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: [email protected]
• 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
L. Salvarius
B. Infantis
Placebo
Treatment Period
Com
posi
te L
iker
t Sco
re
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
te L
iker
t Sco
re
6
2
4
0
8
-2 1 4 8 12
L. Salvarius
B. Infantis
Placebo
Treatment Period
Com
posi
te L
iker
t Sco
re
6
2
4
0
8
-2 1 4 8 12
L. Salvarius
B. Infantis
Placebo
L. Salvarius
B. Infantis
Placebo
Treatment Period
Com
posi
te L
iker
t Sco
re
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