On Indigestion

Last week I wrapped up my time in the clinical setting. I conducted assessments of patients, most of them presenting with IBD (inflammatory bowel disease) flares. These conditions cause inflammation of the GI tract that can lead to abdominal pain, diarrhea, ulcers, bleeding and weight loss. As a result, many patients have nutrition-related concerns and are at risk for malnutrition and malabsorption. Going on rounds with the team gave me insight into how doctors think, how they assess, diagnose and treat these conditions. Endoscopies, colonoscopies, flex-sigmoidoscopies, double balloon enteroscopies were daily rituals in the unit. Sometimes surgery was discussed and many patients already had various -ectomies and -ostomies and had this -itis and that -itis. Allergies to steroids and antibiotics, bacterial infections, narcotic addictions, MRSA and C.diff were all part of the daily discussions. These were very complicated cases.

But the way doctors think is not the way dietitians think. After rounds with doctors I would later meet with patients to gather the bits of information that were rarely, if ever, discussed. I wanted to learn what they typically eat, what foods they avoid, what foods are triggers, and how their condition impacts their energy and level of function. I would observed their physical appearance to see if they showed signs of wasting, weight loss and malnutrition using a host of indicators under what is called a "subjective global assessment." I would keep an eye on how many days they were NPO (nothing by mouth). I would lament the Skittles, Rice Krispie treats, Goldfish crackers and Coca-Cola on their trays, but didn't have the courage to suggest that after landing in the hospital with severe GI distress these were perhaps not the best choices for healing foods. I would provide ADA handouts on the types of foods recommended for Crohn's and ulcerative colitis, even though I disagreed with some of their suggestions. I realized that my thought process is much more outpatient-oriented, thinking along the lines of "what dietary recs can I provide this patient to help them maintain remission so they do not end up here again?" while an inpatient dietitian has to consider the patients' needs right here and now. In time I began to speak up and share more patients' nutrition concerns with the doctors, who freely admitted they did not usually take such things into account. And by the end of my rotation I hoped that maybe, just maybe, the two dietetic interns who followed these attendings, residents, interns and medical students around for several weeks made enough of an impression that they will consider consulting with a dietitian in the future to optimize patient care.

The experience certainly made me wonder when diet became so separated from medical care. During my time in the GI unit I also worked with several interns on an unrelated project, researching the history of popular beliefs about health and diet in the Janice Bluestein Longone Culinary Archives at the Clements Library at U of M. We put together a presentation to introduce a talk given by Harvard School of Public Health's Eric Rimm who served on the advisory committee for the 2010 U.S. Dietary Guidelines and came to speak about the process.

A short list of our discoveries:

1. We've known for a long time that eating too much can cause indigestion.

"If more than ordinary quantity of food be taken, a part of it will remain undissolved in the stomach, and produce the usual unpleasant symptoms of indigestion." The physiology of digestion considered with relation to the principles of dietetics (1836)

2. Whole grains are far superior to refined grains

"Flour of the entire wheat is without doubt the purest flour in the world, and makes the best bread now known to housekeeping or culinary science, because it contains...all the bone, mucle, brain and nerve feeding elements of the wheat kernel, so unfortunately lacking in white flour..."The Boston Cooking-School Magazine of Culinary Science and Domestic Economics (1898)
3. We eat too much meat.

"The spirit as well as the letter of this book is universally needed. Overeating of meat has had its day, and left us as a reminder much sickness and sorrow."  Mrs. Rorer's Vegetable Cookery and Meat Substitutes (1909)

There was a time when the connection between food and health was undisputed. Now it's often dismissed as lacking sufficient evidence. I've been wondering how we got here, and having just started my next rotation working with the National School Lunch Program I think I have some ideas. Stay tuned.

Eating Healthfully May Be Good For You, New Study Suggests

Last week's Well blog on the New York Times website made a radical claim: "Eating Brown Rice to Cut Diabetes Risk". The piece focuses on a recent study from Harvard that concludes: "Substitution of whole grains, including brown rice, for white rice may lower risk of type 2 diabetes." Really? Is this news to anyone? It doesn't take a degree in nutrition to know that eating whole grains - that is, the entire grain without the removal of the bran - is better than eating a refined grain in which the bran is removed. The bran provides fiber, which has become a buzzword in the food biz, touted for all sorts of health benefits. Fiber is an interesting topic in and of itself because the different types, soluble vs insoluble, confer different results, but most whole foods will contain some measure of both. Whole grain also have a lower glycemic index (GI) than refined ones, referring to the rate at which they elevate blood sugar levels. In this there are gradations - long grain brown rice will have a lower GI than short grain brown rice, but brown rice overall has a lower GI than white rice. This may be very significant when discussing the risk of developing diabetes. Additionally, whole grains provide magnesium, an important micronutrient that may also account for the lower rates of diabetes in those who eat whole grains.

The study does have some limitations but overall I don't know that anyone is trying to say that it is wrong in its conclusion. And while I certainly believe in the importance of evidence-based research, I sometimes wonder why so much funding is supporting studies of interventions that are already well known, widely understood, and frankly, common sensical. (Really, soda consumption may be linked to obesity?) About two months ago I signed up for e-bulletins on new research from MedlinePlus. Since then I've received daily digests with quick links to all sorts of health research news. Here's a sampling from this past two weeks:

1. Least Healthy More Apt to Think Genes Explain Disease Risk: Survey also found these people were not as interested in information on lifestyle changes

2. Early School Start Times Raise Risk of Teen Car Crashes: When high school classes began later, number of accidents dropped, study found

3. Obesity Can Take Toll on Sex Life: Stigma may lead to fewer sexual encounters, poorer sexual health, study finds

4. Stricter Rules Can Steer Kids Away From TV: And physically active kids watch less television, researchers report

5. Poor aerobic fitness, low physical activity linked to greater high blood pressure risk

Where's the big science here? Obviously I've chosen specific examples of studies that make my point. I do believe there is a place for research and it plays an important role in the scientific process. But does every intervention really need to be studied in this way? Because at the end of the day all studies have limitations and the best results yielded will still demand further research to back them up. Which is not to say that we should stop conducting research, but just recognize that research is not the be-all, end-all.

Here are some of the concerns I have: research gives the placebo effect a bad rap: if people think they're being treated and they actually see improved results, isn't that a good thing? Doesn't that in fact point to the effect of the mind in the healing process? Also, research may show a likely relationship, but how that translates for the individual will vary. Yes, most people who exercise and eat whole grains and fruits and vegetables may have lower risks for cancer and diabetes and heart disease but they may not. Each of us has our own genetic map and that living healthfully can only go so far in determining your health outcome. In fact, this very news may impact whether someone even bothers to take care of his or her health (see study #1 above).

The important role of research is to provide us with enough certainty to make educated decisions. But there are some decisions that we are well-equipped to make on own. So next time you're at a Thai restaurant, order the brown rice. And while you're at it, have some green tea.