Nutrition – Precision Digestive Care

Fermented dairy products like kefir may reduce the risk of colon cancer!

Posted on July 3, 2018 - 7:19 pm by Frederick Gandolfo MD

Fermented dairy sounds rather disgusting, as the name suggests something akin to spoiled milk, but in reality most fermented milk products are actually quite delicious! Fermented dairy products are foods like yogurt, cheese, sour cream, and kefir among others. The process of fermentation is usually done by bacteria such as Lactobacillus species, and results in a product that is more shelf-stable than milk, while retaining all of the protein and other substances that give milk its healthy reputation. Fermented dairy has been enjoyed by people dating back to about 10,000 B.C., so that trendy kefir stuff you are now seeing at the local food store is really nothing new…

Please click here to read the full article on my informational site ‘Retroflexions.’

Junk Food and Cancer: Is There a Link?

Posted on February 18, 2018 - 3:42 pm by Frederick Gandolfo MD

I think it’s safe to say that most people already know that eating “junk food” is probably not really a good thing to do. You can show the average five-year-old a bunch of broccoli and a candy bar, and ask her which food is healthier, and she’ll regrettably pick the broccoli (and then take the candy bar out of your hand, run away, and eat it!)

But just how bad is junk food for you really? Do we even know what happens to the body after eating too much junk? A study published in the BMJ just last week aims to answer some of our questions about the harmful effects of a poor diet with some shocking, but not entirely unexpected, results. In order to understand the data, we first need to define the concept of “junk food” as it was used by the authors. This study looked at the worst types of junk that we can eat, the so-called ultra-processed foods. Ultra-processed foods are usually pretty easy to spot…they almost always come in a package of some sort, usually have a long shelf-life, and are often made in a factory. chocolate More specifically, ultra-processed foods are defined in this study as mass-produced packaged breads, snacks, confectionary, desserts, sodas and sweetened drinks; meat products such as chicken nuggets, meat balls, fish sticks and the like; instant noodles/soups, frozen ready-to-eat meals, and other food products made mostly of sugar, hydrogenated oils, fats, modified starches, and protein isolates. Often processed foods are deeply chemically processed and have flavoring agents, artificial coloring, and emulsifiers added.

Now that we have defined the problem, let’s take a second to realize just how much of this stuff most of us eat on a daily basis. How many of these “treats” do we open for ourselves or our children? Look in your pantry or freezer today and I bet there are a bunch of packages of snacks, cakes, muffins, frozen meatballs, chicken nuggets, and desserts in there looking right back at you. How many “foods” do we eat that were shaped by a machine into some pleasing shape and injected with modified fats and preservatives before being deep-fried, flash frozen and shipped out from a factory somewhere?

factory

The study that we are talking about basically followed over 100,000 people (78% women) in France over an eight-year period and monitored their dietary intake of ultra-processed foods amongst other things. They followed these people for the development of cancer until the study period ended in 2017. It’s important to note that they calculated the amount of ultra-processed foods that were consumed by weight (not by calories), which allowed diet sodas and other artificially-sweetened products to still be counted in the overall intake of junk food. The study results were also statistically adjusted for other lifestyle factors such as smoking, alcohol intake, obesity, exercise, and others in an attempt to correct for any confounding variables. woman drinking soda

Yes, soda is an ultra-processed food. Diet soda and juices were also counted as junk in the study.

Here is what they found: A 10% increase in the proportion of ultra-processed foods in the diet was associated with a 12% increased risk of developing any cancer. The risk of breast cancer was increased by 11%. For colon cancer (a particular concern to us gastroenterologists), there was a nonsignificant trend towards increased risk with eating ultra-processed foods. Is this conclusion a big surprise? Not really, but this study was the first to actually put some numbers on the risk. I, for one, like numbers when it comes to nutritional advice…it keeps us in the realm of science and hopefully away from veering into pseudoscience territory.

Alright, we get it…eating garbage is bad for your health. Now we know that eating 10% more garbage is associated with increasing your risk of developing cancer by more than 10%. But how might ultra-processed junk foods cause cancer in people? The study authors have a few thoughts on that:

Ultra-processed foods have poor nutritional quality…lots of sugar and fat, and not much fiber and micronutrients.
Eating junk food is correlated with obesity, which is correlated with a host of cancers due to many factors. The authors tried to control for this and concluded that the increased cancer risk seen here was not entirely explained by increased body weight. That is, the junk food itself seemed to increase the risk of cancer, regardless of a person’s waist size.
Excess salt in ultra-processed foods like soups and meat products is associated with an increased risk of stomach cancer.
Multiple different food additives (colorings, emulsifiers, artificial sweeteners) are associated with cancer, at least in lab animals. We should use caution applying lab animal data to human beings, but should not discount the idea that the cumulative exposure to these various food additives may add up to cause real problems if we eat a large enough quantity of ultra-processed foods over a long enough period of time.
Carcinogenic nitrosamines found after charring or overcooking meats are associated with various gastrointestinal cancers.
Extreme processing with heat treatment, pre-frying, etc. is associated with the formation of a substance called acrylamide which is associated with kidney and endometrial cancer.
Some of the plastic packaging that ultra-processed foods are stored in for extended periods contain a substance called bisphenol A, which can leach into the food and be ingested, possibly causing endocrine problems that may lead to cancer down the line.

So what is the bottom line? If we want to take care of our bodies the best we can, we should avoid these ultra-processed foods as much as possible. They are associated not only with high cholesterol, obesity, and high blood pressure, but now also with many different cancers. We should view these “foods” of convenience as what they really are, a shortcut to bad health at the sake of saving a little time. Eating junk food treats our taste buds to a temporary high at the cost of our long-term health. Knowing this, you can still enjoy the occasional doughnut or packaged snack, but this really should be a rare indulgence, not a daily or weekly occurrence.

How Exactly Does Alcohol Cause Liver Problems?

Posted on January 12, 2018 - 3:53 pm by Frederick Gandolfo MD

Alcohol has been enjoyed by people throughout the world from the beginning of recorded history up until present day. It is an important part of many cultures and social gatherings, but because alcohol is available almost everywhere it is also easily misused and abused. By now, it is pretty much common knowledge that drinking a lot of alcohol is not really great for your liver. But how does alcohol actually cause liver damage?

To understand how alcohol causes damage, we need to understand what happens in the body when alcohol is ingested. After alcohol is consumed it is absorbed by the stomach and small intestine and delivered to the liver through the portal vein. The liver now has to deal with the alcohol by metabolizing it into something less toxic for the body.

The liver detoxifies alcohol in two main ways: First, there is an enzyme called alcohol dehydrogenase which is present in the liver cells with the main job of breaking down alcohol into something called acetaldehyde. The only problem is that acetaldehyde is kind of toxic too, and can cause damage to the normal proteins in the liver. If too much acetaldehyde forms, one can experience flushing, nausea, vomiting, palpitations…hopefully this doesn’t sound too familiar! Acetaldehyde is then broken down by an enzyme called aldehyde dehydrogenase to a substance called acetate, which is released from the liver cells and can be turned into energy by the heart and muscles.

Alcohol is also broken down by a family of liver enzymes (called cytochrome P450 enzymes) which also convert alcohol to acetaldehyde. However, not only is acetaldehyde toxic in its own right, but the cytochrome P450 enzyme system also causes the formation of nasty reactive oxygen species as a byproduct. (Reactive oxygen species are also called “free radicals” and are unstable molecules that cause damage by oxidizing critical proteins and other materials in cells. Think of pouring hydrogen peroxide on an open wound…that is what free radical damage looks like, only on a smaller cellular level.

This is a huge oversimplification and there are many other ways that alcohol a) gets metabolized, and b) causes liver damage. However, since this is not a textbook we will move on to the fun stuff next.

Alcoholic liver disease (ALD) is the general term used for liver problems related to excess alcohol ingestion. There is a spectrum of liver disease seen with alcohol use, which usually occurs in a continuum from mild and reversible, to severe and irreversible.

The first manifestation of ALD is alcoholic fatty liver. The alcohol-induced inflammation described above alters metabolism of triglycerides and fatty acids in the liver favoring accumulation of these substances in the liver cells. The liver becomes swollen and inflamed, leading to the leakage of liver enzymes into the blood. Blood tests may show high levels of these liver enzymes (called AST and ALT). Ultimately, fatty liver is reversible once excess drinking is stopped.

However, if the patient with alcoholic fatty liver continues to drink, one of two things will usually happen depending on the patient’s sex, genetic predispositions, nutritional state, the time course of the drinking, the sheer amount of alcohol consumed, and many other factors: Alcoholic hepatitis or alcoholic cirrhosis.

If someone drinks a large amount of alcohol in a relative short period of time, they are at risk of developing alcoholic hepatitis. In alcoholic hepatitis, the inflammation in the liver goes into overdrive causing liver swelling, abdominal pain, fever, jaundice (yellow skin), and often ascites (fluid in the abdominal cavity) and/or encephalopathy (confusion). Left untreated, alcoholic hepatitis is often fatal, and unfortunately even with the best medical care the outcome remains rather grim. Once activated, the massive levels of liver inflammation seen in alcoholic hepatitis can continue to worsen even after the patient quits drinking alcohol entirely.

Most patients who survive the experience of alcoholic hepatitis eventually find out that underneath all that liver inflammation is cirrhosis. Cirrhosis is when the liver becomes fibrotic (filled with scar tissue) and functions poorly, causing a host of problems. Cirrhosis also can occur slowly and quietly without having to progress through alcoholic hepatitis; this is often seen in the “heavy social drinker” who never really drinks that much in any one sitting. However, over the course of a week or so, the heavy social drinker consumes quite a bit of alcohol and as we know, weeks lead to months, which lead to years. Just like interest in a retirement account, the slow progressive damage adds-up over the years of “social drinking” and causes cirrhosis just the same as if the person binge-drank their way there in only a few years of heavy alcoholism. At least when someone drinks with fury the liver damage is expected: The slow silent damage is more insidious since there are no great ways to tell that liver damage is happening until the damage is done. In fact, liver function blood tests may be normal despite the presence of cirrhosis.

There is an old adage that states “The dose makes the poison.” That is, anything can be a poison in sufficient quantity (think water, potassium, or oxygen for example), and if you take a real poison like cyanide and dilute it down so it’s barely detectable than it ceases to cause damage. In that same vein, alcohol is basically poison that people ingest willingly for pleasure, but just how much alcohol does it take to poison your liver? How many drinks separate safe social drinking from “heavy” social drinking, from a full blown bender? Well, that is an excellent topic for a future post, so stay tuned!

Can you eat seeds, nuts, and popcorn if you have diverticulosis? Can diet prevent diverticulitis?

Posted on October 24, 2017 - 4:09 pm by Frederick Gandolfo MD

Diverticulitis is a common and sometimes serious problem that affects several hundred thousand people each year. Diverticulitis is the condition where small outpouchings or “pockets” in the wall of the large intestine called diverticula become inflamed and infected, and typically presents as a constant lower abdominal pain, associated with fever or chills, and often bloating or constipation symptoms. Despite becoming even more common in recent years, not much is understood about why diverticulitis occurs.

Diet has long been implicated in the formation of these diverticula which can eventually become inflamed leading to diverticulitis (the condition of just having the pockets without an associated infection/inflammation is called diverticulosis). We know that diverticular disease is rare in countries where fiber intake is high, and we know that when populations change to a more westernized diet (poor in fiber/rich in protein, fat and processed sugars) the rate of diverticular disease rises accordingly. So if fiber is protective against developing diverticular disease in the first place, does it stand to reason that supplementing fiber when one already has diverticulosis will help prevent future complications?

The answer to the above question is unknown, but because fiber is a mostly harmless supplement and has other health benefits, we often recommend fiber supplementation to patients after they are diagnosed with diverticulosis or diverticulitis. But what about the common advice of avoiding seeds, nuts, corn, and popcorn that is readily doled out by some doctors and most family members/friends as soon as they hear the words diverticulosis or diverticulitis? One can reason that it makes common sense to try to avoid having sharp, hard, indigestible seeds getting stuck in a diverticulum and causing an abrasion or perforation which may lead to infection and other nastiness. But does this recommendation have any valid scientific reasoning behind it?

While I’m not sure when or where this recommendation started, it probably belongs more under the category of “old wives’ tale” rather than scientific fact. Let me explain my reasoning for this:

It is very commonly observed during colonoscopy that patients with diverticulosis are found to have a small ball of stool impacted in each and every diverticulum. Presumably, this is the natural state of affairs in the colon of the patient with diverticulosis. So if small hard pellets of stool (mostly composed of indigestible waste and bacterial mass) do not cause an infection, why would a small seed or nut cause a problem? Nevertheless, people still take great pains to avoid seeds, nuts, and corn, causing themselves a fair amount of grief when it comes to meal options. Is this all worth it?

I would reason that it is not necessary to avoid seed and nuts if you have diverticular disease. Probably the best evidence we have that seeds, nuts, corn, and popcorn do not cause complications in patients with diverticular disease comes from a study published in JAMA in 2008 showing that not only was intake of nuts, seeds, popcorn, and corn NOT associated with developing diverticulitis, but in fact the opposite was true. Eating more seeds, nuts, corn, and popcorn actually seemed to be associated with LESS of a chance of developing diverticulitis! These foods are thought to be somewhat anti-inflammatory, and therefore may protect against diverticulitis.

So what is the ideal diet to prevent development of diverticular disease? I think it is pretty obvious that a high-fiber diet is king in preventing the development of diverticulosis. But what if you are late to the high-fiber party but still want to make some changes to prevent that next attack of diverticulitis? Starting a high-fiber diet later in life may still help to reduce the progression of more diverticula, but unfortunately there is no way to reverse the existing diverticula (besides surgical resection of the diseased segment of colon). However, there are still diet changes you can make that might help.

It seems that diets high in red meat are also associated with the development of diverticulitis. This is independent of the effect of fiber, as red-meat eaters develop diverticulitis more often than their vegetarian counterparts even after controlling for fiber intake between the groups. What is more interesting is that researchers found that the recent diet for the past 1-4 years before developing diverticulitis seemed to shape the risk more than the lifelong diet habits. That means that changing to a high-fiber, low-red-meat diet now can still lessen your chance of developing diverticulitis in the near future. But look at the bright side–at least you can eat all the seeds, nuts, corn, and popcorn you want!