tag:theconversation.com,2011:/us/topics/inflammatory-bowel-disease-1623/articlesInflammatory bowel disease – The Conversation2023-12-21T11:58:11Ztag:theconversation.com,2011:article/2183072023-12-21T11:58:11Z2023-12-21T11:58:11ZWhy IBD is so hard to treat – and how scientists are making progress<figure><img src="https://images.theconversation.com/files/564472/original/file-20231208-21-jio13j.jpg?ixlib=rb-1.1.0&rect=8%2C8%2C5455%2C3628&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">IBD can be debilitating </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/illustration-intestine-internal-organs-womens-body-1828134221">Emily frost/Shutterstock</a></span></figcaption></figure><p>Inflammatory bowel disease (IBD) is a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478758/">life altering</a> chronic illness that is <a href="https://bmjopen.bmj.com/content/13/3/e065186">rising dramatically globally</a>. It is stubbornly difficult to treat, and many people find the treatments we have just don’t work for them. </p>
<p>Over the last 30 years, there has been almost a 50% increase in cases – now affecting around 5 million people. Not to be confused with irritable bowel syndrome (IBS) which is a condition that affects the digestive system, IBD is more serious. It is the term for two severe illnesses called <a href="https://www.nhs.uk/conditions/crohns-disease/">Crohn’s disease</a> and <a href="https://www.nhs.uk/conditions/ulcerative-colitis/">ulcerative colitis</a>. More women are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9958616/#:%7E:text=Male%20predominance%20in%20IBD.,%2C%202.32%3A1%20in%20CD.">diagnosed with Crohn’s disease</a> while more men are affected by ulcerative colitis. </p>
<p>People with IBD can experience a variety of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4106026/">symptoms</a>, ranging from diarrhoea and blood in the stool, to weight loss and belly aches. On paper, this may sound no worse than mild food poisoning, however, this is no normal stomach upset. </p>
<p>Experiences are often extreme; people with IBD can suffer excruciating pain and in some cases, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9963331/">require surgery</a> to remove parts of the bowel. This is done by redirecting the bowel to a hole in the abdomen, where faeces are collected in a <a href="https://www.nhs.uk/conditions/colostomy/">colostomy bag</a>. </p>
<p>However, we still don’t fully understand the cause of IBD. </p>
<h2>The impact of inflammation</h2>
<p>The main symptom of IBD is excessive and uncontrolled <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5805548/">inflammation</a> – normally a sign of the body fighting off an infection. Although inflammation is an important aspect of our immune system, in IBD it is happening when the body is not under attack. Since we don’t know what causes this over-the-top reaction, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8720971/">treatments</a> are limited to managing the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3964397/">derailed immune system</a>. </p>
<figure class="align-center ">
<img alt="Man holds his abdomen." src="https://images.theconversation.com/files/566014/original/file-20231215-17-6sqtab.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566014/original/file-20231215-17-6sqtab.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566014/original/file-20231215-17-6sqtab.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566014/original/file-20231215-17-6sqtab.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566014/original/file-20231215-17-6sqtab.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566014/original/file-20231215-17-6sqtab.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566014/original/file-20231215-17-6sqtab.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many people with IBD are still in pain after treatment.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/men-stomach-pain-causes-abdominal-include-2134025051">onstockphoto/Shutterstock</a></span>
</figcaption>
</figure>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8373857/">Inflammation is controlled</a> by cell signalling. Our cells detect bacteria using receptors that attach to parts of bacteria. This activates the receptor, causing it to send a signal to proteins, and each protein sends on more signals, creating a signal cascade. This is what tells the body it’s under attack. </p>
<p>Many treatments follow the strategy of intercepting signals and preventing the signal cascade from starting. However, they are <a href="https://journals.lww.com/co-gastroenterology/abstract/2022/07000/management_of_refractory_inflammatory_bowel.6.aspx">not effective</a> for many people. </p>
<p>Scientists are trying to target a different protein network, called <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2924159/">NOD2</a>, that often goes haywire in people with IBD but is not targeted by current treatments. A protein, called <a href="https://www.frontiersin.org/articles/10.3389/fphar.2021.650403/full">RIPK2</a>, seems like a promising target since it is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6939834/">only found</a> in this network. Researchers from the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10485824/">European Molecular Biology Laboratory</a> are investigating its structure to help scientists design a new medication that will block the signals from this protein. </p>
<h2>Importance of the microbiome</h2>
<p>Another inspiration for new treatments comes from the bacteria residing in our guts. This community of bacteria, called the gut microbiome, has been associated with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6314516/">all sorts of health conditions</a> ranging from asthma to obesity. </p>
<p>Gut bacteria work closely with our bodies and play a vital role in digesting food and managing our <a href="https://www.nature.com/articles/s41422-020-0332-7">immune system</a>. In a healthy person, there is a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4143175/">fine balance</a> between gut bacteria and the immune system. Disruption of this balance can lead to disease, starting from minor discomfort to more severe, long-term conditions. </p>
<p>Scientists are trying to understand how our bodies interact with gut bacteria, and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8102608/">what changes</a> when people develop IBD. </p>
<p>The gut microbiome is an ecosystem. Just like a forest has animals eating different things, microbes can form a <a href="https://www.frontiersin.org/articles/10.3389/fevo.2019.00153/full">food web</a>. Some bacteria will use up one type of food, while others feed off other foods. Some rely on the waste of other bacteria after they’ve eaten. It is now believed that disruption to the gut microbiome is a characteristic of IBD and contributes to its development and progression.</p>
<p>It’s a chicken and egg situation. Is there a change in the bacteria and food web that alters our bodies? Or does something else in the body, like our immune system, change the food web, subsequently limiting which bacteria can grow? Scientists aren’t sure of the answer. </p>
<p>Instead of trying to figure out what happens first, a team at the <a href="https://www.nature.com/articles/s41467-023-42112-w">Hudson Institute of Medical Research</a> in Australia have focused on investigating which interactions in the food web are the most affected in IBD. This could help scientists to prioritise certain gut bacteria, or their food source, to restore the balance in the microbiome and improve patients’ symptoms. </p>
<p>Hopefully, this specialised targeting of the microbiome will lead to more effective and longer lasting treatments. </p>
<p>Although we have a long way to go before these ideas for treatments can become a reality, it is a step in the right direction. Targeting a new signalling pathway will hopefully control the inflammation in more patients. And studying the microbiome may reveal how we can reverse changes associated with IBD.</p>
<p>Since they are key features of IBD, these developments could allow doctors to stop the disease in the early stages and reduce complications.</p><img src="https://counter.theconversation.com/content/218307/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Falk Hildebrand receives funding from the Biotechnology and Biological Sciences Research Council (BBSRC), European Research Council, Bill & Melinda Gates Foundation and Natural Environment Research Council (NERC).</span></em></p><p class="fine-print"><em><span>Katarzyna Sidorczuk receives funding from the Biotechnology and Biological Sciences Research Council (BBSRC) and European Research Council H2020 StG.</span></em></p><p class="fine-print"><em><span>Wing Koon receives funding from the UKRI Medical Research Council for the Microbes, Microbiomes, and Bioinformatics Doctoral Training Partnership as a CASE Award in collaboration with Oxford Nanopore Technologies.</span></em></p>The current treatments for inflammatory bowel disease do not work for everyone. Tapping into new areas of biology may be the key to developing new therapies.Falk Hildebrand, Researcher in Bioinformatician, Quadram InstituteKatarzyna Sidorczuk, Research Scientist in Metagenomics, Quadram InstituteWing Koon, PhD student in Bioinformatics, Quadram InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1853372022-09-08T12:32:16Z2022-09-08T12:32:16ZYes, Black patients do want to help with medical research – here are ways to overcome the barriers that keep clinical trials from recruiting diverse populations<figure><img src="https://images.theconversation.com/files/483100/original/file-20220906-4642-3md5uc.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Creating a safe space for patients to ask questions and provide fully informed consent could help increase clinical trial recruitment.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/ethnic-woman-in-medical-consultation-with-female-royalty-free-image/1168998661">FatCamera/E+ via Getty Images</a></span></figcaption></figure><p>Clinical trial participants are <a href="https://doi.org/10.1001/jamanetworkopen.2021.11516">predominantly white</a>. Despite Black and Hispanic people respectively making up 12% and 16% of the U.S. population in 2011, together they made up <a href="https://www.fda.gov/science-research/womens-health-research/dialogues-diversifying-clinical-trials">only 6% of clinical trial participants</a> overall that year. </p>
<p><a href="https://www.nimhd.nih.gov/resources/understanding-health-disparities/diversity-and-inclusion-in-clinical-trials.html">Clinical trials that are representative</a> of all patients are essential to ensure that treatments are effective for everyone. Drugs work differently for each person <a href="https://theconversation.com/why-prescription-drugs-can-work-differently-for-different-people-168645">based on different factors</a>. Including diverse patient populations in clinical trials makes sure these factors are accounted for. But the <a href="https://doi.org/10.1016/j.cpcardiol.2018.11.002">perception that recruiting white patients</a> is easier, less time-consuming and more cost-efficient than recruiting underrepresented or underserved patients contributes to health disparities seen today.</p>
<p>We are <a href="https://www.researchgate.net/profile/Julia-Liu-9">gastroenterology researchers</a> at Morehouse School of Medicine who run clinical trials and study ways to improve participant diversity. Identifying and addressing the barriers to enrolling in research that patients face can not only increase participation, but can also lead to better patient care.</p>
<h2>The problem of access</h2>
<p>Barriers to clinical trial participation start with a <a href="https://doi.org/10.1177%2F107327481602300404">lack of access to trials</a>. </p>
<p>Clinical trials have specific eligibility criteria, and may require a number of study-related visits to the hospital where they’re conducted. But underserved and underrepresented populations often aren’t seen in practices that recruit patients for clinical trials. </p>
<p>Typically, clinical trials are designed by research-focused physicians working in <a href="https://www.cancertodaymag.org/summer2017/a-new-look-for-clinical-trials-diversity/">urban medical centers</a>. The majority of Black and Hispanic patients have <a href="https://doi.org/10.1377/hlthaff.2021.01409">limited access to the health care system</a> as a whole, and the centers that serve them often do not have the research infrastructure or resources to run clinical trials.</p>
<p>While researchers have made attempts to <a href="https://doi.org/10.1093/ibd/izac124">increase the diversity of clinical trial participants</a>, <a href="https://doi.org/10.1016/j.cpcardiol.2018.11.002">misconceptions and biases</a> within the medical community about underrepresented populations limit these outreach efforts. For example, <a href="https://doi.org/10.1353%2Fhpu.2006.0126">beliefs persist</a> that Black patients aren’t willing to participate in research studies and are noncompliant and mistrustful due to historical abuse from medical researchers, such as in the <a href="https://doi.org/10.1093%2Fqje%2Fqjx029">Tuskegee syphilis study</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/7qAld9bGwlA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Limited access to clinical trials is both a product of and driving factor behind health disparities.</span></figcaption>
</figure>
<h2>A colon cancer case study</h2>
<p>One example of how lack of diversity in clinical trial participation can lead to poor health for patients is outcomes for <a href="https://www.cdc.gov/ibd/what-is-IBD.htm">inflammatory bowel disease</a>. IBD is a chronic condition that comes in two forms, ulcerative colitis and Crohn’s disease. Patients with IBD have an <a href="https://doi.org/10.3748%2Fwjg.v20.i29.9872">increased risk of developing colorectal cancer</a>.</p>
<p>Black patients account for 75% of IBD cases at Morehouse School of Medicine. Many of our current patients were either previously misdiagnosed or only treated for their symptoms in the emergency room without further investigation. This has led to many of our patients getting diagnosed with IBD when the disease is already at an advanced stage, making it more difficult to treat.</p>
<p>Julia Liu started Morehouse’s <a href="https://clinicaltrials.gov/ct2/show/NCT04369053">first colorectal cancer clinical trial</a> in 2021. The Prevention of Colorectal Cancer Through Multiomics Blood Testing study evaluated whether a particular blood test could aid in early colorectal cancer screening. Due to misconceptions about Black patients’ interest in research, we anticipated few patients would participate in the trial because our patient base is 90% African American. The sponsor for the study expected an enrollment rate as low as one to three patients per week at our site. </p>
<p>However, when enrollment began, we saw high interest among our Black patients. After three months, we had enrolled <a href="https://eposters.ddw.org/ddw/2022/ddw-2022/353760/krystal.mills.fact.or.myth.black.patients.do.not.want.to.participate.in.html?f=listing%3D1%2Abrowseby%3D8%2Asortby%3D2%2Amedia%3D2%2Ace_id%3D2236%2Alabel%3D24500%2Aot_id%3D26916">100 patients, 85% of whom were Black</a>.</p>
<p>So how did we do it?</p>
<h2>Identifying barriers</h2>
<p>First, we identified the participation barriers our Black and Hispanic patients faced.</p>
<p>We conducted a pilot study to identify more broadly the main barriers to research participation in underserved and underrepresented populations in our area. We reviewed enrollment rates, failures to meet eligibility and data issues, among others, from our past studies to see where we could improve.</p>
<p>We evaluated the role of mistrust by <a href="https://doi.org/10.1093/ibd/izac124">surveying patients at an IBD education conference</a>. Although patients often cited mistrust of health care providers and systems as a major barrier to trial participation, 70% of patients with a college education trusted their gastroenterologists, and 100% of patients with less than a college education trusted their doctors. Moreover, while 83% of respondents knew about the Tuskegee syphilis study, only 23% indicated that their decision to not participate in research was influenced by that study.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/483278/original/file-20220907-12-uce7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Clinician showing clipboard to patient in exam room" src="https://images.theconversation.com/files/483278/original/file-20220907-12-uce7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/483278/original/file-20220907-12-uce7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/483278/original/file-20220907-12-uce7s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/483278/original/file-20220907-12-uce7s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/483278/original/file-20220907-12-uce7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/483278/original/file-20220907-12-uce7s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/483278/original/file-20220907-12-uce7s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">There often isn’t enough time to talk about the details of participating in a clinical trial during an office visit.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/doctor-with-a-tablet-computer-royalty-free-image/898328226">FatCamera/E+ via Getty Images</a></span>
</figcaption>
</figure>
<p>We also identified other barriers based on our experience working with Black patients in other clinical trials. A significant one was low levels of <a href="https://medlineplus.gov/healthliteracy.html">health literacy</a>, or the ability to understand and make informed health care decisions. Another was limited access to specialty care, particularly when patients have been waiting for months for an appointment. Lack of transportation was another.</p>
<p>Time was another barrier. Because many of our patients have limited exposure to clinical studies, they have many questions and concerns that most clinicians <a href="https://doi.org/10.1016/j.cpcardiol.2018.11.002">do not have the time</a> to answer in the space of a standard appointment. Patients also could not afford the time commitment required for complex clinical trials. An informed consent process can take over an hour, and many trials require frequent and prolonged hospital visits, for which patients may not be able to take paid time off.</p>
<h2>Implementing solutions</h2>
<p>After identifying these barriers, we worked to create solutions to help our patients participate in research.</p>
<p>We pre-screened potential study participants by looking through their electronic medical records and provider referrals. This helped us identify qualifying patients and proactively reach out to them.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/483274/original/file-20220907-12-jyw7dk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two researchers looking at test tube" src="https://images.theconversation.com/files/483274/original/file-20220907-12-jyw7dk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/483274/original/file-20220907-12-jyw7dk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/483274/original/file-20220907-12-jyw7dk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/483274/original/file-20220907-12-jyw7dk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/483274/original/file-20220907-12-jyw7dk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/483274/original/file-20220907-12-jyw7dk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/483274/original/file-20220907-12-jyw7dk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Training research and clinical staff on cultural competency could increase trial recruitment and improve care.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/detection-of-the-pathogen-coronavirus-infection-in-royalty-free-image/1207087144">valentinrussanov/E+ via Getty Images</a></span>
</figcaption>
</figure>
<p>We also trained research staff as well as hospital administration, faculty, staff and students on the study, offering tips on how to interact with underserved and underrepresented patients.</p>
<p>Most importantly, we encouraged our clinicians and researchers to create a safe space for participants to be able to ask questions. This also provides an opportunity to work out ways to accommodate a patient’s schedule. </p>
<h2>Making an effort</h2>
<p>Working with diverse participants can be challenging, but so is every other aspect of clinical research. Our results showed that intentional recruitment, flexibility and creative solutions can help increase enrollment of underrepresented populations in clinical trials.</p>
<p>Partnering with an institution dedicated to serving underserved populations can also help. But above all, research participants are looking for a genuine interest in their well-being.</p><img src="https://counter.theconversation.com/content/185337/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Overcoming the access barriers and biases that underrepresented and underserved communities face could not only improve research participation but also improve care.Julia Liu, Professor of Medicine, Morehouse School of MedicineRaKetra Snipes, Physician Assistant in Gastroenterology, Morehouse School of MedicineLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1522332021-01-27T01:10:59Z2021-01-27T01:10:59ZDo men really take longer to poo?<figure><img src="https://images.theconversation.com/files/377953/original/file-20210111-15-ruzndd.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C667&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-man-toilet-using-phone-619346291">from www.shutterstock.com</a></span></figcaption></figure><p>There’s a common assumption men take longer than women to poo. People say so on <a href="https://twitter.com/trenduso/status/1100968885203931136">Twitter</a>, in <a href="https://www.sammichespsychmeds.com/men-bathroom-memes/">memes</a>, and <a href="https://www.youtube.com/watch?v=nLcEU6ahlOI">elsewhere</a> <a href="https://www.livescience.com/why-men-take-longer-to-poop.html">online</a>. But is that right? What could explain it? And if some people are really taking longer, is that a problem?</p>
<p>As we sift through the evidence, it’s important to remember pooing may involve time spent sitting on the toilet and the defaecation process itself.</p>
<p>And there may be differences between men and women in these separate aspects of going to the toilet. But the evidence for these differences isn’t always as strong as we’d like.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-we-have-to-poo-every-day-we-asked-five-experts-98701">Do we have to poo every day? We asked five experts</a>
</strong>
</em>
</p>
<hr>
<h2>Men may spend longer sitting on the toilet</h2>
<p>Men do appear to spend more time sitting on the toilet. An <a href="https://www.dailymail.co.uk/femail/article-2641550/Britons-favourite-loo-terature-revealed-Sports-biographies-erotic-magazines-bathroom-reading-material-poll.html">online survey</a> by a bathroom retailer suggested men spend up to 14 minutes a day compared with women, who spend almost eight minutes a day. But this survey doesn’t have the rigour of a well-designed scientific study.</p>
<p>Would there be any physiological reason to explain why men spend longer on the toilet? Well, the evidence actually suggests the opposite.</p>
<p>We know it <a href="https://www.tandfonline.com/doi/abs/10.1080/00365520310000410">takes longer</a> for food to travel through the intestines in women than in men. Women are also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6175559/">more likely to suffer</a> from constipation related to irritable bowel syndrome than men. So, you’d expect women to take longer to defaecate, from the start of the bowel motion to expulsion.</p>
<p>But this is <a href="https://pubmed.ncbi.nlm.nih.gov/12870773/">not the case</a> even if you take into account differences in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5986479/">fibre intake</a> between men and women.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-irritable-bowel-syndrome-and-what-can-i-do-about-it-102579">Explainer: what is irritable bowel syndrome and what can I do about it?</a>
</strong>
</em>
</p>
<hr>
<p>Instead, how long it takes someone to poo (the defaecation time) is <a href="https://pubmed.ncbi.nlm.nih.gov/28470247/">heavily influenced</a> by the mucus lining the large bowel. This mucus makes the bowel slippery and easier for the stools to be expelled. But there’s no evidence this mucus lining is different in men and women. </p>
<p>One thing we do know, however, is mammals from elephants to mice have a similar defaecation time, <a href="https://pubs.rsc.org/en/content/articlelanding/2017/sm/c6sm02795d#!divAbstract">around 12 seconds</a>. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1100968885203931136"}"></div></p>
<p>For humans, it’s slightly longer, but still quick. In <a href="https://pubmed.ncbi.nlm.nih.gov/12870773/">one study</a> it took healthy adults an average two minutes when sitting, but only 51 seconds when squatting. Again, there were no differences in defaecation time between men and women, whether sitting or squatting. </p>
<p>If there’s no strong evidence one way or the other to explain any gender differences in how long it takes to poo, what’s going on? For that, we need to look at the total time spent on the toilet.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/whats-the-best-way-to-go-to-the-toilet-squatting-or-sitting-63991">What's the best way to go to the toilet – squatting or sitting?</a>
</strong>
</em>
</p>
<hr>
<h2>Why do people spend so long on the toilet?</h2>
<p>What I call the “toilet sitting time” is the time of defaecation itself and the time allocated to other activities sitting on the toilet. For most people, the time spent just sitting, aside from defaecating, accounts for most of their time there.</p>
<p>So what are people doing? Mainly reading. And it seems men are <a href="http://news.bbc.co.uk/2/hi/health/1230115.stm">more likely</a> to read on the toilet than women.</p>
<p>For instance, a <a href="https://pubmed.ncbi.nlm.nih.gov/19019015/">study</a> of almost 500 adults in Israel found almost two-thirds (64%) of men regularly read on the toilet compared with 41% of women. The longer people spent on the toilet, the more likely they were to be reading. However, in the decade or more since this study was conducted, you’d expect adults would be more likely to be reading or playing games on their mobile phones rather than reading paper books.</p>
<p>People might also be sitting longer on the toilet for some temporary relief from the stresses of life.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/380091/original/file-20210121-19-q4weg1.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Meme about men avoiding parenting responsibilities by sitting on the toilet for longer" src="https://images.theconversation.com/files/380091/original/file-20210121-19-q4weg1.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/380091/original/file-20210121-19-q4weg1.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=417&fit=crop&dpr=1 600w, https://images.theconversation.com/files/380091/original/file-20210121-19-q4weg1.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=417&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/380091/original/file-20210121-19-q4weg1.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=417&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/380091/original/file-20210121-19-q4weg1.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=524&fit=crop&dpr=1 754w, https://images.theconversation.com/files/380091/original/file-20210121-19-q4weg1.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=524&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/380091/original/file-20210121-19-q4weg1.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=524&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sometimes, people just need time to themselves.</span>
<span class="attribution"><a class="source" href="https://www.sammichespsychmeds.com/men-bathroom-memes/">Ramblin Mama</a></span>
</figcaption>
</figure>
<p>One <a href="https://www.dailymail.co.uk/femail/article-2641550/Britons-favourite-loo-terature-revealed-Sports-biographies-erotic-magazines-bathroom-reading-material-poll.html">poll</a> found 56% of people find sitting on the toilet relaxing, and 39% a good opportunity to have “some time alone”. Another <a href="https://www.independent.co.uk/life-style/bathrooms-shower-washing-habits-poll-a8988626.html">online survey</a> revealed one in six people reported going to the toilet for “peace and quiet”. Although these are not scientific studies, they offer useful insights into a social phenomenon.</p>
<p>Then there can be medical reasons for a prolonged defaecation time, and consequently a lengthier time sitting on the toilet. </p>
<p>An anal fissure (a tear or crack in the lining of the anus) can make defaecation a painful and lengthy process. These fissures are <a href="http://eknygos.lsmuni.lt/springer/526/178-191.pdf">just as common</a> in men as in women. </p>
<p>And <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306148/">obstructive defaecation</a>, where people cannot empty the rectum properly, is a common cause of chronic constipation. This is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3030249/">more common</a> in middle-aged women. </p>
<h2>Are there any harms from spending too long on the loo?</h2>
<p>In a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7236649/">Turkish study</a>, spending more than five minutes on the toilet was associated with haemorrhoids and anal fissures. Another study from <a href="https://pubmed.ncbi.nlm.nih.gov/31996480/">Italy</a> noted the longer the time people spent on the toilet, the more severe their haemorrhoids.</p>
<p><a href="http://www.annalsgastro.gr/files/journals/1/earlyview/2019/ev-01-2019-19-AG4360-0355.pdf">One theory</a> behind this is prolonged sitting increases pressure inside the abdomen. This leads to less blood flow into the veins of the rectum when passing a bowel motion, and ultimately to blood pooling in the vascular cushions of the anus. This makes haemorrhoids more likely to develop. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-why-do-people-get-haemorrhoids-and-how-do-you-get-rid-of-them-94820">Explainer: why do people get haemorrhoids and how do you get rid of them?</a>
</strong>
</em>
</p>
<hr>
<h2>What can we do about this?</h2>
<p>In addition to the usual advice about increasing the amount of fibre in your diet and ensuring you drink enough water, it would be sensible to limit the amount of time spent on the toilet.</p>
<p>Different researchers recommend a <a href="https://pubmed.ncbi.nlm.nih.gov/28150480/">different</a> <a href="https://pubmed.ncbi.nlm.nih.gov/27723447/">upper limit</a>. But I <a href="https://pubmed.ncbi.nlm.nih.gov/30346317/">and others</a> recommend the SEN approach:</p>
<ul>
<li><p><strong>S</strong>ix minute toilet sitting time maximum</p></li>
<li><p><strong>E</strong>nough fibre (eating more fruit and vegetables, and eating wholegrains)</p></li>
<li><p><strong>N</strong>o straining during defaecation. </p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-what-causes-constipation-114290">Health Check: what causes constipation?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/152233/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vincent Ho does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>If you believe the memes, men spend ages in the toilet. But they’re not always pooing. Here’s what they’re really doing.Vincent Ho, Senior Lecturer and clinical academic gastroenterologist, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1441762020-08-21T18:09:51Z2020-08-21T18:09:51ZIBD: How a class of killer T cells goes rogue in inflammatory bowel disease<figure><img src="https://images.theconversation.com/files/353234/original/file-20200817-18-1fz4mrb.jpg?ixlib=rb-1.1.0&rect=18%2C28%2C6211%2C4119&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are currently no permanent treatments for most patients with inflammatory bowel disease.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/woman-having-painful-stomach-ache-royalty-free-image/1188226212?adppopup=true">PokPak05/iStock/Getty Images Plus</a></span></figcaption></figure><p>Between <a href="https://doi.org/10.1016/S2468-1253(19)30333-4">6 and 8 million people worldwide</a> suffer from inflammatory bowel disease, a group of chronic intestinal disorders that can cause belly pain, urgent and frequent bowel movements, bloody stools and weight loss. New research suggests that a malfunctioning member of the patient’s own immune system called a killer T cell may be one of the culprits. This discovery may provide a new target for IBD medicines.</p>
<p>The two main types of IBD are <a href="http://doi.org/10.1016/S0140-6736(16)32126-2">ulcerative colitis,</a> which mainly affects the colon, and <a href="https://doi.org/10.1016/S0140-6736(16)31711-1">Crohn’s disease,</a> which can affect the entire digestive tract. Researchers currently believe that IBD is triggered when an <a href="https://www.nejm.org/doi/full/10.1056/nejmra0804647">overactive immune system attacks harmless bacteria in the intestines</a>. Although there are many treatments for IBD, <a href="https://doi.org/10.1097/mog.0000000000000536">for as many as 75% of individuals with IBD</a> there are no effective long-term treatments. This leaves many patients without good options. </p>
<p>I am a <a href="https://changlab.ucsd.edu">physician-scientist</a> conducting research in immunology and IBD and in a <a href="http://immunology.sciencemag.org/lookup/doi/10.1126/sciimmunol.abb4432">new study</a>, <a href="https://medschool.ucsd.edu/som/medicine/research/labs/chang-lab/people/Pages/default.aspx">my team</a> and our colleagues specializing in <a href="https://goldrathlab.com/">immunology</a>, <a href="https://health.ucsd.edu/specialties/gastro/areas-expertise/ibd-center/Pages/default.aspx">gastroenterology</a> and <a href="https://yeolab.github.io/">genomics</a> examined immune cells from the blood and intestines of healthy individuals and compared them with those collected from patients with ulcerative colitis to gain a better understanding of how the immune system malfunctions in IBD. There are many reasons why current treatments aren’t permanent, but one reason is that scientists don’t fully understand how the immune system is involved in IBD. It is our hope that closing the current knowledge gap about how the immune system is involved in this disorder will eventually lead to new durable treatments for IBD that target the right immune cells.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/353284/original/file-20200817-16-1titleg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/353284/original/file-20200817-16-1titleg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/353284/original/file-20200817-16-1titleg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/353284/original/file-20200817-16-1titleg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/353284/original/file-20200817-16-1titleg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/353284/original/file-20200817-16-1titleg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/353284/original/file-20200817-16-1titleg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/353284/original/file-20200817-16-1titleg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ulcerative colitis is a type of inflammatory bowel disease that results in chronic inflammation and damage to the large intestine.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/ulcerative-colitis-royalty-free-illustration/1143632545?adppopup=true">Graphic_BKK1979/iStock via Getty Images</a></span>
</figcaption>
</figure>
<h2>Immunology 101</h2>
<p>The immune system can be divided into <a href="https://www.youtube.com/watch?v=jeN8v5I5VNA">innate and adaptive branches</a>. The innate branch is our first line of defense and acts quickly – within minutes to hours. But this system senses changes caused by microbes generally. It does not mount a targeted response against a specific pathogen, which means that some invaders can be overlooked. </p>
<p>The adaptive branch is designed to detect specific threats, but is slower and takes a couple of days to get going. T cells are a part of the adaptive immune system and can be further subdivided into <a href="https://theconversation.com/coronavirus-b-cells-and-t-cells-explained-141888">CD4⁺ and CD8⁺ T cells</a>. </p>
<p>CD4⁺ T cells are helpers that aid other immune cells by releasing soluble molecules called cytokines that can induce inflammation.</p>
<p>CD8⁺ T cells can also release cytokines, but their main function is to kill cells infected by microbial invaders. This is why CD8⁺ T cells are often referred to as serial killers. </p>
<p>After the infection is cleared and the pathogen has been destroyed, cells called memory T cells remain. These memory T cells “remember” the pathogen they’ve just encountered and if they see it again, they mount a stronger and faster response than the first time. They and their descendants can also live for a long time, even decades in the case of certain infections like <a href="https://doi.org/10.1099/0022-1317-81-5-1313">measles</a>. </p>
<p>The goal of a <a href="https://www.nytimes.com/interactive/2020/science/coronavirus-vaccine-tracker.html">vaccine</a> is to provide a preview of the microbe so that the immune system can build an army of memory cells against an infectious agent, such as SARS-CoV-2, the virus that causes COVID-19. That way, <a href="https://www.theatlantic.com/health/archive/2020/08/covid-19-immunity-is-the-pandemics-central-mystery/614956/">if the virus attacks</a>, the memory T cells will spring into action and activate an immune response including the <a href="https://www.nature.com/articles/s41467-017-00843-7">production of antibodies from B cells</a>.</p>
<h2>Memory T cells that reside in organs</h2>
<p>Immunologists further subdivide <a href="https://doi.org/10.1038/ni.3031">memory T cells</a> into different classes depending on if and where they travel in the body. Circulating memory T cells are scouts that look for signs of infection by patrolling the blood, lymph nodes and spleen. </p>
<p><a href="https://doi.org/10.1016/j.coi.2018.03.017">Tissue-resident memory cells</a>, abbreviated TRM, are sentries stationed at key ports of entry into the human body – including the skin, lungs, and intestines – and act rapidly to counter an infectious threat. Intestinal TRM also function as peacekeepers and do not tend to overreact against the many harmless microbes living in the intestines.</p>
<p>In the <a href="http://immunology.sciencemag.org/lookup/doi/10.1126/sciimmunol.abb4432">new study</a>, our team analyzed blood and intestinal samples to discover that intestinal CD8⁺ TRM come in at least four different varieties, each with unique features and functions. </p>
<p>We noticed that individuals with ulcerative colitis had higher numbers and proportions of cells belonging to one of these four varieties. This particular variety, which we’ll call inflammatory TRM here, carried instructions to make very large amounts of cytokines and other protein factors that allow them to kill other cells. High levels of certain cytokines can cause inflammation and tissue damage in the body.</p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>It seems that in individuals with ulcerative colitis, the balance of memory cells is shifted in favor of this rogue population of inflammatory TRM that may become part of the problem by causing persistent inflammation and tissue damage.</p>
<p>We also found evidence consistent with the possibility that these inflammatory TRM might be exiting the intestinal tissue and entering the blood. Other studies in <a href="https://doi.org/10.1038/s41590-020-0607-7">mice</a> and <a href="https://doi.org/10.1126/sciimmunol.aav8995">people</a> have shown that TRM, despite being called “tissue-resident,” can leave tissues in certain circumstances. </p>
<p>By leaving the tissue and entering the blood, inflammatory TRM may be able to travel to other parts of the body and cause damage. This possibility may explain why autoimmune diseases that start in one organ, like <a href="https://doi.org/10.1007/s11894-019-0698-1">IBD</a> in the digestive tract or <a href="https://www.emjreviews.com/dermatology/article/psoriasis-beyond-the-skin/">psoriasis</a> in the skin, often affect other parts of the body.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/353248/original/file-20200817-22-1e2ytlu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/353248/original/file-20200817-22-1e2ytlu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/353248/original/file-20200817-22-1e2ytlu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/353248/original/file-20200817-22-1e2ytlu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/353248/original/file-20200817-22-1e2ytlu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/353248/original/file-20200817-22-1e2ytlu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/353248/original/file-20200817-22-1e2ytlu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The balance of memory T cell subtypes changes in individuals with ulcerative colitis. Illustrations created with BioRender.com.</span>
<span class="attribution"><span class="source">John Chang</span></span>
</figcaption>
</figure>
<h2>IBD and other autoimmune diseases as a memory problem</h2>
<p>The very features that make memory T cells so desirable for vaccines – their capacity to live for such a long time and mount a stronger response when they encounter a microbial invader for the second time – may explain why autoimmune diseases are chronic and lifelong.</p>
<p>It is important to point out that none of the current drug treatments for IBD specifically target long-lived memory cells, which might be a reason why these therapies don’t work long-term in many individuals. One therapeutic approach might be to target inflammatory TRM for destruction, but this could result in side effects like suppression of the immune system and increased infections.</p>
<p>Our findings build on previous studies showing that <a href="https://doi.org/10.1053/j.gastro.2017.07.047">different TRM varieties</a>, like the <a href="https://doi.org/10.1038/s41590-018-0298-5">CD4⁺ subtype</a>, may also be involved in IBD, while other studies show that TRM play a role in autoimmune diseases affecting other organs like the <a href="https://doi.org/10.1126/scitranslmed.3010641">skin</a> and <a href="https://doi.org/10.1126/sciimmunol.aba4163">kidneys</a>.</p>
<p>The possibility that T cell memory is co-opted in IBD is exciting, but there is much that we still don’t understand about TRM. Can we selectively target inflammatory TRM for destruction? Would this be an effective treatment for IBD? Can we do so without causing major side effects? Further research will be needed to answer these important questions and to strengthen the link between TRM and IBD.</p><img src="https://counter.theconversation.com/content/144176/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Chang receives research grant funding from the National Institutes of Health, the Kenneth Rainin Foundation, Takeda, and Eli Lilly.</span></em></p>Researchers discover clues to the origin of inflammatory bowel disease and a possible strategy for treatment.John Chang, Professor of Medicine, University of California, San DiegoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/960982018-06-11T22:15:34Z2018-06-11T22:15:34ZWhy we all need to be proactive about our bowels<figure><img src="https://images.theconversation.com/files/222281/original/file-20180607-121234-1k1m10h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Manipulating environmental exposures to optimize a healthy microbiome may hold the promise of preventing chronic inflammatory diseases, such as Crohn's disease and ulcerative colitis.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Inflammatory bowel disease (IBD) is a mounting burden on health-care systems globally. </p>
<p>A 2012 study found that Crohn’s disease and ulcerative colitis (two types of IBD) are significantly on the rise. A follow-up study published last year in <em>The Lancet</em> demonstrated that these diseases <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32448-0/abstract">affect over 0.3 per cent of the population in North America, Oceania and many countries in Europe</a>. </p>
<p>In Canada, the number of individuals affected by IBD is estimated to rise to around 0.7 per cent of the total population this year, and <a href="https://academic.oup.com/jcag/article/1/suppl_2/47/4916529">to almost a full percentage of the population (roughly 400,000 afflicted individuals) by 2030</a>. </p>
<p>IBD was conservatively estimated to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3495699">cost Canadians $2.8 billion per year in direct and indirect costs, as of 2012</a>.</p>
<p>Like the horse charging at a steaming locomotive in Alex Colville’s 1954 painting, <em>Horse and Train</em>, our health-care system is on track to crash with the unstoppable force of IBD. </p>
<p>Unless, that is, we turn our head and aim for an opening. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/222081/original/file-20180606-137315-1kg1po4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/222081/original/file-20180606-137315-1kg1po4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/222081/original/file-20180606-137315-1kg1po4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/222081/original/file-20180606-137315-1kg1po4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/222081/original/file-20180606-137315-1kg1po4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/222081/original/file-20180606-137315-1kg1po4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/222081/original/file-20180606-137315-1kg1po4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Alex Colville’s painting ‘Horse and Train’</span>
<span class="attribution"><span class="source">(Copyright A.C.Fine Art Inc. NO REUSE)</span></span>
</figcaption>
</figure>
<p>This opening is “proactive medicine” — preventing the disease from occurring in the first place. </p>
<p>One way of achieving this may be to manipulate environmental exposures and optimize <a href="https://www.bmj.com/content/360/bmj.j5145">a healthy gut microbiome</a>: The 100 trillion or so symbiotic microbes that live within our bodies that are necessary for our survival. </p>
<h2>A chronic and incurable disease</h2>
<p>Part of the reason for the dramatic increase in the number of individuals afflicted with IBD is because <a href="https://www.sciencedirect.com/science/article/pii/S0016508511013783?via%3Dihub">it is a disease of the young, most commonly diagnosed between the ages of 18 and 35</a>. </p>
<p>IBD is a chronic and incurable disease with low mortality. Those diagnosed with IBD are not likely to die from the disease; they can live long lives. This combination of young age at diagnosis and low mortality leads to <a href="http://www.nature.com/articles/nrgastro.2015.150">an epidemiologic concept called compounding prevalence</a>. </p>
<p>We all know about compounding interest: If we start saving money in our 20s, over time and with a steady interest rate, our savings will experience compound growth. In our 60s, we will be left with a large sum of money for retirement.</p>
<p>Compounding prevalence, in contrast, is when new individuals are being added to the affected population (diagnosed with the disease) but existing cases are not being removed — leading to a steady rise in the number afflicted with disease. </p>
<p>A recent study forecasted that <a href="https://academic.oup.com/jcag/article/1/suppl_2/47/4916529">the prevalence of IBD will rise an average of three per cent per year over the next decade</a>.</p>
<p>We are facing an impending disaster for our health-care systems, but one that may be averted by looking for solutions and altering our course now. </p>
<h2>Smoking, diet and cleanliness</h2>
<p>More often than not, clinicians are trained to practice reactive medicine: Treating a disease after it develops. For example, we treat Crohn’s disease with powerful, expensive, immune system suppressing medications; when these fail, we remove segments of the patients’ bowels. </p>
<p>Frequently, however, the disease returns, forcing us to continue this vicious cycle. The burgeoning number of patients with chronic inflammatory diseases who are being managed in a predominantly reactive health-care system has the potential to squeeze the system within an inch of its life — both in terms of fiscal and staffing resources. </p>
<p>We need to change the future of health care by starting to practice proactive medicine.</p>
<p>In order to prevent a disease, you have to understand the disease. In 2018, we have come to understand that chronic inflammatory diseases arise from <a href="https://www.sciencedirect.com/science/article/pii/S0016508516352672?via%3Dihub">interactions between susceptibility genes and environmental exposures linked to the Westernization of society</a>, such as <a href="https://www.nature.com/articles/nrgastro.2015.34">smoking, diet and even our intense focus on cleanliness</a>. </p>
<p>Mutations in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3491803/">susceptibility genes</a> can affect the interaction of the immune system and the gut microbiome. And this microbiome is set in early childhood where decisions such as <a href="https://www.nature.com/articles/nrgastro.2015.34">bottle feeding or using antibiotics in infancy</a> may raise the risk of developing IBD later in life.</p>
<p>Manipulating environmental exposures to optimize a healthy microbiome may hold the promise of preventing chronic inflammatory diseases. Examples can include breastfeeding, avoiding unnecessary antibiotics early in life and avoiding cigarettes.</p>
<h2>We must prioritize proactive medicine</h2>
<p>This is the critical moment at which we need a major investment from government, industry and the public to fund clinical and laboratory research to explain the origin of chronic inflammatory diseases and foster strategies for disease prevention.</p>
<p>Diseases like IBD have significantly increased in diagnoses and are already affecting millions of people in North America, and many more around the world. </p>
<p>Health-care systems must account for the exponential rise in cases of chronic inflammatory diseases or face an unstable system, overwhelmed by a flood of complex patients. </p>
<p>Averting this disaster requires a collective shift from clinicians, government and the public — towards supporting proactive medicine. </p>
<p>Prioritizing proactive medicine will mean funding research to create the best available evidence to develop recommendations around healthy living — from infancy to adulthood — to ultimately lower the number of people afflicted with chronic inflammatory diseases. </p>
<p>By doing so, we may stand a chance at stemming the global rise of chronic diseases like IBD and avoid an ugly encounter with the proverbial train upon the tracks.</p><img src="https://counter.theconversation.com/content/96098/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gilaad Kaplan has received speaking or consultancy honoraria from AbbVie, Janssen, Pfizer, and Shire. He has received a grant from Abbvie, Janssen, Merck, and Shire. Dr. Kaplan has received research funding from the Canadian Institutes of Health Research, Alberta Innovates, Health Canada, Crohn's and Colitis Canada, Broad Medical Research Program and the Canadian Foundation for Innovation. Dr. Kaplan is the Scientific Director of Alberta Health Services’ Digestive Health Strategic Clinical Network. He is a member of the Scientific and Medical Advisory Committee of Crohn’s and Colitis Canada. </span></em></p><p class="fine-print"><em><span>Stephanie Coward receives funding from an Izaak Walton Killam Doctoral Scholarship and an Eyes High Doctoral Recruitment Scholarship (from the University of Calgary). She is affiliated with the Canadian Gastrointestinal Epidemiology Consortium as a trainee member. </span></em></p><p class="fine-print"><em><span>Joseph W. Windsor does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Halting the rapid rise in inflammatory bowel disease will require a proactive approach to medicine, and a focus on the gut.Gilaad Kaplan, Associate Professor, Gastroenterology, University of CalgaryJoseph W. Windsor, Research Assistant, Cumming School of Medicine, University of CalgaryStephanie Coward, PhD Candidate in Epidemiology, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/867642018-01-02T20:51:04Z2018-01-02T20:51:04ZThree reasons to get your stress levels in check this year<figure><img src="https://images.theconversation.com/files/199170/original/file-20171214-27568-nrfd00.jpg?ixlib=rb-1.1.0&rect=0%2C450%2C1879%2C916&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People who are chronically stressed are more than twice as likely to have a heart attack than those who aren't.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/1K9T5YiZ2WU">Tim Gouw</a></span></figcaption></figure><p>It’s difficult not to get stressed in our fast-paced lives. Whether you’re working overtime, battling exams, or caring for a sick relative, chronic stress has become commonplace. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/196461/original/file-20171127-2009-9zdxrs.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/196461/original/file-20171127-2009-9zdxrs.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=823&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196461/original/file-20171127-2009-9zdxrs.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=823&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196461/original/file-20171127-2009-9zdxrs.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=823&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196461/original/file-20171127-2009-9zdxrs.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1034&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196461/original/file-20171127-2009-9zdxrs.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1034&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196461/original/file-20171127-2009-9zdxrs.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1034&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Adrenaline allows us to act quickly.</span>
</figcaption>
</figure>
<p>When we’re acutely stressed, the fight-or-flight system jumps into action, sending a surge of adrenaline through the body. This product of evolution dramatically increases our reaction speed and once allowed us to escape or fight a predator. </p>
<p>But our bodies are not designed to cope with ongoing activity of these stress pathways. </p>
<p>The psychological effects of stress – such as irritability, loss of appetite, and difficulty sleeping – are obvious to anyone who has been under pressure. But stress also has subtle, underlying effects on almost every part of the body, including the heart, gut and immune system. </p>
<p>Here are just three reasons to get your stress levels in check this year. </p>
<h2>1. You’re at risk of a heart attack</h2>
<p>When activated, the fight-or-flight system causes blood pressure to spike and redirects blood flow away from non-essential parts of the body and into the muscles. </p>
<p>Consistently high blood pressure or frequent spikes strain the coronary arteries serving the heart. Higher blood pressure with each beat causes arteries to slowly stiffen and become clogged, which impedes blood flow to the heart.</p>
<p>One study found people who were chronically stressed, either in their work or home life, were <a href="https://www.ncbi.nlm.nih.gov/pubmed/15364185">more than twice as likely to have a heart attack</a> than those who weren’t.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-what-do-my-blood-pressure-numbers-mean-29212">Health Check: what do my blood pressure numbers mean?</a>
</strong>
</em>
</p>
<hr>
<p>Another effect of stress on the cardiovascular system is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2633295/">hyper-responsiveness</a>. When a person is suffering low but persistent levels of stress, their response to an added source of stress is much more intense than normal, leading to larger spikes in heart rate and blood pressure. </p>
<p>Again, the increased blood pressure damages blood vessels and increases the chances of blockages and heart attacks.</p>
<h2>2. Your bathroom habits are unpredictable</h2>
<p>The same systems that increase blood pressure and heart rate during stress also cause food to be digested more slowly. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/196637/original/file-20171128-2089-1hj5igm.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/196637/original/file-20171128-2089-1hj5igm.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/196637/original/file-20171128-2089-1hj5igm.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=649&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196637/original/file-20171128-2089-1hj5igm.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=649&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196637/original/file-20171128-2089-1hj5igm.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=649&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196637/original/file-20171128-2089-1hj5igm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=816&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196637/original/file-20171128-2089-1hj5igm.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=816&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196637/original/file-20171128-2089-1hj5igm.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=816&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Chronic stress can make you constipated or have diarrhoea.</span>
<span class="attribution"><span class="source">Marcella Cheng/The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>The chemicals produced by the stomach and intestines change when you’re stressed. Food gets broken down in different ways and the body may have difficulty absorbing the nutrients from it. This can lead to constipation, diarrhoea and general intestinal discomfort. </p>
<p>Chronic stress has <a href="https://www.ncbi.nlm.nih.gov/pubmed/22314561">also been linked</a> to more serious diseases such as irritable bowel syndrome and inflammatory bowel disease. While the reasons for this still aren’t clear, it’s thought that chronic stress causes bowel disease by increasing inflammation from intestinal immune cells called mast cells.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/so-you-think-you-have-ibs-coeliac-disease-or-crohns-heres-what-it-might-mean-for-you-39128">So you think you have IBS, coeliac disease or Crohn’s? Here’s what it might mean for you</a>
</strong>
</em>
</p>
<hr>
<p>Treatment for these diseases usually revolve around managing the painful and uncomfortable symptoms instead of addressing the underlying cause. However some therapies, <a href="https://www.ncbi.nlm.nih.gov/pubmed/20554042">such as the hormone melatonin</a>, work by reducing the effects of stress on the gut.</p>
<h2>3. You’re more likely to get sick</h2>
<p>We’ve long known that stress makes people more vulnerable to catching minor illnesses but we’ve only begun to understand <em>how</em> stress affects the immune system over the past few decades. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/196650/original/file-20171128-2066-12vxfas.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/196650/original/file-20171128-2066-12vxfas.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/196650/original/file-20171128-2066-12vxfas.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=566&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196650/original/file-20171128-2066-12vxfas.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=566&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196650/original/file-20171128-2066-12vxfas.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=566&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196650/original/file-20171128-2066-12vxfas.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=712&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196650/original/file-20171128-2066-12vxfas.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=712&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196650/original/file-20171128-2066-12vxfas.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=712&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Students who were less stressed when receiving the vaccination had a better immune response than their anxious peers.</span>
<span class="attribution"><span class="source">Marcella Cheng/The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>The best examples of this come from a study of chronically stressed carers who look after patients with Alzheimer’s disease, and another of medical students in the middle of their exam period. </p>
<p>When given the flu vaccine, the stressed caretakers had a lower immune response to the vaccine than normal. </p>
<p>Conversely, when the medical students in the middle of their exam periods were vaccinated against hepatitis, the students with better social support and lower levels of stress and anxiety had a much better immune response to the vaccine than other students.</p>
<p>In other words, when the participants were stressed, their immune system didn’t function as it should to recognise and defend against the virus. The same occurs for colds and flus, other viruses, bacterial infections and even <a href="https://www.ncbi.nlm.nih.gov/pubmed/15465465">cancer</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-the-immune-system-19240">Explainer: what is the immune system?</a>
</strong>
</em>
</p>
<hr>
<p>When stress causes the immune system to break down, a bug that might have been under control can suddenly start flourishing. Once a person begins feeling sick, their stress levels will likely rise and make it <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361287/">harder for the immune system</a> to fight off the disease. This prolongs the illness and increases the risk it will be passed on to another person.</p>
<h2>How to reduce your stress levels</h2>
<p>There are many strategies available to reduce the effects of stress, but their health benefits have only recently started to be researched and understood over the past few decades. </p>
<p>An interesting example of this came from an experiment in 2002, where subjects were given injections of artificial adrenaline to increase their blood pressure and heart rate. But when one of the subjects got bored and started meditating, their heart rate <a href="https://www.ncbi.nlm.nih.gov/pubmed/12372589">suddenly dropped back to normal</a>, even with the researchers attempting to increase it artificially.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/196655/original/file-20171128-2016-18lsj0e.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/196655/original/file-20171128-2016-18lsj0e.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/196655/original/file-20171128-2016-18lsj0e.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=332&fit=crop&dpr=1 600w, https://images.theconversation.com/files/196655/original/file-20171128-2016-18lsj0e.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=332&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/196655/original/file-20171128-2016-18lsj0e.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=332&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/196655/original/file-20171128-2016-18lsj0e.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=417&fit=crop&dpr=1 754w, https://images.theconversation.com/files/196655/original/file-20171128-2016-18lsj0e.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=417&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/196655/original/file-20171128-2016-18lsj0e.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=417&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Meditation helps some people lower their blood pressure.</span>
<span class="attribution"><span class="source">Marcella Cheng/The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>This finding was applied in a 2008 study, where researchers took newly diagnosed breast cancer patients and enrolled them in a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2586059/">mindfulness-based stress-reduction program</a> that focused on breath awareness, meditation and yoga.</p>
<p>After eight weeks of participation in the program, the immune systems of the women had all made a remarkable recovery, and were functioning just as well as a healthy person’s immune system. The women also reported feeling much more optimistic about their future, as well as feeling more connected with their family and friends.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/mindfulness-how-to-be-in-the-moment-right-here-right-now-31576">Mindfulness: how to be in the moment ... right here, right now</a>
</strong>
</em>
</p>
<hr>
<p>Interestingly, short bursts of acute stress can be beneficial to immune function, particularly of that associated with exercise. While solid evidence is still lacking in humans, <a href="https://www.ncbi.nlm.nih.gov/pubmed/26895752">mice received a huge benefit from frequent exercise</a> while fighting off melanoma.</p>
<p>In the end, it comes down to being aware of your stress levels, and what works for <em>you</em> to get your stress in check. You might be surprised at just how many of your bodily functions benefit from you being a bit more relaxed.</p><img src="https://counter.theconversation.com/content/86764/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Mattarollo receives funding from National Health and Medical Research Council. Previously received funding from Leukemia Foundation Queensland and Cancer Australia/Cure Cancer Australia. </span></em></p><p class="fine-print"><em><span>Michael Nissen receives funding from the Australian Federal Government in the form of a Research Training Program scholarship.</span></em></p>Stress has subtle, underlying effects on almost every part of the body, including the heart, gut and immune system.Stephen Mattarollo, NHMRC Career Development Fellow, Diamantina Institute, The University of QueenslandMichael Nissen, PhD Candidate in Immunology, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/788412017-07-16T19:57:59Z2017-07-16T19:57:59ZThe brain and the gut talk to each other: how fixing one could help the other<figure><img src="https://images.theconversation.com/files/176843/original/file-20170705-15991-khi2jp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People with chronic bowel conditions may need to use the toilet 20 to 30 times a day.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/daveynin/4753012363/in/photolist-8f1qZ2-iWhuse-7u2KbS-bxbRFV-Fq8rbJ-5b878q-nUSaon-4r8Qm8-LKwH5-6n3yth-bdeJRa-6U13A3-5C7aE6-8EqfxB-iDrDsb-JtEDwA-8xwJn6-835Bi5-aoTP7D-bDxGVx-byLg7S-dtxhQJ-a5fxwE-bx1P3e-EK9aF-NKvr4Z-JmPm4u-6fSMwj-bnrRHW-iYFAj6-pvkPrB-dkTtSc-b1FAye-2WH8ay-8xjqcX-bwu8vK-jvxQ6o-fpprtj-db4qc-699kYH-wJNJH-b7T4yt-ckkMiL-dwpTPu-nT5DdF-8aRBjT-fMemM-am2Swr-2CCiog-dVB5dV">daveynin/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>It’s widely recognised that emotions can directly affect stomach function. As early as 1915, influential physiologist <a href="https://archive.org/details/cu31924022542470">Walter Cannon noted</a> that stomach functions are changed in animals when frightened. The same is true for humans. Those who <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1440-174%206.2004.03508.x/full">stress a lot</a> often report diarrhoea or stomach pain.</p>
<p>We now know this is because the brain communicates with the gastrointestinal system. A whole ecosystem comprising <a href="http://www.nature.com/nature/journal/v449/n7164/full/nature06244.html">100 trillion bacteria</a> living in our bowels is an active participant in this brain-gut chat.</p>
<p>Recent discoveries around this relationship have made us consider using talk therapy and antidepressants as possible treatments for symptoms of chronic gut problems. The aim is to interfere with the conversation between the two organs by telling the brain to repair the faulty bowel.</p>
<p>Our research found <a href="http://www.thelancet.com/journals/langas/article/PIIS2468-1253(16)30206-0/abstract">talk therapy can improve depression</a> and the quality of life of patients with gastrointestinal conditions. Antidepressants may also have a <a href="http://journals.lww.com/ibdjournal/fulltext/2017/04000/Antidepressants_in_Inflammatory_Bowel_Disease___A.6.aspx">beneficial effect</a> on both the course of a bowel disease and accompanying anxiety and depression.</p>
<h2>What are gastrointestinal conditions?</h2>
<p>Gastrointestinal conditions are incredibly common. About <a href="http://www.gastrojournal.org/article/S0016-5085(97)00250-3/abstract">20% of adults and adolescents</a> suffer from irritable bowel syndrome (IBS), a disorder where abdominal discomfort or pain go hand-in-hand with changes in bowel habits. These could involve chronic diarrhoea and constipation, or a mixture of the two. </p>
<p>IBS is a so-called functional disorder, because while its symptoms are debilitating, there are no visible pathological changes in the bowel. So it is diagnosed based on symptoms rather than specific diagnostic tests or procedures.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/176848/original/file-20170705-21549-xixeme.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/176848/original/file-20170705-21549-xixeme.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/176848/original/file-20170705-21549-xixeme.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176848/original/file-20170705-21549-xixeme.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176848/original/file-20170705-21549-xixeme.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176848/original/file-20170705-21549-xixeme.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176848/original/file-20170705-21549-xixeme.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176848/original/file-20170705-21549-xixeme.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People with chronic gut conditions can experience severe pain that affects their quality of life.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>This is contrary to inflammatory bowel disease (IBD), a condition where the immune system reacts in an exaggerated manner to normal gut bacteria. Inflammatory bowel disease is associated with bleeding, diarrhoea, weight loss and anaemia (iron deficiency) and can be a cause of death. It’s called an organic bowel disease because we can see clear pathological changes caused by inflammation to the bowel lining. </p>
<p>Subtypes of inflammatory bowel disease are Crohn’s disease and ulcerative colitis. Around <a href="https://worldibdday.org/about-us">five million people worldwide</a>, and more than <a href="https://www.crohnsandcolitis.com.au/site/wp-content/uploads/Australian_Educator_Autumn_2014.pdf">75,000 in Australia</a>, live with the condition.</p>
<p>People with bowel conditions may need to use the toilet 20 to 30 times a day. They also suffer pain that can affect their family and social lives, education, careers and ability to travel. Many experience anxiety and depression in response to the way the illness changes their life. But studies also suggest those with <a href="http://gut.bmj.com/content/61/9/1284.long">anxiety</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/18796096">depression</a> are more likely to develop bowel disorders. This is important evidence of brain-gut interactions.</p>
<h2>How the brain speaks with the gut</h2>
<p>The brain and gut <a href="http://www.sciencedirect.com/science/article/pii/S0016508509003461?via%3Dihub">speak to each other constantly</a> through a network of neural, hormonal and immunological messages. But this healthy communication can be disturbed when we stress or develop chronic inflammation in our guts.</p>
<p>Stress can influence the type of bacteria inhabiting the gut, making our bowel flora less diverse and possibly more <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3039072/">attractive to harmful bacteria</a>. It can also <a href="http://www.sciencedirect.com/science/article/pii/S001650851201493X?via%3Dihub">increase inflammation</a> in the bowel, and vulnerability to infection.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/174838/original/file-20170621-30161-2l3p36.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/174838/original/file-20170621-30161-2l3p36.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/174838/original/file-20170621-30161-2l3p36.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/174838/original/file-20170621-30161-2l3p36.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/174838/original/file-20170621-30161-2l3p36.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=458&fit=crop&dpr=1 754w, https://images.theconversation.com/files/174838/original/file-20170621-30161-2l3p36.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=458&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/174838/original/file-20170621-30161-2l3p36.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=458&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ever ‘gone with your gut’ when making a decision? You’re probably receiving signals from your gastrointestinal tract, which communicates directly with your brain.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Chronic intestinal inflammation may lower our sensitivity to positive emotions. When we become sick with conditions like inflammatory bowel disease, our <a href="https://insights.ovid.com/pubmed?pmid=21744432">brains become rewired</a> through a process called neuroplasticity, which changes the connections between the nerve signals. </p>
<p>Anxiety and depression are common in people suffering chronic bowel problems. Approximately 20% of those living with inflammatory bowel disease <a href="https://insights.ovid.com/pubmed?pmid=26841224">report feeling anxious or blue</a> for extended periods of time. When their disease flares, this rate may exceed 60%. </p>
<p>Interestingly, in a <a href="http://www.cghjournal.org/article/S1542-3565(16)00047-1/fulltext">recent large study</a> where we observed 2,007 people living with inflammatory bowel disease over nine years, we found a strong association between symptoms of depression or anxiety and disease activity over time. So, anxiety and depression are likely to make the symptoms of inflammatory bowel disease worse long-term.</p>
<p>It makes sense then to offer psychological treatment to those with chronic gut problems. But would such a treatment also benefit their gut health?</p>
<hr>
<p><em><a href="https://theconversation.com/gut-feeling-how-your-microbiota-affects-your-mood-sleep-and-stress-levels-65107"><strong>Gut feeling: how your microbiota affects your mood, sleep and stress levels</strong></a></em></p>
<hr>
<h2>Inflammatory bowel disease</h2>
<p>Our <a href="http://www.thelancet.com/journals/langas/article/PIIS2468-1253(16)30206-0/abstract">recent study</a> combined data from 14 trials and 1,196 participants to examine the effects of talk therapy for inflammatory bowel disease. We showed that talk therapy - particularly cognitive behavioural therapy (CBT), which is focused on teaching people to identify and modify unhelpful thinking styles and problematic behaviours - might have short-term beneficial effects on depression and quality of life in people with inflammatory bowel disease. </p>
<p>But we did not observe any improvements in the bowel disease activity. This could be for several reasons. Inflammatory bowel disease is hard to treat even with strong anti-inflammatory drugs such as steroids, so talk therapy may not be strong enough. </p>
<p>Talk therapy may only help when it’s offered to people experiencing a flare up in their disease. The majority of the included studies in our review were of people in remission, so we don’t know if talk therapy could help those who flare. </p>
<p>On the other hand, in our <a href="http://journals.lww.com/ibdjournal/fulltext/2017/04000/Antidepressants_in_Inflammatory_Bowel_Disease____A.6.aspx">latest review</a> of 15 studies, we showed antidepressants had a positive impact on inflammatory bowel disease as well as anxiety and depression. It’s important to note the studies in this review were few and largely observational, which means they showed associations between symptoms and antidepressant use rather than proving antidepressants caused a decrease in symptoms.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/176866/original/file-20170705-16505-1jhx2we.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/176866/original/file-20170705-16505-1jhx2we.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/176866/original/file-20170705-16505-1jhx2we.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176866/original/file-20170705-16505-1jhx2we.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176866/original/file-20170705-16505-1jhx2we.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176866/original/file-20170705-16505-1jhx2we.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176866/original/file-20170705-16505-1jhx2we.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176866/original/file-20170705-16505-1jhx2we.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Studies show talk therapy improves the symptoms of irritable bowel syndrome.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<h2>Irritable bowel syndrome</h2>
<p>When it comes to irritable bowel syndrome, the studies are more conclusive. According to a meta-analysis combining 32 trials,
both <a href="http://gut.bmj.com/content/58/3/367">talk therapy and antidepressants</a> improve bowel symptoms in the disorder. A recent <a href="https://www.ncbi.nlm.nih.gov/pubmed/24935275">update to this meta-analysis</a>, including 48 trials, further confirmed this result.</p>
<p>The studies showed symptoms such as diarrhoea and constipation improved in 56% of those who took antidepressants, compared to 35% in the group who received a placebo. Abdominal pain significantly improved in around 52% of those who took antidepressants, compared to 27% of those in the placebo group. </p>
<p>Symptoms also improved in around 48% of patients receiving psychological therapies, compared with nearly 24% in the control group, who received another intervention such as usual management. IBS symptoms improved in 59% of people who had cognitive behavioural therapy, compared to 36% in the control group. </p>
<p>Stress management and relaxation were found to be ineffective. Interestingly, hypnotherapy was also found effective for bowel symptoms in 45%, compared to 23% of control therapy participants.</p>
<h2>What now?</h2>
<p>Better studies exploring the role of talk therapy and antidepressants for symptoms of inflammatory bowel disease need to be conducted. We should know in a few years which patients are likely to benefit.</p>
<p>In the meantime, there is enough evidence for doctors to consider referring patients with irritable bowel syndrome for talk therapy and antidepressants.</p><img src="https://counter.theconversation.com/content/78841/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Antonina Mikocka-Walus has received research grants from the Crohn's and Colitis Foundation of America, the Broad Foundation, Crohn's & Colitis Australia, the Wellcome Trust, ForCrohns, Janssen Australia, Abbott Australia, Department of Health and Aging.</span></em></p>Our brain and gut are constantly talking to each other, so it makes sense mental health and stomach issues have a close relationship.Antonina Mikocka-Walus, Senior Lecturer in Health Psychology, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/651062016-10-11T19:04:53Z2016-10-11T19:04:53ZWhat the consistency of your poo says about your health<figure><img src="https://images.theconversation.com/files/140636/original/image-20161006-20134-nmmjr4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">What does it mean when it's too hard or too soft?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-424455349/stock-photo-man-looking-in-the-toilet-bowl.html?src=pp-same_model-427517689-5&ws=1">Nomad_Soul/Shutterstock</a></span></figcaption></figure><p><em>Our gut does more than help us digest food; the bacteria that call our intestines home have been implicated in everything from our mental health and sleep, to weight gain and cravings for certain foods. <a href="https://theconversation.com/au/topics/gut-series-32096">This series</a> examines how far the science has come and whether there’s anything we can do to improve the health of our gut.</em></p>
<hr>
<p>Number twos are a tricky subject. We all do them. Indeed, excreting waste is critical to life. But polite society and its rules of etiquette ensure we’re rarely brave enough to speak about them. </p>
<p>The faeces (or stools) we produce can provide a valuable real-time window into the health of your large bowel (or colon) and gastrointestinal tract. So let’s put those rules aside.</p>
<p>Scientists research many odd topics and stool form is no exception. In 1998, Stephen Lewis and Ken Heaten from the University of Bristol developed a <a href="http://www.continence.org.au/pages/bristol-stool-chart.html">seven-point stool form scale</a>, ranging from constipation (type 1) to diarrhoea (type 7).</p>
<p>Today, the Bristol Stool Chart allows people with gastrointestinal symptoms to clearly describe to their doctor what they are seeing in the toilet without having to provide samples.</p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/141158/original/image-20161011-3909-p1j1kp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/141158/original/image-20161011-3909-p1j1kp.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=764&fit=crop&dpr=1 600w, https://images.theconversation.com/files/141158/original/image-20161011-3909-p1j1kp.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=764&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/141158/original/image-20161011-3909-p1j1kp.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=764&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/141158/original/image-20161011-3909-p1j1kp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=960&fit=crop&dpr=1 754w, https://images.theconversation.com/files/141158/original/image-20161011-3909-p1j1kp.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=960&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/141158/original/image-20161011-3909-p1j1kp.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=960&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<hr>
<p>For most of us, the form of stool we excrete can vary widely depending, in part, on what we’ve been doing. A period of dehydration, perhaps associated with a day of sustained exercise, or the delaying of a bowel movement, may be followed by a drier stool form than normal. </p>
<p>Conversely, an unusually spicy meal might be followed by a bowel movement with a looser stool. </p>
<h2>How should your stools look?</h2>
<p>Ideally, stools should be easy to pass without straining and without any intense sense of urgency. </p>
<p>On the Bristol Stool Chart, these are types 3, 4 and 5: sausage-like with some cracks in the surface, up to 2 to 3 cm in diameter; longer sausage or snake-like with a smooth consistency, similar to that of toothpaste with a typical diameter of 1 to 2 cm; or soft blobs with clear cut edges. </p>
<p>While arguably easier to clean up, the drier stool forms (types 1 and 2) tend to compact into large stool that can apply long term pressure to and abrade the lining of the large bowel.</p>
<p>During a bowel movement, dry stools may distend the anal canal beyond its normal aperture. This may require straining – and pain – to pass. </p>
<p>Straining to pass dry stools increases the risk of laceration of the anus, haemorrhoids, prolapse and the condition <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/diverticulosis-and-diverticulitis">diverticulosis</a>. This is when pouches form on the wall of the large bowel due to over-distension. These can become sites for infection or inflammation. </p>
<p>Watery stool forms may be associated with gut infections, for example with a gut parasite like <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/gastroenteritis-giardiasis"><em>Giardia</em></a>, or an <a href="http://www.mayoclinic.org/diseases-conditions/inflammatory-bowel-disease/basics/definition/con-20034908">inflammatory disorder</a> such as Crohn’s disease. </p>
<p>As a rule, softer but not watery stool forms are best. </p>
<p>Any change of bowel habit that leads to the sustained production of drier stools and a sense of incomplete emptying – or watery stools and a feeling of urgency – should be discussed with your doctor. </p>
<h2>Why does water matter?</h2>
<p>Even to the casual toilet bowl observers among us, the most obvious differentiating factor between stool forms is their water content. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/140639/original/image-20161006-20123-1xfxxwu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/140639/original/image-20161006-20123-1xfxxwu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/140639/original/image-20161006-20123-1xfxxwu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/140639/original/image-20161006-20123-1xfxxwu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/140639/original/image-20161006-20123-1xfxxwu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/140639/original/image-20161006-20123-1xfxxwu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/140639/original/image-20161006-20123-1xfxxwu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Drinking enough water is important for good bowel health.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-2867845/stock-photo-young-boy-gulping-down-water-from-a-tap.html?src=TTOBZ4pTQSnoZK-F-MU_Ng-2-34">David H.Seymour/Shutterstock</a></span>
</figcaption>
</figure>
<p>The large bowel is an amazing recycling and repurposing centre for the body. Water recycling is one of its key functions. </p>
<p>Every day, our bodies invest around 9 litres of fluids into the digestion of food, including around 1.5 litres of saliva, 2.5 litres of stomach secretions and 0.8 litres of bile. But clearly we don’t defecate anywhere near this volume. </p>
<p>The longer it takes for digested food to pass through the large bowel, the more water gets reclaimed and the drier the stool becomes. So factors affecting the transit rate of food through our gastrointestinal tract will have significant influence on stool form. </p>
<p>Affluence and lifestyle impact on transit time. Antibiotics, pain killers (particularly opiate-containing drugs such as Endone but also more common pain-killers containing codeine) as well as physical inactivity all reduce how well the gut contracts. This slows the passage of food through the large bowel, which can lead to constipation.</p>
<h2>What about diet?</h2>
<p>Our diets also play a significant part in driving stool form and health. </p>
<p>Observational studies performed in south and eastern Africa in the 1970s and 80s compared the gastrointestinal health of Caucasians eating a Western-style diet and native Africans living a <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1588096/">traditional lifestyle</a>. The researchers found drier stool forms and constipation were more common in people consuming <a href="http://www.ncbi.nlm.nih.gov/pubmed/11427691">Western-style diets</a>. </p>
<p>This was associated with increased incidence of bowel cancer, inflammatory bowel diseases as well as other chronic diseases of rising incidence in Western societies. </p>
<p>The results were attributed to differing levels of fibre in the diets of these two populations and these conclusions have been clearly confirmed for bowel cancer in <a href="http://www.wcrf.org/int/research-we-fund/continuous-update-project-cup">numerous studies</a>.</p>
<p>Fibre impacts on transit time, stool form and health in two ways. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/140641/original/image-20161006-20132-113td4o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/140641/original/image-20161006-20132-113td4o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/140641/original/image-20161006-20132-113td4o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/140641/original/image-20161006-20132-113td4o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/140641/original/image-20161006-20132-113td4o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=523&fit=crop&dpr=1 754w, https://images.theconversation.com/files/140641/original/image-20161006-20132-113td4o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=523&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/140641/original/image-20161006-20132-113td4o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=523&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Western diets are more likely to leave us constipated.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-213705436/stock-photo-sofia-bulgaria-august-23-2014-mcdonalds-meal-on-a-stret-background-near-their-restaurant.html?src=lwq_-VF5lAIkpq_Q_toYwA-1-49">SSokolov/Shutterstock</a></span>
</figcaption>
</figure>
<p>First, when a healthy, well-hydrated person eats fibrous foods such as wheat bran with lots of roughage, the food takes up water and swells. This increases the volume of the stool, softening it, stimulating more rapid transit. At the same time, it dilutes and more rapidly clears any toxins that may have been ingested with the food. </p>
<p>More potent components of dietary fibre also exist: fermentable carbohydrates such <a href="http://www.csiro.au/hungrymicrobiome/food.html">resistant starch</a> (a form of starch that is not digested in the small intestine), <a href="https://www.cancer.gov/publications/dictionaries/cancer-drug?cdrid=38642">beta glucans</a> and <a href="https://www.sciencedaily.com/releases/2013/07/130716115728.htm">fructo-oligosaccharides</a>, which are commonly found in whole grains, legumes, pulses, fruit and vegetables. These are a key nutritional source for the trillions of bacteria that inhabit the large bowel (the gut microbiota). </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/YB-8JEo_0bI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">What is the human microbiome?</span></figcaption>
</figure>
<p>Key waste products of this bacterial feast, short-chain fatty acids, are <a href="http://www.cell.com/cell/pdf/S0092-8674(16)30592-X.pdf">like gold to our bodies</a>. One of these short-chain fatty acids, <a href="http://www.livestrong.com/article/553726-what-foods-are-high-in-butyrate/">butyrate</a> (which is also the food acid that gives parmesan cheese its haunting aroma), reduces transit time by strengthening contraction of muscles lining the large bowel. </p>
<p>On the way, these short-chain fatty acids strengthen, grow and repair the cell layers that line the large bowel. They destroy cancerous cells, reduce inflammation and pain in the gut, and enhance satiety. Worth feeding, you might say! </p>
<p>But one gastronomic casualty of the Westernisation of our diets has been fibre. A typical Westerner may consume as little as 12-15g of fibre per day. While no upper limit for daily fibre intake has been defined, healthy Australians are recommended to consume at least <a href="https://www.nrv.gov.au/nutrients/dietary-fibre">30g of dietary fibre</a> per day, with around 15-20g of that comprising resistant starch. </p>
<p>So clearly we have some distance to go. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/140647/original/image-20161006-20139-7az6hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/140647/original/image-20161006-20139-7az6hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/140647/original/image-20161006-20139-7az6hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/140647/original/image-20161006-20139-7az6hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/140647/original/image-20161006-20139-7az6hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/140647/original/image-20161006-20139-7az6hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/140647/original/image-20161006-20139-7az6hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">We need 30g of fibre a day.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-191953970/stock-photo-healthy-breakfast-with-high-fibre-bran-flakes-blueberry-and-banana.html?src=cOSRlSf4qatnmJvgzJEz-g-1-0">Brian A Jackson/Shutterstock</a></span>
</figcaption>
</figure>
<p>There is a caveat here, however. If you have gastrointestinal symptoms – such as an upset stomach, nausea, vomiting, and diarrhoea – fibre may not always help. You may need to carefully consider the type of fibre you consume, with the help of your doctor. </p>
<p>The roughage component of some fibre sources may exacerbate symptoms for people with <a href="https://www.bowelcanceraustralia.org/diverticular-disease">diverticular disease</a>, for instance. </p>
<p>Symptoms of irritable bowel syndrome may be exacerbated by fibre sources rich in <a href="http://www.med.monash.edu/cecs/gastro/fodmap/">fermentable fructose oligo, di or mono saccharides and polyols</a> (FODMAP). This includes onion, garlic, apples, pears, milk, legumes, some breads and pasta, and cashews. </p>
<p>For most of us, though, more fibre in our diets should reduce food transit times, soften stools, make bowel movements more comfortable and improve bowel health. </p>
<hr>
<p><em>Read the other articles in our Gut series <a href="https://theconversation.com/au/topics/gut-series-32096">here</a>.</em></p><img src="https://counter.theconversation.com/content/65106/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Trevor Lockett receives funding from NHMRC and the Cancer Councils of Victoria, New South Wales, Queensland and South Australia. </span></em></p>For most of us, the form of stool we excrete can vary widely depending, in part, on what we’ve been doing.Trevor Lockett, Group Leader, Personalised Health, CSIROLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/151732013-07-23T20:11:57Z2013-07-23T20:11:57ZExplainer: what is inflammatory bowel disease?<figure><img src="https://images.theconversation.com/files/27911/original/kv5ygnkb-1374563238.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Inflammatory bowel disease is one of a variety of unrelated but ongoing gastrointestinal disorders.</span> <span class="attribution"><span class="source">J.B. Hill</span></span></figcaption></figure><p><a href="http://www.cdc.gov/ibd/">Inflammatory bowel disease</a> is a group of inflammatory conditions of the colon and small intestine that can cause life-threatening complications and may require surgery. Luckily, current therapies offer real benefits and there are some <a href="http://www.mayoclinic.org/medicalprofs/ibd-pipeline-drugs-pudd0412.html">promising drugs</a> in the pipeline.</p>
<p>The disease is one of a variety of unrelated but ongoing gastrointestinal disorders. Of these, some of the most common complaints are about gluten intolerance and functional bowel problems (when the gut doesn’t work properly, such as when someone has irritable bowel syndrome). Crohn’s disease and ulcerative colitis are examples of inflammatory bowel disease. </p>
<p>All of these problems have very different causes, although having one of them may put you at an increased risk of developing another.</p>
<h2>Causes and effects</h2>
<p>The precise causes of inflammatory bowel disease <a href="http://www.med.unc.edu/gi/specialties/ibd/about-ibd/what-causes-inflammatory-bowel-diseases-ibd">are not known</a>. What we do know is that, in general, people with inflammatory bowel disease are likely to have a genetic predisposition for the disease. Their genes make it more likely that they will develop inflammatory bowel disease although they may never do so. </p>
<p>If they develop the disease, it’s most likely because of an environmental trigger – stress, for instance, or malnutrition or certain drugs. But, in most people, the trigger may never be known. </p>
<p>Factors in the gut, such as a disruption in the balance between good and bad bacteria, can also contribute to the onset of the disease.</p>
<p>The effect of inflammatory bowel disease on the gut is actually caused by the person’s immune system. Once activated, the disease attacks the body’s cells instead of foreign cells such as bacteria, fungi or viruses. </p>
<p>This initiates the sort of angry red inflammation in the gut that would normally get rid of infections. Unfortunately, in the case of inflammatory bowel disease, the immune system reacts to bacteria that are normally resident in the gut. And, in so doing, the disease causes severe damage that can cause a perforation (a hole through the wall of the gut). </p>
<p>This is a life-threatening event and, at this point, surgery is the only treatment option. The many surgeries some people suffering from inflammatory bowel disease have to undergo during their life is extremely burdensome. </p>
<p>But there’s an indirect benefit for the community in this – the resulting surgical samples can sometimes be used to help researchers who are trying to find a cure for inflammatory bowel disease.</p>
<h2>Current and new treatments</h2>
<p>Inflammatory bowel disease is not active all the time – it is prone to flare-ups that are separated by quiet times during which the disease is in remission. This makes treatment more complicated because it can be hard to know if the remission is caused by a new drug or if it’s spontaneous. </p>
<p>Most cases of inflammatory bowel disease are initially handled by giving the sufferer an anti-inflammatory drug that will hopefully induce remission. Once in remission, many patients take immunosuppressant drugs that decrease the likelihood of another flare-up. </p>
<p>Immunosuppressants are drugs that modify how the immune system works and generally lower its activity. Many new drugs that fall into this general class are being developed. </p>
<p>With the immune attack reduced, the gut can often heal on its own and stay healthy for longer. Current treatment strategies generally start with older drugs but if these fail, <a href="http://en.wikipedia.org/wiki/Biological_therapy_for_inflammatory_bowel_disease">biological therapies</a>, such as infliximab, are tried. A biological therapy also targets the immune system. The active compounds often originate from human, animal or bacterial sources - for example, infliximab is an antibody. </p>
<p>These drugs are effective in many people but they can have severe side-effects and become less effective over time.</p>
<p><a href="http://www.nature.com/nrd/journal/v12/n6/full/nrd4037.html">Three new such drugs</a> (all using the same approach) are currently undergoing the lengthy regulatory approval process overseas. They inhibit a protein in the body called an “integrin”, which helps cells stick together. In inflammatory bowel disease, the integrins are what allow immune cells to invade the intestine and start the inflammatory process.</p>
<p>The role of integrins has been known for many years, but the problem is that they are located everywhere in the body. Drugs that block all integrins are dangerous for various reasons, for example, because blood clotting is dependent on integrins. </p>
<p>These new drugs block only one specific type of integrin and seem to be safe and effective. They target a kind of integrin that is only found on some white blood cells that are crucial for an immune response in inflammatory bowel disease. </p>
<p>To date, these drugs have been mainly tested on patients who have already failed using current therapies. There’s hope that once these drugs are registered, they will find an earlier use in less severely affected patients.</p>
<p>It’s likely that one or more of these new drugs will get regulatory approval before long, but it may be another four or five years before they would be prescribed to patients. Clinical trials to monitor their safety and effectiveness will be required first.</p><img src="https://counter.theconversation.com/content/15173/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Bertrand receives funding from National Health and Medical Research council for projects relating to gastrointestinal health.</span></em></p><p class="fine-print"><em><span>Lu Liu receives funding from National Health and Medical Research Council.</span></em></p>Inflammatory bowel disease is a group of inflammatory conditions of the colon and small intestine that can cause life-threatening complications and may require surgery. Luckily, current therapies offer…Paul Bertrand, Senior Lecturer in School of Medical Sciences, RMIT UniversityLu Liu, Senior Lecturer in Pharmacology, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/99262012-10-17T03:29:19Z2012-10-17T03:29:19ZColonic therapy: panacea or placebo?<figure><img src="https://images.theconversation.com/files/16617/original/99349y3s-1350436544.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The available evidence shows colonic therapy is neither safe nor effective.</span> <span class="attribution"><span class="source">MoHotta18</span></span></figcaption></figure><p><em>PANACEA OR PLACEBO – A weekly series assessing the evidence behind complementary and alternative medicines.</em></p>
<p>Colonic therapy – also known as colonic irrigation, colonic hydrotherapy or a high enema – is an alternative therapy which allegedly helps remove toxins and waste from the bowel (or colon). </p>
<p>The process involves pumping large volumes of fluids into the colon via tubes inserted into the rectum. The fluids can be water or water infused with herbs or enzymes. Some even swear by coffee enemas as a health cure-all.</p>
<h2>Early colonic therapy</h2>
<p>Historically, colonic therapy was based on the <a href="http://journals.lww.com/jcge/fulltext/1997/06000/colonic_irrigation_and_the_theory_of.2.aspx">ancient theory</a> of autointoxication – that intestinal waste products from incomplete digestion could poison the body and therefore cause disease. </p>
<p>The theory can be traced back to the medicine of most ancient cultures. In the west, <a href="http://www.ncbi.nlm.nih.gov/pubmed/2668399">humoral medicine</a> came from the idea that all diseases were caused by the imbalance of the four body humors; conversely, health constituted a balanced mix of these humors. Waste products formed in the intestinal tract were thought to be a major potential contributor to humoral imbalance. In fact, both Hippocrates and later Galen viewed autointoxication as a major etiologic factor of disease.</p>
<p>In the 19th century, autointoxication was an imperative doctrine of medicine. And by the turn of the century, there appeared to be some possible scientific backing. <a href="http://en.wikipedia.org/wiki/%C3%89lie_Metchnikoff">Elie Metchikoff</a>, who received the 1908 Nobel Prize for his theory on phagocytosis, proposed that “chronic poisoning by intestinal microbes weakens our cellular elements… and might provoke senile phenomena”.</p>
<p>When it became clear that the scientific rationale was wrong and colonic irrigation was not merely useless but also potentially dangerous, it was exposed as quackery and subsequently went into decline. </p>
<p>There has been some recent resurgence of colonic irrigation. But even today’s experts on colonic irrigation can only provide <a href="http://www.sciencedirect.com/science/article/pii/S096522999580007">theories and anecdotes</a> in its support. </p>
<h2>Claims versus evidence</h2>
<p>Practitioners and supporters of colonic therapy variously claim the procedure can detoxify the body, boost the immune system and prevent or alleviate a range of health problems.</p>
<p>But the human body rarely needs such assistance. The digestive system is cleverly designed to absorb nutrients from foods and pass remaining waste material out of the body. It also has the capacity to expel toxins, illness-causing microorganisms and foreign substances. </p>
<p>A <a href="http://www.ncbi.nlm.nih.gov/pubmed/19724266">systematic review of the scientific literature</a> found there is no evidence to support the use of colonic therapy for general health promotion or maintenance. The 2010 review examined published literature of both the traditional and complementary and alternative medicine arenas.</p>
<p>There are, however, multiple <a href="http://www.jfponline.com/Pages.asp?AID=9783">case reports</a> of harmful effects from colonic therapy. Mild side effects reported following colonic irrigation include cramping, bloating, nausea and local discomfort or pain.</p>
<p>Serious <a href="https://www.mja.com.au/journal/2004/181/10/rectal-perforation-colonic-irrigation-administered-alternative-practitioners">adverse effects</a> have included infection, bowel perforation, air embolism and electrolyte imbalances. Such complications require medical or surgical intervention, and indeed fatalities have also been documented. People with a history of gastrointestinal diseases such as inflammatory bowel disease may be at higher risk of these adverse effects.</p>
<h2>Colonic therapy and cancer</h2>
<p>Controversially, colonic therapy has also been used as part of alternative cancer treatment programs such as <a href="http://gerson.org/gerpress/the-gerson-therapy/">Gerson therapy</a>. </p>
<p>Apart from the lack of efficacy and potential risks of colonic irrigation, medical professionals are concerned that people with symptoms or a diagnosis of cancer who are attracted to these alternative therapies may delay seeking appropriate medical advice or treatment. Bowel cancer, for instance, is successfully treated in about 90% of cases if it is diagnosed and managed early. Delay in seeking effective treatment can be a fatal mistake.</p>
<p>More recently, colonic irrigation has also been promoted as an alternative cleansing preparation for colonoscopy – a medical procedure which examines the lining of the bowel for abnormalities such as polyps and cancer.</p>
<p>As colonic irrigation is performed through the anus, it will not necessarily clean the upper colon adequately. And without adequate cleansing, a perfect view of the bowel cannot be obtained at colonoscopy, running the risk of missing potentially important pathology.</p>
<p>Bowel cleansing before colonoscopies currently involves dietary modification and the use of a laxative or bowel preparation medication. A number of these medications are available, so there is no place for colonic irrigation as an alternative to current medical practice in Australia.</p>
<p>What about the idea that food waste accumulates in the colon? </p>
<p>The respected American Cancer Society <a href="http://www.cancer.org/Treatment/TreatmentsandSideEffects/ComplementaryandAlternativeMedicine/ManualHealingandPhysicalTouch/colon-therapy">has determined</a> that the “available scientific evidence does not support the premise that toxins accumulate on intestinal walls or that toxicity results from poor elimination of waste from the colon”. And <a href="http://www.bowelcanceraustralia.org">Bowel Cancer Australia</a>, a national organisation dedicated to reducing the impact of bowel cancer in the community, agrees.</p>
<p>So it’s clear that despite colonic irrigation’s long history, there is no scientific evidence to support the claims that it improves health. There are, however, many reasons to avoid the procedure.</p>
<p><em><strong>Read the other instalment of panacea or placebo:</strong></em></p>
<ul>
<li><p><a href="https://theconversation.com/modern-acupuncture-panacea-or-placebo-8102">Modern acupuncture</a></p></li>
<li><p><a href="https://theconversation.com/myotherapy-panacea-or-placebo-9183">Myotherapy</a></p></li>
</ul><img src="https://counter.theconversation.com/content/9926/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Graham Newstead is Chair of the Bowel Cancer Australia Awareness Advisory Board.
</span></em></p>PANACEA OR PLACEBO – A weekly series assessing the evidence behind complementary and alternative medicines. Colonic therapy – also known as colonic irrigation, colonic hydrotherapy or a high enema – is…Graham Newstead, Head, Colorectal Unit, Prince of Wales Private Hospital; Conjoint Associate Professor of Surgery, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/73692012-10-16T03:27:04Z2012-10-16T03:27:04ZThe future of personalised medicine … for your gut<figure><img src="https://images.theconversation.com/files/14115/original/5vzhwk5v-1344495859.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Patients struggling with unpleasant and debilitating gastrointestinal diseases may benefit from some of these advances.</span> <span class="attribution"><span class="source">KayVee INC</span></span></figcaption></figure><p>The emerging field of <a href="https://theconversation.com/personalised-medicine-may-be-truly-personal-1114">personalised medicine</a> seeks to tailor therapies to suit an individual’s metabolism or genetic make-up. This strategy has worked well with medication for specific forms of <a href="http://theconversation.com/meeting-halfway-the-untapped-potential-of-gender-specific-drugs-2876">breast cancer</a> and more generally with drugs which are metabolised by liver enzymes, such as the immunosuppressant <a href="http://www.ncbi.nlm.nih.gov/pubmed/15788214">thiopurines</a> for inflammatory bowel disease.</p>
<p>We’re now beginning to realise that a personalised approach to medicine can help improve the health of your gut in many ways. </p>
<h2>Good vs bad bacteria</h2>
<p>Your lower gut is home to a phenomenal number of bacteria made up of so-called <a href="http://www.nature.com/nature/journal/v486/n7402/full/nature11209.html">good strains and bad strains</a>. The good bacteria help your immune system develop, salvage nutrients and keep the bad bacteria in check. For their part, the bad strains are associated with bowel cancer, inflammatory bowel disease and a host of other conditions such as obesity.</p>
<p>Eating live cultures of the good strains may help with common gut complaints such as bloating. But live cultures don’t survive long in the upper intestine – most are gone within 48 hours. Even those bacteria protected within a pill are unlikely to gain a foothold in the already thriving ecology of your lower intestine. </p>
<p>Until recently, it wasn’t even clear what kinds of bacteria were present in your lower bowel, much less the relative numbers of each. </p>
<p>Now, new genetic testing in <a href="http://www.ncbi.nlm.nih.gov/pubmed/22626027">mice</a> has shown we may be able to identify thousands of different strains of bacteria in the human gut - <a href="http://www.nature.com/nature/journal/v486/n7402/full/nature11209.html">work that is now underway</a>. This would allow us to map our individual bacterial community and better understand the role particular bacteria play in producing (or reducing) common gastrointestinal complaints.</p>
<h2>Investigations</h2>
<p>The best way to find out what’s happening inside your gut is to have a look. And there’s nothing more personal than taking a few pictures along the way. This generally involves an <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Endoscopy">endoscope</a> – a camera attached to several metres of fibre optics – which is gently fed down your oesophagus and to regions below. </p>
<p>Endoscopy (or <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Colonoscopy">colonoscopy</a>) is the most common (and unfortunately priciest) outpatient procedure at most hospitals. One reason for the expense is that it takes a highly skilled clinician to safely perform these procedures. A slip while taking pictures can tear the gut wall which, if left untreated, can cause the bacterial community to move into your abdomen’s <a href="http://www.wisegeek.com/what-is-the-peritoneal-cavity.htm">peritoneal cavity</a>. </p>
<p>With the advent of cheap digital cameras, many companies have tried to place a tiny camera inside a pill. This development is important, as <a href="http://www.ncbi.nlm.nih.gov/pubmed/22446606">colonoscopy-based bowel cancer screening programs</a> dramatically increase the number of expensive procedures. Thus a cheaper and more efficient alternative is needed. </p>
<p>Once swallowed, the pill-cam travels down the entire gastrointestinal tract along with any other food. Until recently, a special harness was needed to help communicate with the camera and track its position in the gut. Even then, only a few pictures could be taken on the way through – often missing important but small features that can lead to incorrect diagnoses. </p>
<p>Imagine driving a car and looking for a particular small lane way. Traffic is busy and it’s impossible to get more than a glimpse out of the window. Now imagine you are using the Google street view camera – you have a continuous, wide angle shot of the whole street that you can review at home. This is what the recently released <a href="http://www.capsovision.com/">CapsoVision</a> does. The capsule makes a scrapbook of images from your entire gastrointestinal tract which reduces the guesswork in diagnosing problems. </p>
<p>Researchers are hoping that in future, these capsules will be paired with computerised diagnoses systems to analyse all these images and help the clinician plan your personalised treatment. </p>
<h2>Next steps for therapies</h2>
<p>While bowel cancer can potentially shorten your life expectancy, many other diseases of the gastrointestinal tract are life-long and come with a variety of unpleasant symptoms. Common gastrointestinal diseases - such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS) or even <a href="http://www.ncbi.nlm.nih.gov/pubmed/22188520">obesity</a> (which is associated with pain, reflux and diarrhoea) - are ripe for a personalised approach. </p>
<p>For IBD, the front-line class of drug called <a href="http://www.ncbi.nlm.nih.gov/pubmed/15788214">thiopurines</a> is metabolised by several families of liver enzymes. For some people, genetic variation in these enzymes can greatly affect the levels of thiopurines that are available to help reduce the inflammation in the gut.</p>
<p>There are many important hormones in the gut which regulate gastrointestinal function as well as alter how you feel, such as being satisfied after a meal. Serotonin, a gut hormone that helps keep your meal moving, is particularly important in this process and has been the <a href="http://www.ncbi.nlm.nih.gov/pubmed/20408739">target</a> of several classes of drug designed to reduce the symptoms of IBS, constipation, slowed gastric emptying and reflux. </p>
<p>Given that the levels of serotonin in your gut can determine whether some therapies are effective or not suggests another area that could benefit from a personalised approach, perhaps by characterising the levels of all gastrointestinal hormones and their receptors.</p>
<p>Technology is driving many of the advances in personalised medicine and is allowing for the variation in individuals to be taken into account during treatment. </p>
<p>Patients struggling with unpleasant and debilitating gastrointestinal diseases may benefit from some of these advances today such as the pill-cam or your drug metabolism profile; while cataloguing your microbial community or your gut’s hormonal control system will take five to ten years before applications appear in the clinic.</p><img src="https://counter.theconversation.com/content/7369/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Bertrand receives funding from NH&MRC.</span></em></p>The emerging field of personalised medicine seeks to tailor therapies to suit an individual’s metabolism or genetic make-up. This strategy has worked well with medication for specific forms of breast cancer…Paul Bertrand, Senior Lecturer in School of Medical Sciences, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/65962012-07-13T04:36:34Z2012-07-13T04:36:34ZExplainer: Crohn’s disease and intestinal immune balance<figure><img src="https://images.theconversation.com/files/10875/original/gpcq3yy2-1337578795.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Chron's disease causes the wall of the intestine to become inflamed.</span> <span class="attribution"><span class="source">Flickr/Rob Wiltshire</span></span></figcaption></figure><p><a href="http://www.ncbi.nlm.nih.gov/pubmed/21738156">Scientific</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/22586430">medical articles</a>, and <a href="http://www.nacc.org.uk/content/ibd.asp">websites</a> by Crohn’s disease associations give similar definitions of the illness: “Crohn’s disease is a chronic, inflammatory disorder which may involve any part of the gastrointestinal tract from mouth to anus, however is mostly confined to the ileum and the colon.” </p>
<p>But what does this actually mean? And how does the disease affect its sufferer? </p>
<p>Crohn’s disease was first identified in 1623 by a German surgeon Dr. Wilhem Fabry, and later described (in 1932) by the American physician Burril B. Crohn. The cause of the disease is likely to be multifactorial – involving environmental, genetic and immunological factors – but it still remains unclear. </p>
<p>Some <a href="http://www.ncbi.nlm.nih.gov/pubmed/21565393">studies</a> have recently shown that changes in gut bacteria may underlie the problem, predisposing certain people to the disease or initiating its symptoms.</p>
<h2>Anatomy of the disease</h2>
<p>Crohn’s disease is a form of inflammatory bowel disease (IBD). It causes the wall of the intestine to become inflamed, thick and swollen and may simultaneously or successively involve one or several gastrointestinal tract segments. </p>
<p>Usually, the disease involves the large bowel or colon (colitis), the part of the small bowel connected to the large bowel or ileum (ileitis), or both (ileo-colitis). Having “-itis” after an organ name means inflammation so colitis means inflammation of the colon. Involvement of the anus is common, affecting about a third of patients, but other parts of the digestive system, such as the oesophagus or the stomach are less often involved. </p>
<p>Patients often suffer unpredictable bouts of the disease, called flares, followed by periods of remission. But continuous chronic forms of the disease also exist. Crohn’s may stop progressing, particularly following effective treatment and the lesions it has caused in the gastrointestinal tract may be partially or completely repaired.</p>
<p>Clinical symptoms come and go unpredictably, and vary depending on the part of the digestive tract segment or segments involved (colon, ileum, anus, or whatever). Patients may experience cramping abdominal pain, diarrhoea (watery or bloody) and rectal bleeding. </p>
<p>Crohn’s can have other symptoms involving mainly the skin, peripheral joints (such as knees or elbows), the spine, the eyes or the bile ducts. Flares are usually accompanied with general symptoms, such as fatigue, loss of appetite, weight loss and fever, which are not specific to this disease.</p>
<h2>Diagnosis and complications</h2>
<p>Diagnosis at an early stage is rare – it’s often delayed because the general and non-specific symptoms often mislead clinicians. There’s no single and definitive test enabling a diagnosis of Crohn’s disease with complete certainty. </p>
<p>A diagnosis is made on the basis of detailed personal and family history, physical examination, laboratory blood tests (which may show inflammation in the blood), and examination of part of the bowel that can be performed either by endoscopic or radiological studies. </p>
<p>Endoscopy is direct inspection of the gastrointestinal tract with a flexible tube fitted with a camera that’s inserted through the anus or mouth. The procedure involves removing a small piece of tissue from the inflamed segment, which is usually performed to confirm diagnosis. Results from such tests will define whether a person is suffering from Crohn’s disease. </p>
<p>Although rarely fatal, complications related to Crohn’s disease may be serious. They include a narrowing of an intestinal segment (intestinal stenosis), which may lead to a block in the passage of intestinal contents (occlusion), perforation, abscesses, fistula (a tunnel connecting one loop of the bowel to another or to the bladder, or skin for instance), anal incontinence, venous thrombosis and cancer of the inflamed intestinal part. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/Z7xKYNz9AS0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>The disease is associated with major morbidity, increased mortality, disability, economic loss, substantial psychological impairment and financial burdens. Not surprisingly, it has a significant effect on patients’ self-reported quality of life.</p>
<h2>An autoimmune disease?</h2>
<p>There’s some debate around whether Crohn’s disease is an autoimmune illness – where the body’s immune system attacks the body itself, destroying healthy tissue. Immune tolerance in the gastrointestinal tract is the result of a fine balance between immune cells that have the capacity to respond to gut flora (killing it and upsetting the balance) and regulatory immune cells making sure that this doesn’t happen.</p>
<p>But rather than being a true autoimmune illness with immune reaction against self tissue antigens, Crohn’s disease may reflect a breakdown in the normal immuno-suppression of gut immune cells, which then get out of control and react strongly to the gut flora. This, in turn, leads to a very severe inflammatory response with pathological consequences for the integrity of intestinal tissues.</p>
<p>Crohn’s disease equally affects both women and men, but it appears to be slightly more predominant in women in some <a href="http://www.ncbi.nlm.nih.gov/pubmed/22553396">studies</a>. Prevalence also varies according to ethnic origins and countries. The <a href="http://www.ncbi.nlm.nih.gov/pubmed/22553396">highest incidence and prevalence</a> have been reported in Northern Europe and North America. </p>
<p>Crohn’s disease starts mainly in adolescence and in young adults between 20 and 30 years of age, but may occur at any age. The largest risk factors are family history, followed by smoking. Smoking is not just an important lifestyle risk factor, but also a risk for aggravating the course of the disease.</p>
<h2>Treatment options</h2>
<p>Each clinical form of Crohn’s disease requires specific treatment strategies. Treatment is designed to prevent flares and reduce their severity and duration when they occur, helping maintain normal function, and preventing serious complications. And while there’s no specific medical or surgical cure, symptoms are treatable and can be controlled. </p>
<p>Short-term goals are to quickly control visceral involvement and weigh up the risks of immunosuppressive therapy. In the long term, the idea is to define the minimum effective treatment allowing remission and improving patients’ quality of life. Changes in lifestyle, such as stopping smoking, are an important aspect of controlling Crohn’s disease. </p>
<p>Drugs that suppress or modulate the immune system are usually prescribed as conventional therapy. Approaches involving artificial nutrition can be effective in certain cases. Surgery is performed when major complications arise such as perforation or stenosis, keeping in mind that surgery is decided as a last resort option due to the possibility of relapses. </p>
<p>In the absence of a cure, patients have to learn how to live with this condition. New treatments, such as biologics, have revolutionised the treatment of Crohn’s disease, leading to improvement of patients’ quality of life. Disease management is moving towards an increasingly more personalised approach as opposed to a one-size-fits-all broad immunosuppressive but toxic approach. And this is the good news. </p>
<p><br>
<em>See more <a href="https://theconversation.com/topics/explainer">Explainer articles</a> on The Conversation.</em></p><img src="https://counter.theconversation.com/content/6596/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Scientific and medical articles, and websites by Crohn’s disease associations give similar definitions of the illness: “Crohn’s disease is a chronic, inflammatory disorder which may involve any part of…Fabien B. Vincent, Rheumatologist; PhD student, Department of Immunology, Faculty of Medicine, Nursing and Health Sciences, Monash UniversityFabienne Mackay, Professor and Chair, Department of Immunology, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/30902011-10-10T19:39:47Z2011-10-10T19:39:47ZHelp or hindrance? Antibiotics’ role in chronic inflammatory diseases<figure><img src="https://images.theconversation.com/files/4284/original/NOVAMOXIN_antibiotic.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Antibiotics' ability to kill gut germs could be contributing to the rise of chronic inflammatory diseases. </span> <span class="attribution"><span class="source">Bmramon/Wikimedia Commons</span></span></figcaption></figure><p>We sometimes forget that antibiotics kill beneficial microorganisms as well as those that threaten our health. In fact, the damage they wreak on “good” germs could be responsible for the growth of certain types of diseases in modern society. </p>
<p>The complex ecosystem of microbes within our guts – our gut “microbiome” – is absolutely essential for health and our use of antibiotics could be permanently injuring it.</p>
<p>In <a href="http://www.nature.com/nature/journal/v476/n7361/full/476393a.html">recent commentary</a> published in <a href="http://www.nature.com/">Nature</a> magazine, Dr Martin Blaser highlighted several such unintended consequences of antibiotic use. </p>
<p>Dr Blaser suggests antibiotic use is killing beneficial bacteria, leading to permanent loss of protective flora. He suggests this may be fuelling the dramatic increase in chronic inflammatory conditions such as obesity, type 1 diabetes, inflammatory bowel disease, allergies and asthma.</p>
<p>Blaser supports his argument by presenting data from a <a href="http://gut.bmj.com/content/60/1/49.abstract">recent Danish study</a> that showed a three-fold increase in inflammatory bowel disease (IBD) in children who had received seven or more courses of antibiotics, compared with children who had received none. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/4289/original/5693290240_a4f42f6f2f_o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/4289/original/5693290240_a4f42f6f2f_o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=565&fit=crop&dpr=1 600w, https://images.theconversation.com/files/4289/original/5693290240_a4f42f6f2f_o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=565&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/4289/original/5693290240_a4f42f6f2f_o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=565&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/4289/original/5693290240_a4f42f6f2f_o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=710&fit=crop&dpr=1 754w, https://images.theconversation.com/files/4289/original/5693290240_a4f42f6f2f_o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=710&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/4289/original/5693290240_a4f42f6f2f_o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=710&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Not all bacteria are harmful.</span>
<span class="attribution"><span class="source">AJC1</span></span>
</figcaption>
</figure>
<p>Importantly, the effect was almost twice as strong for antibiotics taken less than three months before the onset of IBD. </p>
<p>This suggests a link between inflammatory bowel disease and antibiotics, but this link may be one in which the antibiotics act as a disease trigger rather than a risk factor. </p>
<p>An easy way to understand the difference between a trigger and a risk factor is to think about someone with high blood pressure who has a heart attack while competing in a fun run. </p>
<p>High blood pressure is a risk factor and the trigger is the added stress on the heart caused by running. </p>
<p>In the case of inflammatory bowel disease, in which the immune system has an inappropriate response to gut bacteria, it can be difficult to distinguish between the role of individual bacteria as targets of the response (that is, triggers) and the role of the entire gut bacterial ecosystem as a factor in protecting against IBD.</p>
<p>But the three-fold change in IBD rates, while statistically significant, can explain only a small part of the 15-fold increase in IBD cases in Denmark in the last 30 years. </p>
<p>We urgently need to understand other environmental risk factors that have produced such a profound increase. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/4288/original/4533589633_0507d84ee3_b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/4288/original/4533589633_0507d84ee3_b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/4288/original/4533589633_0507d84ee3_b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/4288/original/4533589633_0507d84ee3_b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/4288/original/4533589633_0507d84ee3_b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/4288/original/4533589633_0507d84ee3_b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/4288/original/4533589633_0507d84ee3_b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The hygiene hypothesis suggests birth order is key to avoiding allergies.</span>
<span class="attribution"><span class="source">Charlotta Wasteson</span></span>
</figcaption>
</figure>
<p>One explanation for the rising rates of allergic and inflammatory diseases is the <a href="http://www.ncbi.nlm.nih.gov/pubmed/2513902?dopt=Citation">hygiene hypothesis, formulated by Dr David Strachan</a> in 1989. </p>
<p>Strachan, who was the first to suggest a role for microbes in protecting against allergy, concluded that “allergic diseases were prevented by infection in early childhood, transmitted by unhygienic contact with older siblings, or acquired prenatally from a mother infected by contact with her older children.” </p>
<p>His analysis of hay fever rates in the United Kingdom showed birth order alone had a four-fold effect on hay fever and eczema. </p>
<p>Since the effect was seen within families sharing the same living conditions, Strachan’s analysis ruled out many factors commonly blamed for allergies, such as pollution, processed food and vaccinations. </p>
<p>Colonisation of the gut by microbes in early life may be the “infection in early childhood” that explains Strachan’s birth order effect. </p>
<p>These gut microbes can be killed by antibiotics, leaving the immune system acutely vulnerable to inflammatory diseases such as IBD. But the gut microbiome usually rebounds with time and is <a href="http://www.ncbi.nlm.nih.gov/pubmed/20847294">remarkably resilient in the long term</a> unless exposed to multiple courses of antibiotics.</p>
<p>But if beneficial gut microbes are never transmitted to babies in the first place, then the negative effect will be far more severe in response to later antibiotic treatment.</p>
<p>We need to ensure conditions are ideal for transmission of beneficial microbial ecosystems from mother to baby. This could be done by recognising that, for instance, caesarean-section births prevent normal colonisation of the baby’s gut. </p>
<p>We also need to understand how the interaction of a healthy microbiome with the immune system prevents diseases such as allergies, type 1 diabetes and IBD.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/4286/original/2447205771_1f3517551c_b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/4286/original/2447205771_1f3517551c_b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/4286/original/2447205771_1f3517551c_b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/4286/original/2447205771_1f3517551c_b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/4286/original/2447205771_1f3517551c_b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/4286/original/2447205771_1f3517551c_b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/4286/original/2447205771_1f3517551c_b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Caesarean-section births prevent normal colonisation of the baby’s gut.</span>
<span class="attribution"><span class="source">Hryck</span></span>
</figcaption>
</figure>
<p><a href="http://theconversation.com/how-clean-is-too-clean-trust-your-gut-instincts-855">My research at Sydney’s Centenary Institute</a> has indicated the crucial link between the microbiome and the immune system may be via a small subset of immune cells called regulatory T cells. </p>
<p>We are now working to understand how regulatory T cells read cues from the microbiome. </p>
<p>Our aim is to build a picture of the ideal microbiome required for immune health to ensure that every child starts life with the best possible chance of achieving long-term immune health, free of allergy, autoimmunity and inflammatory disease.</p><img src="https://counter.theconversation.com/content/3090/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Barbara Fazekas de St Groth receives funding from ARC and NHMRC.</span></em></p>We sometimes forget that antibiotics kill beneficial microorganisms as well as those that threaten our health. In fact, the damage they wreak on “good” germs could be responsible for the growth of certain…Barbara Fazekas de St Groth, Professor of Immunology, Centenary InstituteLicensed as Creative Commons – attribution, no derivatives.