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Disease risks and other issues related to poor digestive health.

DNA Testing Provides Whole-Body Approach to Cancer Screening

The 2009 Digestive Disease Week in Chicago presented numerous findings with regard to the GI tract and associated diseases. Among those findings is the usefulness of DNA testing of stool samples for the presence of cancer.

Previously, stool DNA testing was used for the early detection of colorectal cancer; recently scientists and physicians have discovered this screening is also a useful source of detection for other cancers such as pancreas, stomach, bile ducts and esophagus. This is a tremendous shift from the single organ approach to screening of such cancers. DNA sampling provides a “whole-body” approach to screening for multiple cancers at one time, potentially paving the way for early detection of cancers previously not screened.

According to ABC News, “The test developed by Mayo Clinic researchers, which checked a patient’s stool for the DNA of cells regularly shed from the surface of several types of tumors, detected 65 percent of esophageal cancers, 62 percent of pancreatic cancers, 75 percent of bile duct and gallbladder cancers and 100 percent of stomach and colorectal cancers. The test was equally successful at detecting early-stage and late-stage cancers.”

The report goes on to note, “One in four cancer deaths are the result of gastrointestinal cancers, the news release notes. These cancers are quite curable if detected at an early stage, but the only one widely tested for is colorectal cancer, generally through colonoscopy.”

Research and news with regard to GI disease continues to move in a positive direction.

Probiotics Shed Light on Obesity and Diabetes

Keeping up with the latest scientific developments on probiotics and human health is becoming very challenging because every month there are new and very exciting findings.

Recently, there have been several reports on how intestinal bacteria play a role in nutrition, obesity and diabetes.

Here are a few of the results of those studies:

  1. Patients who received probiotics after gastric bypass surgery lost more weight than those who received a placebo (1).
  2. Women who took probiotics starting in the first trimester of pregnancy were less likely at one year postpartum to have central or abdominal obesity as compared to the control group who did not take a probiotic (2).
  3. In a study of overweight adolescents who went on a weight loss diet, those who were successful at losing weight had a healthy change in the composition of the intestinal bacteria (3).

These and others studies in humans and animals have discovered that our intestinal bacteria affect the amount of calories we extract from the food we eat, and how we store or use those calories. The studies further suggest that obese and lean people have different intestinal bacterial flora.

Probiotics’ Regulation of Obesity and Type 2 Diabetes

There are ongoing scientific investigations aimed at determining how the gut bacteria participate in the regulation of our weight and the development of obesity and Type 2 diabetes.

In a series of experiments, it was found that mice fed a normal diet had 40% higher body fat content than germ-free mice fed a similar diet (4). The bacteria in the colon, particularly Bifidobacteria, can metabolize certain starches in our diet that we can’t digest otherwise. These extra calories harvested by the bacteria contribute to our net calorie balance. A mere 1-2% increase in calorie absorption on a daily basis can add up to many extra pounds over a year.

These studies are a little confusing. If a healthy gut flora includes Bifidobacteria, why don’t the lean individuals who have more of the Bifidobacteria gain weight?

Scientists are trying to sort out these conflicting results. To understand how the good bacteria can help control weight gain, it is important to briefly review a little biochemistry.

Whole grain foods contain starches that are resistant to digestion in the small intestines. These starches enter the colon where they are used as fuel by Bifidobacteria and Lactobacillus. The bacteria break the starches down and produce short chain fatty acids (SCFA) by a process called fermentation. The SCFA are absorbed in the colon and contribute to the calories in the diet. But the SCFA also have other effects.

One proposed mechanism is that the short chain fatty acids produced by the Bifidobacteria stimulate the release of intestinal hormones that slow the stomach emptying after a meal (5). This results in a sense of fullness or satiety with less calorie intake; it takes less to fill you up. It may be that people with the healthy bacteria who consume whole grain foods don’t eat as much.

In addition, the healthy bacteria in lean individuals suppress the proliferation of a group of bacteria called “gram negative bacteria.” Gram negative bacteria can produce a substance called lipopolysaccharide (LPS) that causes the liver to convert ingested carbohydrate calories into fat instead of burning the calories as an energy source (6). The fat is then stored in our adipose or fat tissues.

Finally, LPS has been shown to lessen our cells’ sensitivity to the insulin our pancreas produces (6). This can result in Type 2 diabetes. Studies have shown that modifying the bacterial content of the intestines can lessen the production of LPS and the potential for developing diabetes.

The evidence indicates that the gut bacteria composition can be different between healthy individuals and those who are obese and have Type 2 diabetes. The challenge is how to manipulate the intestinal bacteria to lessen these metabolic disorders.

Take home message.  Eat whole grain foods, avoid high fatty diets and consider a probiotic like EndoMune. You may just avoid weight gain and the risk of developing diabetes.

Eat healthy and live well.
Lawrence J Hoberman, MD


(1) Probiotics Improve Outcomes After Roux-en-Y Gastric Bypass Surgery: A Prospective Randomized Trial: Woodard G, Encarnacion B, Downey J, et al:J Gastrointest Surg. 2009 Apr 18

(2) Probiotics May Help Ward Off Obesity, Laitinen K:  Study In Pregnant Women. European Association for the Study of Obesity; Presented 2009 May 8

(3) Interplay Between Weight Loss and Gut Microbiota Composition in Overweight AdolescentsSantacruz A, Marcos A, Wärnberg J, Martí A, Martin-Matillas M, Campoy C, Moreno LA, Veiga O, Redondo-Figuero C, Garagorri JM, Azcona C, Delgado M, García-Fuentes M, Collado MC, Sanz Y. Obesity (Silver Spring). 2009 Apr 23

(4) The gut microbiota as an environmental factor that regulates fat storage. Backhed F, Ding H, Wang
T, et al. Proc Natl Acad Sci U S A. 2004 Nov 2;101(44):15718-15723

(5)Oligofructose and long-chain inulin:influence on the gut microbial ecology of rats associated with a human faecal flora. Kleessen B, Hartmann L, Blaut M.  Br J Nutr. 2001;86(2):291-300

(6) Metabolic endotoxemia initiates obesity and insulin resistance. Cani PD, Amar J, Iglesias MA, et al
Diabetes. 2007 Jul;56(7):1761-1772. Epub 2007 Apr 24.


iPhone to Assist IBD Patients

Individuals who suffer from Inflammatory Bowel Disease (IBD), Crohn’s Disease and a variety of other gastrointestinal ailments are often faced with the need to maintain daily bowel logs. Consistent logs help physicians track and monitor a patient’s progress and adjust medication as needed; insufficient data or sporadic logs, however, are often not helpful for monitoring long-term trends.

With this in mind, patients find it burdensome and difficult to remain on track with this daily regimen.

Enter technology…

A new iPhone application, “GI Monitor,” was developed by Brett Shamosh, CEO and founder of WellApps, Inc. For nearly two decades, Shamosh has suffered from IBD, and understands firsthand both the importance and burden of monitoring his daily BMs. In an effort to ease this task, a patient can download this application to their iPhone to monitor bowel movements and other related symptoms. In one organized, simple format, patients can log their individual data digitally, including prescription information.

The iPhone and other mobile devices make sense. Rarely do you leave home without your phone or PDA device; but how often do you want to carry your dietary journal? Shamosh says this was his reason for developing the application.

In the future, Shamosh indicates he would like to track symptoms of all users, and use these results for research benefits. The implications for monitoring trends are promising. As for advances in future releases, since there has been so much interest in not only BM logs but dietary logs, the next release will allow users to input and track dietary intake.

If you currently suffer from a GI ailment, you can download the application for $4.99 at the iTunes Store. The application will also be released in a format compatible with Blackberrys in the near future.

An Expert’s take on Traveler’s Diarrhea

Now that it is getting close to summer, folks are starting to consider vacation travel plans. This newsletter will discuss options for staying healthy when traveling outside the United States to developing countries.

I would like to review the updated recommendations in preventing and treating Traveler’s diarrhea (TD).

Overview: Among travel-related illnesses, acute diarrhea is the most common disorder. A study of Americans visiting developing countries found that 46% acquired diarrhea (1). Destination is the most significant risk factor for developing diarrhea. Areas with highest risk are developing countries in Latin America, the Middle East, Africa and South Asia.

Definition: Traveler’s diarrhea is defined as three or more unformed stools per 24 hours starting during or shortly after a period of foreign travel with at least one of the following symptoms: fever, nausea, vomiting, or abdominal cramps. Most episodes last 3-4 days without therapy, but some infections can cause severe diarrhea and dehydration requiring hospitalization and IV fluids.

Etiology: The cause of TD is exposure to food and water that has been contaminated with fecal matter due to poor sanitary and public health conditions.

The organisms that cause the diarrhea are bacteria, viruses and parasites. Studies have found that bacteria like E. Coli, Shigella and Campylobacteria account for 80% of the episodes (2). Parasites and viruses are less common causes although there have been a number of outbreaks on cruise ships due to viruses (3).

Prevention: Travelers are advised to ”boil it, cook it, peel it, or forget it.” Unfortunately, despite pre-travel advice, many travelers still develop diarrhea even when avoiding high risk foods. The general recommendations include avoid raw vegetables, fruits that you have not peeled, unpasteurized dairy products, cooked food not served steaming and tap water, including ice. Although it smells and looks great…don’t eat food from street vendors!

Drug prophylaxis: There have been a number of studies evaluating different medications taken on a daily basis in order to prevent the development of diarrhea.

Antibiotics: It is not generally recommended to prescribe antibiotics as a prophylaxis to prevent TD as it can lead to drug resistant organisms (4). In immuno-compromised individuals or those with serious health issues, use of prophylactic antibiotics may be beneficial. Taking daily antibiotics like ciprofloxin (Cipro) 500mg, or levofloxacin (Levaquin) 500mg have been used successfully to prevent bacterial diarrhea in 90% of those treated (5).

Rifaximin (Xifaxan) is a non-absorbable antibiotic that has also been shown to lessen the risk of TD in 75% of those taking a single 200mg dose daily. However, the antibiotic does not protect against invasive bacteria like Samonella.

Bismuth subsalicylate: Pepto-Bismo provides a protection rate of 60% when given as two tablets 4 times daily (6). It does cause the tongue and stool to turn black and can cause ringing in the ears. It is not recommended to use this regimen for more than 3 weeks.

Probiotics: A statistical analysis of 12 control trials found that 85% of TD cases were prevented by probiotics (6). The dosage of probiotic bacteria given and the type of organisms varied. It is difficult to generalize that all probiotics are effective. The analysis did find that probiotics containing lactobacillus and Bifidobacteria strains were effective. Also, probiotics containing a yeast, Saccharomyces boulardii, lessened the risk of TD (6).

Probiotics are a more natural approach to prophylaxis. The bacteria colonize the intestines and prevent the pathogenic bacteria from successfully producing harmful toxins and invading the mucosa.


Generally, traveler’s diarrhea is a self-limited illness without fever lasting several days. Unfortunately, it is not possible to determine after the first loose stool the length and severity of the illness. Having diarrhea while on vacation or on a business trip can be very disruptive to planned activities. There are several recommendations:

  • Start an antibiotics if the there are 3 or more loose stools in an eight hour period. The drug of choice is still Cipro 500 mg twice daily for 3 days. If there is no fever or blood in the stools, an alternative antibiotic is Rifaximin 200 mg three times daily for 3 days.
  • There are areas (e.g., Thailand) where the bacteria are resistant to Cipro type medication; in these areas, Azithromycin (Zithromax) is recommended 500mg once daily for 3 days.
  • To lessen the diarrhea and cramps, Pepto Bismo 1 oz (2 tbsp) every half hour for a total of 8 doses (16 tbsps) in eight hours. Pepto Bismo eases the cramps, nausea and diarrhea without any serious side effects.
  • Another medication used to lessen diarrhea and cramps is loperamide or Imodium. Take a loading dose (4 mg) after the first loose stool and then 2mg after every loose stool for a total of 8 doses (16 mg) in 24 hours. This will ease the symptoms of diarrhea and help prevent dehydration. A warning though: do not take Imodium if there is fever or blood in the stool. Imodium slows the motility of the colon and can possibly make an invasive infection worse.
  • Rehydration packets like CeraLyte electrolyte packets can be added to water to help maintain hydration. Otherwise, replace fluids with plenty of water and replace lost electrolytes using foods like broth and saltine crackers.

Final Recommendation

  • If traveling to a developing country, access the CDC webpage for information on immunizations and other health questions.
  • Contact your physician regarding prescriptions for the antibiotics to take if you develop TD. It is important to start therapy on a timely basis. Trying to obtain medical care and medicines while traveling delays treatment and medications purchased abroad may be substandard.
  • Take a good probiotic like EndoMune on a daily basis. Start 2-3 days before you travel. In general, good probiotics should be refrigerated. Studies have shown that EndoMune will survive at room temperature for months. It is best not to store probiotics in temperatures greater than 85 degrees for prolonged periods.

Finally, I hope all your travels are joyful, safe, and healthy. Don’t forget to pack your camera…and some EndoMune.

Eat healthy, exercise and live well!!
Dr. Hoberman

(1) Hill DR: Occurrence and self-treatment of diarrhea in a large cohort of Americans traveling to developing countries. Am J Trop Med Hyg 2000;62:585-9.

(2) Steffen R, Sack RB:Epidemiology. In: Ericsson CD, DuPont HL, Steffen R, eds. Travelers’ diarrhea; Hamilton, Ont.: BC Decker, 2003: 112-23

(3) Chapin AR, Carpenter CM, Dudley WC, et al: Prevalence of norovirus among visitors from the United States to Mexico and Guatemala who experienced traveler’s diarrhea. J Clin Microbiol 2005;43:1112-1117.

(4) Centers for Disease Control:

(5) Rendi-Wagner P, Kollaritsch H. Drug prohylaxis for traveler’s diarrhea. Clin Inft. Dis 2002;34:628-33.

(6) Steffen R, Heusser R, DuPont HL: Prevention of travelers’ diarrhea by nonantibiotic drugs. Rev Infect Dis; 1986;8(suppl 2);S151-9.

(7) McFarland LV: Meta-analysis of probiotics for the prevention of traveler’s diarrhea. Travel Med Infect Dis. 2007;2:97-105.

Study on Antibiotic-Associated Diarrhea

A study recently published in the Journal of Medical Microbiology further explores the potential benefits of probiotics at maintaining intestinal health while ingesting antibiotics such as Augmentin.

The study concluded probiotics, particularly Bifidobacteria, may be helpful in returning to a pre-antibiotic baseline:

This study does identify a benefit of probiotics, in part through increasing Bifidobacterium that may limit the disruption of gut microbiota by antibiotics, stabilizing concentrations of Enterobactereaceae and Bacteroides in particular. While this does not represent a clinical end point in itself this study provides important insight into the nature of the disruption of gut microbiota by antibiotics and a possible mechanism whereby probiotics limit gastrointestinal adverse events associated with antibiotics.

Further studies are necessary to assess the clinical relevance of these observations.

Engelbrektson, Anna, et al. “Probiotics to minimize the disruption of feacal microbiotia in healthy subjects undergoing antibiotic therapy.” Journal of Medical Microbiology (2009), 58, 663-670.

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