellis v. Ohio, 378 U.S. 184, 197 (1964)

27

Defining Digestive Health

“Good digestive health indicates an ability to process nutrients through properly functioning gastrointestinal organs, including the stomach, intestines, liver, pancreas, esophagus and gallbladder. Most people who are in good digestive health are of appropriate weight and don’t regularly experience symptoms like heartburn, gas, constipation, diarrhea, nausea or stomach pain. Eating a nutritious diet is needed to maintain a healthy digestive system and may prevent and treat certain digestive diseases.”

American Gastroenterology Association

28

Definition – Digestive Health

• Ability to digest, absorb and utilize nutrients • Eliminate waste products• Optimizes vitality, and resilience• Appropriate weight is central theme • Don't regularly experience bothersome digestive

symptoms• This state of well-being is achieved by:

– consuming a nutritious diet– minimizing emotional stressors– embracing physical activity

• Oriented to the prevention of chronic disease.

29

Other Approaches to Health

Bio-Medical – the body as machine; disease oriented

Behavioral – health as energy – lifestyle

Bio-psycho-social – attempts to address deficiencies of behavioral model within biomedical context

Socio-environmental – a means to realize aspirations and change environments

30

Strengths of Digestive Health Approach

• Individualized to the person

• Creates energy and balance in self

• Focus on individual responsibility

• Focus on lifestyle change for health and disease prevention

• Spiritual connection to natural environment

31

32

Leading GI Symptoms Prompting U.S. Outpatient Clinic Visits in 2002

Rank GI Symptom# of Visits

(Millions)Rank GI Symptom # of Visits

(Millions)

1Abdominal pain, cramps, spasms

11.89

Other GI Symptoms (unspecified) 0.89

2 Diarrhea 3.7 10 Anorectal Symptoms 0.87

3 Vomiting 2.6 11 Melena 0.81

4 Nausea 2.1 12 Abdominal Distension 0.79

5 Constipation 1.8 13 Dysphagia 0.76

6 Rectal Bleeding 1.5 14 Lower Abdominal Pain 0.75

7 Heartburn 1.4 15 Appetite Decrease 0.55

8 Dyspepsia 0.9

Shaheen NJ et al . Am J Gastroenter 2006.National Ambulatory Medical Care Survey 2002.

33

Physician Diagnoses for GI Disorders in Outpatient Clinic Visits

Rank DiagnosisNumber of Visits

(Millions)

1 GERD 5.51

2 Abdominal Pain 4.17

3 Gastroenteritis 3.32

4 Constipation 2.56

5 Dyspepsia, Gastritis 2.29

6 Irritable Bowel Syndrome 2.06

7 Hemorrhoids 1.54

8 Diverticular Disease 1.49

9 Hepatitis C infection 1.24

10 Hernia, noninguinal 1.23

Shaheen NJ et al . Am J Gastroenter 2006.National Ambulatory Medical Care Survey 2002.

34

MDVisitsPer

Year

MDVisitsPer

Year

IBSIBS NormalNormal00

11

22

33

44

55

ComplaintsComplaints

66

Non-GINon-GI

GIGI

Drossman DA, et al., Dig Dis Sci 1993; 38:1569Drossman DA, et al., Dig Dis Sci 1993; 38:1569

Physician Visits per Year (GI and non-GI)

35

Work or School AbsencesWork or School Absences

IBSIBS NormalNormal00

22

44

66

88

1010

1212

1414

Daysper Year

Daysper Year

Drossman DA, et al., Dig Dis Sci 1993; 38:1569Drossman DA, et al., Dig Dis Sci 1993; 38:1569

36

Beyond the economic costs… QOL matters too!

37

Barriers toward Digestive Health Promotion

• Medical culture oriented towards cure– Doctors’ preference vs. patients’ preference– ER and House vs. “The Preventionist”

• If you cannot avoid an illness, at least catch it early and prevent it from causing harm.

• Identification of risk factors• Modification of risk factors early in course• “Periodic Health Examination”

38

Where is Digestive Health Accomplished?

• Health Provider Level– learning how to screen effectively– counseling effectively (integrative health approach)

• Societal Level– public education– regulations oriented toward healthy lifestyle– national prevention guidelines

• Patient Level– being inquisitive– taking interest in health

39

What is new in Digestive Health research in 2007?

• Dietary fructose

• Weight Disorders – CNS role in eating behaviors– Weight Loss and Longevity– Doctor-Dietitian Duo– Gut ecology and Obesity

• Probiotics

40

Fructose Malabsorption in Normal Persons

• Dose-response study from which they developed a fructose malabsorption breath test .

• 20 persons got on 4 separate days:– 10% solution of 15 g, 25 g, or 50g fructose– 33% solution 50 g fructose

• Analyzed H2 and CH4 over 5 hours

Rao, S, et al. Clin Gastro and Hepatol 2007.

41

H2 and CH4 concentration after intake of different doses of fructose

Rao, S, et al. Clin Gastro and Hepatol 2007.

42

Results

• No subject tested (+) with 15 g. No gender differences.• 10% (+) with 25 g fructose but were asymptomatic. • 50 g (10% solution)

– 80% (+) breath test • H2 - 65%• CH4 in 5%• Both H2 and CH4 10%

– 55% had symptoms• 50 g (33% solution)

– 60% (+)– 45% experienced symptoms.

Rao, S, et al. Clin Gastro and Hepatol 2007.

43

Conclusions

• Healthy subjects absorb up to 25 g

• Many exhibit malabsorption and intolerance with 50 g

• For suspected malabsorption: 25 g should be test dose, and measure at 30 minute intervals for 3 hours

Rao, S, et al. Clin Gastro and Hepatol 2007.

44

Alonso-Alonso, M. et al. JAMA 2007;297:1819-1822.

Brain Areas Involved in the Regulation of Food Intake and Schematic Representation of Their Interactions

45

Mean Percent Weight Change during a 15-Year Period in the Control Group and the Surgery Group, According to

the Method of Bariatric Surgery

Sjostrom L et al. N Engl J Med 2007;357:741-752

46

Unadjusted Cumulative Mortality

Sjostrom L et al. N Engl J Med 2007;357:741-752

47

Survival According to BMI in the Surgery Group and the Control Group

Adams TD et al. N Engl J Med 2007;357:753-761

48

Effect of Onsite Dietitian (D) Counseling on Outpatient Weight Loss and Lipids

in a Physician (MD) Office

• Intro: D sees patients at same visit w/ MD (fully reimbursable).

• Intervention: D counsels on diet (DASH) + exercise (30 min/d). One f/u w MD and D.

• Results: Max WL = 5.6%; average WL @ 2.6 years = 5.3%; Δ LDL = - 9%; Δ TG = - 34%; Δ HDL = + 10%; Δ SBP = - 3 mmHg; Δ DBP = - 4 mmHg.

• Conclusion: concurrent counseling is effective in achieving & maintaining WL & is reimbursable

Welty, FK et al. Am J Cardiol 2007;100:73–75

Using Bugs as Drugs:

How to be a Probioticist in 2007

50

DefinitionsProbiotic:

• live microorganisms that when administered in adequate amounts confer a health benefit on the host

Prebiotic:• nondigestible food ingredients (e.g. oligasaccharides) that may beneficially

affect the host by selectively stimulating the growth and/or the activity of a limited number of bacteria in the colon

Synbiotics:• combination nutritional supplements comprised of probiotics and prebiotics

Neutraceutical: • Original: food that provided medical or health benefit• Current: dietary supplements that contain a concentrated form of a bioactive

substance originally derived from a food.

FAO/WHO. Guidelines for the evaluation of probiotics in food. 2002

51

6

2

4

0

8

-2 1 4 8 12

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B. Infantis

Placebo

Treatment Period

Com

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te L

iker

t Sco

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Figure 1. O’Mahony et al. Gastroenterology 2005 (128)541-551.

6

2

4

0

8

-2 1 4 8 12

L. Salvarius

B. Infantis

Placebo

Treatment Period

Com

posi

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6

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4

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8

-2 1 4 8 12

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Com

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iker

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6

2

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L. Salvarius

B. Infantis

Placebo

L. Salvarius

B. Infantis

Placebo

Treatment Period

Com

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iker

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Figure 1. O’Mahony et al. Gastroenterology 2005 (128)541-551.

52

250

150

50

0

100

200

p=0.001300

B. infantis 35624 L. salvarius 4331 Placebo Healthy Volunteers

Pre treatment

Post treatment

IL-1

0:IL

- 12

ratio

’

250

150

50

0

100

200

p=0.001300

B. infantis 35624 L. salvarius 4331 Placebo Healthy Volunteers

Pre treatment

Post treatment250

150

50

0

100

200

p=0.001p=0.001300

B. infantis 35624 L. salvarius 4331 Placebo Healthy Volunteers

Pre treatment

Post treatment

Pre treatment

Post treatment

IL-1

0:IL

- 12

ratio

’ O” Mahony et al. Gastroenterology 2005 (128)541551.

53

C. Diff6 Trials

McFarland, LV. AJG 101 (4), 812-822. 2006.

54

55

Ley et al. Nature. 2006

56

The case of Mrs. K

• 32 y/o executive with 2 months of bloating, gas, constipation

• Most likely diagnosis: Bloating

• What do others call this?

• Why do I not label her as IBS? She fulfills criteria?

• Where do I see her?

57

Mrs. K – 32 y/o AAF executive

• Feels “bloated”, gassy, infrequent stools

• Lower abdominal cramps

• Improved with BM’s (approx 3/week)

• Occurs unpredictably, for last 7 months

• Lasts for few days, then goes away

• No interference w/ daily activities

• Worried it might be “something serious”

58

Mrs. K: History and Physical

• PMH: “food poisoning” one year ago• PSH: none• MEDS: docusate qd• FH: mother has “minor depression”• SH: married, no T/E/D, unemployment

soon• Physical exam: normal; BMI = 24• Labs: Nl. CBC, Chem-10, ESR & CRP

59

How are we treating IBS?STRATEGY 1: Symptom based therapy

Pain

BloatingDiarrhea

ConstipationCourtesy of Pimentel, M.

60

STRATEGY 2: Hypothesis-based

DYSMOTILITY

ACUTEGASTROENTERITIS

SIBO

SEROTONIN

IBS

BRAIN-GUT AXIS

Salmonella, E. coli, Campylobacter, …

Agonist/Antagonist

Courtesy of Pimentel, M.

What Next?

62

Digestive Health Approach

• Reassurance that its not serious• Symptom and food diary• Screen for lactose and fructose

intolerance• Write a Dietary Rx:• Diet without flatulogenic foods• Slowly increase H20 and fiber content

of foods over weeks (dried plums, apples, etc).

63

The Challenge of Digestive Health:

"Live sensibly — among a thousand people, only one dies a natural death, the rest succumb to irrational modes of living.“

-Maimonides 1135-1204 A.D.

THE END