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A Better Approach to Treating GERD


Woman_with_stomach_ache

Gastroesophageal reflux disease (GERD) is estimated to affect 18-27% of the North American population.1 The most popular treatments, stomach acid reducers, are a booming business. Both H2 blockers and proton pump inhibitors (PPIs) are used widely, with the latter currently being taken by an estimated 15.3 million Americans.2 But is this really the best way to treat GERD? Taking an over-the-counter acid blocker for occasional heartburn symptoms may not be a big issue, but in practice, many patients with chronic reflux are prescribed acid blockers indefinitely. Recent research suggests that this long-term approach has some significant drawbacks. 

Studies have demonstrated that medications that reduce stomach acidity increase the likelihood of C. difficile infection in both adult3 and pediatric populations.4 Children on H2RA medications were 4.5 times more likely to acquire a C. difficile infection.4 PPIs may also raise the risk of C. difficile infection in patients in intensive care with stress-related ulcers.5 Another study found evidence that in adults who take PPIs, the risk of myocardial infarction is significantly increased.6 A meta-review recently correlated PPI usage with an increased risk of dementia,7 as did a cohort study in JAMA Neurology.8 Isn’t there a better way to treat the increasingly common issue of GERD?

At The Institute for Functional Medicine's GI Advanced Practice Module (APM), you can learn how to treat GERD and other gastrointestinal problems without using medications that can cause serious side effects. We’ll provide strategies for addressing common GI issues, including GERD, that get to the underlying cause of the problem and provide great outcomes with limited need for medications. You’ll come away with tools to help prevent GERD naturally, address problems with the microbiome, and improve overall gastrointestinal function. Join us this October, 28-30, either via live stream or onsite in Chicago, IL, to untangle gastrointestinal problems and learn how to design personalized interventions that improve patient health without all the side effects.



References

  1. El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut. 2014;63(6):871-80. doi: 10.1136/gutjnl-2012-304269.
  2. IMS Institute for Healthcare Informatics. Medicine use and shifting costs of healthcare: a review of the use of medicines in the U.S. in 2013. QuintilesIMS. http://www.imshealth.com/en/thought-leadership/quintilesims-institute/reports/use-of-medicines-in-the-us-2013. Published April 2014. Accessed July 21, 2015.
  3. Mezoff EA, Cohen MB. Acid suppression and the risk of Clostridium difficile infection. J Pediatr. 2013;163(3):627-30. doi: 10.1016/j.jpeds.2013.04.047.
  4. Brown KE, Knoderer CA, Nichols KR, Crumby AS. Acid-suppressing agents and risk for Clostridium difficile infection in pediatric patients. Clin Pediatr (Phila). 2015;54(11):1102-06. doi: 10.1177/0009922815569201.
  5. Ro Y, Eun CS, Kim HS, et al. Risk of Clostridium difficile infection with the use of a proton pump inhibitor for stress ulcer prophylaxis in critically ill patients. Gut Liver. 2016;10(4):581-86. doi: 10.5009/gnl15324.
  6. Shah NH, LePendu P, Bauer-Mehren A, et al. Proton pump inhibitor usage and the risk of myocardial infarction in the general population. PLoS One. 2015;10(6):e0124653. doi: 10.1371/journal.pone.0124653. 
  7. Wijarnpreecha K, Thongprayoon C, Panjawatanan P, Ungprasert P. Proton pump inhibitors and risk of dementia. Ann Transl Med. 2016;4(12):240. doi: 10.21037/atm.2016.06.14.
  8. Gomm W, von Holt K, Thomé F, et al. Association of proton pump inhibitors with risk of dementia: a pharmacoepidemiological claims data analysis. JAMA Neurol. 2016;73(4):410-16. doi: 10.1001/jamaneurol.2015.4791.


The Connection Between Leaky Gut and Arthritis


Arthritic_hands

While Functional Medicine practitioners have long recognized the bidirectional relationship between gut health and systemic health, awareness of the importance of the gut to overall health has skyrocketed in the past decade. One recent example of the connection between gut health and systemic health that has been uncovered is rheumatoid arthritis (RA).

Inflammatory biomarkers are known to emerge years before a definitive diagnosis of rheumatoid arthritis is possible.1 One theory dating back to the beginning of the 20th century suggested that RA emerges from mucosal tissues and dysbiosis, and only later do problems occur in the synovial fluid and joints.2,3,4 More recent research seems to support this chain of events.

For example, research suggests that IgA antibodies, which are closely associated with mucosa, are elevated in preclinical and recently diagnosed RA patients.5 People with RA have been shown to have different gut microbial populations than people with other inflammatory diagnoses2—in particular, individuals newly diagnosed with RA have higher populations of Prevotella copri.6 Higher levels of gingival disease and unhealthy oral microbiota are also associated with the early stage of RA.7 Gut bacteria have also been found in the synovial fluid of RA mouse models, suggesting that treatment of mucosal surfaces and the microbiome may curtail or affect the development and course of RA.8 This suggests that RA might be avoidable if the signs are recognized early enough and gut health can be restored.9

Kara Fitzgerald, ND

What can you do for patients with a leaky gut that is causing systemic inflammation? Many factors are known to affect gut permeability. IFM educator Kara Fitzgerald, ND, writing with Romilly Hodges, MS, CNS, provides an overview of the many factors that increase and decrease gut permeability in this informative blog post.10 From reductions in NSAIDs to botanical support, there are many recommendations you can provide.

Functional Medicine helps clinicians understand the critical roles of gut mucosal integrity and microbial dysbiosis on patient health and provides key insights into preventing and treating chronic diseases related to gut dysfunction. Learn more about the interplay between the digestive system and the rest of the body at IFM’s GI Advanced Practice Module (APM), this October 28-30 in Chicago, IL. You’ll return to your practice with a new set of tools for treating the long list of chronic diseases that have origins in the gut.



References

  1. Karlson EW, Chibnik LB, Tworoger SS, et al. Biomarkers of inflammation and development of rheumatoid arthritis in women from two prospective cohort studies. Arthritis Rheum. 2009;60(3):641-52. doi: 10.1002/art.24350.
  2. Brusca SB, Abramson SB, Scher JU. Microbiome and mucosal inflammation as extra-articular triggers for rheumatoid arthritis and autoimmunity. Curr Opin Rheumatol. 2014;26(1):101-07. doi: 10.1097/BOR.0000000000000008.
  3. Toivanen P. Normal intestinal microbiota in the aetiopathogenesis of rheumatoid arthritis. Ann Rheum Dis. 2003;62(9):807-11. doi: 10.1136/ard.62.9.807.
  4. Yeoh N. Burton JP, Suppiah P, Reid G, Stebbings S. The role of the microbiome in rheumatic diseases. Curr Rheumatol Rep. 2013;15(3):314. doi: 10.1007/s11926-012-0314-y.
  5. Demoruelle MK, Deane KD, Holers VM. When and where does inflammation begin in rheumatoid arthritis? Curr Opin Rheumatol. 2014;26(1):64-71. doi: 10.1097/BOR.0000000000000017.
  6. Scher JU, Sczesnak A, Longman RS, et al. Expansion of intestinal Prevotella copri correlates with enhanced susceptibility to arthritis. eLife. 2013;2:e01202. doi: 10.7554/eLife.01202.
  7. Scher JU, Ubeda C, Equinda M, et al. Periodontal disease and the oral microbiota in new-onset rheumatoid arthritis. Arthritis Rheum. 2012;64(10):3083-94. doi: 10.1002/art.34539.
  8. Luckey D, Gomez A, Murray J, White B, Taneja V. Bugs & us: the role of the gut in autoimmunity. Indian J Med Res. 2013;138(5):732-43. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3928703/.
  9. Taneja V. Arthritis susceptibility and the gut microbiome. FEBS Lett. 2014;588(22):4244-49. doi: 10.1016/j.febslet.2014.05.034.
  10. Hodges R. Expanding our view on leaky gut: beyond the ON/OFF idea. Dr. Kara Fitzgerald, Functional Medicine. http://www.drkarafitzgerald.com/2016/08/01/expanding-our-view-on-leaky-gut-beyond-the-onoff-idea/. Published August 1, 2016. Accessed Sept 13, 2016.


What Predisposes a Patient to IBS?


Research is still uncovering the causes of and triggers for irritable bowel syndrome (IBS). Many lifestyle and environmental factors affect both the emergence and severity of IBS. Knowing the right questions to inform your patient history rapidly builds the patient relationship as well as improving your diagnostic skills.fatigue_tired_woman_stress_female

A recent study of military personnel found that an important antecedent for many cases of IBS is previous infectious gastroenteritis, which increases risk by two to three times versus controls. Furthermore, a range of cognitive factors affected the risk of emergence of IBS, including posttraumatic stress disorder (PTSD), depression, life stress, and self-reported anxiety. Significant interactions were found between infection, depression, anxiety, and the later emergence of IBS.1

The study did not intervene to treat IBS, but the biopsychosocial model described by the authors suggests that a variety of lifestyle interventions may reduce IBS severity. In addition, restoring a healthy microbiome and reducing gut permeability are known to be crucial for treating IBS. Treating the whole patient, and their internal flora, offers enormous benefits to patients.

Add new tools to your clinical toolkit that can help you recognize and treat the most important antecedents and triggers of gastrointestinal dysfunction at IFM’s GI Advanced Practice Module (APM). Join us in Chicago from October 28-30, to immerse yourself in cutting-edge clinical research and effective personalized treatment plans.



References

  1. Riddle MS, Welsh M, Porter CK, et al. The epidemiology of irritable bowel syndrome in the US military: findings from the millennium cohort study. Am J Gastroenterol. 2016;111(1):93-104. doi: 10.1038/ajg.2015.386.
 

Treating Small Intestine Bacterial Overgrowth


Small intestine bacterial overgrowth (SIBO) can be caused by many factors, and can be detected with a simple hydrogen breath test. Taking the next step and helping the patient restore normal gastrointestinal function can seem more challenging. Of the many choices for treating SIBO, which diets work best for restoring the balance in the gut microbiome?

Restoring normal flora populations can dramatically improve health and eradicate a range of seemingly disconnected symptoms like restless legs, IBS, and polyneuropathy.1 One of the key reasons SIBO treatment remains challenging is because around half of patients treated with either botanicals or antibiotics continue to have positive hydrogen breath tests.1 Dietary interventions that reduce the fermentation of carbohydrates in the gut can help restore a healthy balance among gut bacteria.

In this video, Thomas Sult, MD, discusses dietary interventions for SIBO as well as when he chooses to use a FODMAP or a ketogenic diet:


Join Thomas Sult and the other educators at the GI Advanced Practice Module in Chicago, Illinois, this October 28-30 for clinically useful techniques for addressing all types of gastrointestinal issues. In addition to the latest research, you'll also learn about how to develop individualized treatment protocols using lifestyle, diet, nutraceuticals, pharmaceuticals, and botanicals to help restore gut health.



References

  1. Chedid V, Dhalla S, Clarke JO, et al. Herbal therapy is equivalent to rifaximin for the treatment of small intestinal bacterial overgrowth. Glob Adv Health Med. 2014;3(3):16-24. doi:10.7453/gahmj.2014.019.


Improve Your Diagnosis of Food Reactions


Globally, food allergies (IgE-mediated immune reactions) are increasing in prevalence across ethnicities.1,2,3 Indeed, the CDC reports that “From 1997 to 2007, the prevalence of reported food allergy increased 18% among children under age 18 years.”

In most surveys of parents or individuals, the reported rate of food allergy is much, much higher than can be confirmed with an oral food challenge test.1,2 This finding suggests that many of these reactions are not classical IgE-mediated allergies, but instead are food sensitivities. The science behind food sensitivities is unfolding quickly, and IFM wants to help you diagnose and treat your patients who have food reactions.

A recent study found the presence of objective markers of systemic immune activation and gut epithelial cell damage in patients with non-celiac gluten sensitivity.4 When you have a patient with suspected food reactions that could be causing chronic symptoms, but allergy tests are negative, how do you assess them?

IFM’s GI Advanced Practice Module (APM) presents the science and the clinical strategies to understand food allergies, food sensitivities, and related health concerns. In the following video, expert Functional Medicine practitioner Michael Stone, MD, discusses what you will learn at the GI Advanced Practice Module (APM) about food reactions:


Join us this October 28-30 in Chicago, Illinois, to learn how to assess and treat a wide range of gastrointestinal issues, including how to assess and treat food reactions and many more common but challenging conditions. You’ll walk out the door ready to evaluate the relationship between systemic disease and gastrointestinal dysfunction and develop effective personalized treatments.

References

  1. Prescott SL, Pawankar R, Allen KJ, et al. A global survey of changing patterns of food allergy burden in children. World Allergy Organization J. 2013; 6:21. doi: 10.1186/1939-4551-6-21.
  2. Hadley C. Food allergies on the rise? Determining the prevalence of food allergies, and how quickly it is increasing, is the first step in tackling the problem. EMBO Rep. 2006;7(11):1080-1083. doi:10.1038/sj.embor.7400846.
  3. Sicherer SH, Sampson HA. Food allergy: epidemiology, pathogenesis, diagnosis, and treatment. J Allergy Clin Immunol. 2014 Feb;133(2):291-307; quiz 308. doi: 10.1016/j.jaci.2013.11.020.
  4. Uhde M, Ajamian M, Caio G, et al. Intestinal cell damage and systemic immune activation in individuals reporting sensitivity to wheat in the absence of coeliac disease. Gut. 2016 Jul 25. doi: 10.1136/gutjnl-2016-311964.


NSAIDs, Gut Permeability, and Systemic Disease


Nonsteroidal anti-inflammatory drugs (NSAIDs) have several known side effects, including gastrointestinal (GI) bleeding, bowel inflammation, and even perforations.1 But beyond this localized risk to the GI tract, within hours of their ingestion, these common drugs also induce another condition that can be a gateway to systemic issues: intestinal permeability.1,2

Intestinal permeability has been shown to play a causal role in systemic conditions, including some autoimmune diseases.3,4,5 Recently, research has begun to unravel the many factors that affect intestinal permeability. For instance, proton pump inhibitors (PPIs) have been shown to worsen intestinal permeability caused by NSAIDs in the lower GI tract.2

Understanding the factors that impact intestinal permeability opens many avenues for treatment. For instance, one intriguing but small study found that psychological distress induced by public speaking immediately increased small intestinal permeability in humans.6 A physical stressor (electroshock) did not elicit increases in permeability. On the other hand, soluble fiber may protect against intestinal permeability,7 even that caused directly by NSAIDs.8 Another way to help reduce intestinal permeability is by improving the health of the intestinal microflora.

An educator at IFM, Michael Stone, MD, discusses the overarching importance of the microbiome and gut health on overall disease progression and development of health problems:




Join IFM for the GI Advanced Practice Module this October 28-30 in Chicago, Illinois, to deepen your understanding of how to evaluate the relationship between systemic disease and gastrointestinal dysfunction. You’ll walk out the door ready to individualize treatment protocols for each patient using lifestyle, diet, nutraceuticals, pharmaceuticals, and botanicals.

References

  1. Bjarnason I, Takeuchi K. Intestinal permeability in the pathogenesis of NSAID-induced enteropathy. J Gastroenterol. 2009;44(Suppl 19):23-9. doi: http://dx.doi.org/10.1007/s00535-008-2266-6.
  2. Marlicz W, Loniewski I, Grimes DS, Quigley EM. Nonsteroidal anti-inflammatory drugs, proton pump inhibitors, and gastrointestinal injury: contrasting interactions in the stomach and small intestine. Mayo Clin Proc. 2014;89(12):1699-1709. doi: 10.1016/j.mayocp.2014.07.015.
  3. Lerner A, Matthias T. Rheumatoid arthritis-celiac disease relationship: joints get that gut feeling. Autoimmun Rev. 2015;14(11):1038-47. doi: 10.1016/j.autrev.2015.07.007.
  4. Lerner A, Matthias T. Changes in intestinal tight junction permeability associated with industrial food additives explain the rising incidence of autoimmune disease. Autoimmun Rev. 2015;14(6):479-89. doi: 10.1016/j.autrev.2015.01.009.
  5. Fasano A. Intestinal permeability and its regulation by zonulin: diagnostic and therapeutic implications. Clin Gastroenterol Hepatol. 2012;10(10):1096-1100. doi: 10.1016/j.cgh.2012.08.012.
  6. Vanuytsel T, van Wanrooy S, Vanheel H, et al. Psychological stress and corticotropin-releasing hormone increase intestinal permeability in humans by a mast cell-dependent mechanism. Gut. 2014;63(8):1293-99. doi: 10.1136/gutjnl-2013-305690.
  7. Sahagún AM, Vaquera J, García JJ, et al. Study of the protective effect on intestinal mucosa of the hydrosoluble fiber Plantago ovata husk. BMC Complement Altern Med. 2015;15:298. doi: 10.1186/s12906-015-0827-9.
  8. Satoh H, Urushidani T. Soluble dietary fiber can protect the gastrointestinal mucosa against nonsteroidal anti-inflammatory drugs in mice. Dig Dis Sci. 2016 Jul;61(7):1903-14. doi: 10.1007/s10620-016-4086-5.

Become an Expert in Common GI Conditions


An estimated 60 to 70 million people are affected by digestive diseases in the United States.1 From chronic GERD to IBS and IBD, GI disorders are common, frustrating, and arise from a surprising array of different causes. For the primary care practitioner, being able to successfully treat these issues without sending patients to a specialist or starting them on a never-ending cycle of drugs is increasingly difficult.

Using the Functional Medicine approach, you can learn how to identify the root cause of each patient’s GI issues and design individualized treatments that lead to greatly improved outcomes. Such personalized care for GI disorders has immense potential. One study found that a short-term intervention tailoring foods to lower glycemic response for that individual showed strong, significant effects.2 Another study showed that spending more time with patients in an empathic manner improved GERD symptoms significantly over usual care.3 This type of personalization, paired with an improved understanding of the key triggers for GI dysfunction such as the microbiome, could make a huge difference for the millions who suffer from GI issues.

Join IFM for the GI Advanced Practice Module this October 28-30 in Chicago to learn about state-of-the-art assessments and treatments for common GI conditions. You will return home with the knowledge and know-how to confidently treat these patients in your primary care office and achieve amazing outcomes.

References

  1. National Institutes of Health. Digestive diseases statistics for the United States. https://www.niddk.nih.gov/health-information/health-statistics/Pages/digestive-diseases-statistics-for-the-united-states.aspx
  2. Zeevi D, Korem T, Zmora N, et al. Personalized nutrition by prediction of glycemic responses. Cell. 2015; Nov 19;163(5):1079-94. doi: 10.1016/j.cell.2015.11.001.
  3. Dossett ML, Mu L, Davis RB, et al. Patient-provider interactions affect symptoms in gastroesophageal reflux disease: a pilot randomized, double-blind, placebo-controlled trial. PLoS ONE. 2015;10(9):e0136855. doi:10.1371/journal.pone.0136855.


Frontiers of Immune Reactions: The GI Tract


Most of the immune cells in the body are in the intestines, making the gut the front line of the immune response. Therefore, supporting and enhancing digestive function has a powerful impact on systemic health. Reducing inflammation in the gut may help to calm the immune system overall. In many autoimmune conditions, gut permeability is impaired and microbiome diversity reduced. Even in conditions where gastrointestinal concerns seem peripheral, gut permeability may be central to the development and progression of the disease.

For instance, a recent research study that analyzed the microbiome and mucosal integrity of patients with myalgic encephalopathy (ME), otherwise known as chronic fatigue syndrome (CFS), found an altered microbial environment.1 Some species of anti-inflammatory bacteria normally present in the gut were lacking (i.e., Faecalibacterium, Bifidobacterium), and overall, the ME/CFS patients had less diversity in bacterial populations.1

Understanding how to improve mucosal integrity, decrease intestinal permeability, and support the microbiome may make a huge difference for your patients with chronic illness. IFM educator Robert Rountree, MD, describes the interface of the immune system and the external environment in the following video:



Learn to evaluate the relationship between systemic disease and gastrointestinal dysfunction. Join us for the GI Advanced Practice Module this October 28-30 in Chicago, Illinois. Walk out the door ready to develop and organize individual treatment protocols using lifestyle changes; diet, including the elimination diet; and nutraceutical, pharmaceutical, and botanical treatments.

Reference

  1. Giloteaux L, Goodrich JK, Walters WA, Levine SM, Ley RE, Hanson MR. Reduced diversity and altered composition of the gut microbiome in individuals with myalgic encephalomyelitis/chronic fatigue syndrome. Microbiome. 2016; 4 (1) DOI: 10.1186/s40168-016-0171-4.

How to Encourage Microbial Health


Small intestine bacterial overgrowth (SIBO) has been implicated in a wide range of conditions—which is no surprise, since the majority of the immune system resides in the gut. Yet SIBO is an often underdiagnosed and underappreciated cause of chronic dysfunction. In one study of children with abdominal pain, 63% had SIBO.1 In other research, over a quarter of adults with Crohn’s disease had SIBO.2 A Romanian study found that almost half (45.7%) of IBS patients with diarrhea had SIBO.3

An educator at IFM’s GI Advanced Practice Module (APM) and expert on GI dysfunction, Thomas Sult, MD, discusses his perspective on the importance of addressing SIBO:



How can you start assessing for SIBO and offering treatments that support your patients’ gut microbiome and improve their health? IFM’s GI APM offers the framework to assess and treat gut microbial concerns, along with a range of tools to inform your treatment of common and complex gastrointestinal issues. You’ll learn about the most important and reliable laboratory tests, as well as the predisposing and underlying factors that may lead to GI dysfunction.

Join us October 28–30 in Chicago and come away with a new understanding of how to address SIBO, IBS, IBD, gluten sensitivity, and GERD.



References

  1. Siniewicz-Luzeńczyk K, Bik-Gawin A, Zeman K, Bąk-Romaniszyn L. Small intestinal bacterial overgrowth syndrome in children. Przegla̜d Gastroenterologiczny. 2015;10(1):28-32. doi:10.5114/pg.2014.47494.
  2. Greco A, Caviglia GP, Brignolo P, et al. Glucose breath test and Crohn's disease: Diagnosis of small intestinal bacterial overgrowth and evaluation of therapeutic response. Scand J Gastroenterol. 2015;50(11):1376-81. doi: 10.3109/00365521.2015.1050691.
  3. Moraru IG, Moraru AG, Andrei M, et al. Small intestinal bacterial overgrowth is associated to symptoms in irritable bowel syndrome. Evidence from a multicentre study in Romania. Rom J Intern Med. 2014;52(3):143-50.

Treat the Gut, Heal the Body

The frontier of the immune system is the gastrointestinal tract. For patients with chronic diseases that have an inflammatory component, successful treatment requires restoring the health of the gut and its residents. Unfortunately, discussion of the foods and supplements that can help do this is usually not part of medical school training. Research continues to show that lifestyle factors affect not only the course of gastrointestinal disorders like GERD, IBS, and IBD, but also extra-intestinal inflammatory conditions such as arthritis, cardiometabolic syndrome, and others. IFM’s GI Advanced Practice Module (APM) provides the tools to assess and treat GI dysfunction as well as tailored treatment plans that address the lifestyle factors critical for gut health.

Patrick Hanaway, MD, Chief Medical Education Officer at IFM and Medical Director of the Center for Functional Medicine at the Cleveland Clinic, discusses some of the other key takeaways from the GI APM:


Learn how to assess and treat both intestinal disorders and systemic diseases based in the gut. Join us for the GI APM this October 28-30 in Chicago, Illinois. Return to your practice ready to recognize and treat patients with all types of gastrointestinal dysfunction.

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