3. ALL diseases begin in gut hippocrates Gut health is critical to overall health Unhealthy gut --- diabetes, obesity, RA,depression, CFS autoimmune disease, skin disease ( eczema and psoriasis) Integrity of gut barrier - imp goal Gut flora & gut barrier determine the gut health Our gut is home to 100 trillions organism Gut has 10 times more bacteria than any entire human cells in body WE are more bacterial than human Role of gut flora

4. Relationship between what we eat & development of GI symptoms Example is coeliac disease, affects 1% of the population result of eating gluten (protein ) a new entity : non-coeliac gluten sensitivity, affect >10% of the population. Food intolerances : common affecting up to 40% of individuals who have IBS type symptoms. Dietary interventions studies benefit patients with IBS when trying a FODMAP diet, gluten free diet or probiotics. Area of confusion for both clinicians and the public alike are the entities of Food Allergy and Food Intolerance.....

5. Leaky gut syndrome : increased intestinal permeability. Lining of our intestines : important job : tight junction. Tight junctions compromised, increase in intestinal permeability, "leaky gut“: unhealthy substances get through: immune system reactivity : chronic health problems Like a chicken and egg problem, it is unknown if certain health conditions can cause or are caused by an increase in permeability What Causes Leaky Gut Syndrome? – Bacterial or viral infections – Certain medications – Poor diet and diet toxins like wheat – Excessive alcohol intake chronic stress – hormone imbalance

6. Role in autoimmune disorder and autoimmunity Affect all systems of body What is zonulin : increase in leaky gut but also found in DM, MS, thyroid disiorders, IBD coeliac disease Wheat has gliadin and has similarity to zonulin An unhealthy balance of gut flora, known as dysbiosisgut flora Modern life style and unhealthy gut flora : – antibiotics, – diets in high in refined CHO/sugar/processed foods – diet low in fermentable fibres – diet toxins like wheat and industrial seed oil that cause leaky gut – chronic stress, chronic infections – non breast fed new borns

7. Health Problems Associated with Intestinal Permeability this is only a hypothesis, not a firm conclusion. AcneAllergiesArthritisAsthma AcneAllergiesArthritisAsthma Cardiovascular diseaseCeliac disease Cardiovascular diseaseCeliac disease Chronic hepatic inflammatory disorders Diabetes Diabetes Food allergiesInflammatory bowel disease (IBD) Food allergiesInflammatory bowel disease (IBD) Irritable bowel syndrome (IBS)Metabolic disease Irritable bowel syndromeMetabolic disease

8. How to maintain and restore healthy gut – Avoid all the things listed above – Not always possible – Remove all food toxins – Eat plenty of fermentable fibres (sweet potato) – Eat fermented foods – Treat any intestinal pathogens – Manage stress

9. What to do – Split food, increase frequency & decrease quantity, avoid bed time snacks – Limit intake of difficult to digest CHO like beans pulses, cabbage cauliflower broccoli, ?potato,?rice, prefer lettuce, banana, grapes YOGHURT – Avoid alcohol, soft drinks, caffeine containing drinks milk, fatty/fried foods – Consume fermented dairy products – Introduce fibre gradually over wks – Limit polyol containg foods like artificial sweetners – Avoid overeating, do not rush to eat, chew food slowly – Favor diet based on protein/dairy products, low FODMAP diet – Lifestyle modifications exercise, posture healthy BMI, avoid central obesity OTC drugs – ROLE OF SPECIALIST role of SIBO

10. Fermentable fiber foods: role in health of the lower gut/overall wellness.. What Is Fermentable Fiber? Fermentation is important because it’s the gases and acids produced during the process that result in significant health benefits. The benefits of soluble and insoluble fermentable fibers include: – good bacteria production in the colon – stabilization of blood glucose, – suppression of “bad” LDL cholesterol and triglycerides, – increase of lower gut acid levels: absorb essential minerals such as iron, calcium and magnesium – improving the protective layer in the lower gut – stimulation of the immune system by boosting production of helper cells – reduction in the number of dangerous conditions associated with an unhealthy diet, including obesity and a diverse array of gastrointestinal disorders such as inflammatory bowel disease, diverticulitis

11. Cereals Fibre in g/100g edible portion Rice0.2Wheat1.2 Bajra1.2Maize2.7 Jowar1.6Ragi3.6 Bengal gram, whole 3.9Green gram, whole 4.1 Carrot 4.4Cauliflower 1.2 Lotus stem, dry 25.0Guava 5.2 Dates fresh3.7 Identify packaged foods that are sources of fibre check the per serve column of the nutrition information panel.

13. FODMAP Diet (FODMAP=Fermentable Oligo-Di-Monosaccharides and Polyols) FODMAPs are carbohydrates (sugars) that are found in foods. Not all carbohydrates are considered FODMAPs. The FODMAPs in the diet are: – Fructose (fruits, honey, high fructose corn syrup (HFCS), etc) – Lactose (dairy) – Fructans (wheat, garlic, onion, inulin etc) – Galactans (legumes such as beans, lentils, soybeans, etc) – Polyols (sweeteners containing isomalt, mannitol, sorbitol, xylitol, stone fruits such as avocado, apricots, cherries, nectarines, peaches, plums, etc) – FODMAPs are osmotic (means they pull water into the intestinal tract), may not be digested or absorbed well and could be fermented upon by bacteria in the intestinal tract when eaten in excess Symptoms of diarrhea, constipation, gas, bloating and/or cramping may occur in those who could be sensitive to the effects of FODMAPs.

14. HIGH FODMAP DIET VEGTABLE AND LEGUMES – Garlic, onions, wheat, cauliflower, Beans, Mushrooms, peas, spring onions Fruits- Apples, cherries,dates, guava, lychee, mango, peaches, pears, pomegranate, water melon plums Meat- Sausages, processed meat Cereal, grains, bread- Wheat containing products, bread, cashews, pasta, pastries, muesli, muffins Sweet- High fructose corn syrup, honey, jam, pickle, sugar free sweets, sweeteners Prebiotics food - Fos /inulin/oligofructose Drinks –Bear, coconut water, soy milk, tea(strong), wine, rum, fruit juices ( apple, mango pear large amount) sugar soft drinks (lemonade, cola,soda) Dairy foods- Butter, cheese, gelato, icecream, milk, butter milk

15. LOW FODMAP DIET Vegetables and legumes- Cabbage, carrot, corn, cucumber, ginger, peeper, lentils, lettuce, potato pumpkin, raddish, spinach, sweet potato, tomato, water chestnuts Fruit –Grapes, guava, ripe, kiwi, lemon, orange, papaya, pine apple, tamarind Meats – Beef, chicken, pork, tuna fish, fresh fish, seafood Cereal, grains, breads, biscuits- Wheat free breads, oat bread, wheat free pasta, almonds, buck wheat, brown/whole grain rice, chips, corn flour, coconut mixed nuts, oats, millets, walnuts, sourdough, rice noodles Condiments- Chocolate, maple syrup, mustard sugar(sucrose), vinegers (apple cider) Drinks- Alcohol (bear,vodka, gin whisky. Wine ) Coffee ( black/lactose free milk ) Sugar free soft drinks (diet coke), Tea ( black /green/ herbal) Dairy foods and eggs- Butter, cheese, eggs, tofu, lactose free whipped cream Cooking ingredients, herbs and spices – Oil, Sunflower, vegetable coconut, olive oil, ghee, salt

16. OBESITY based on BMI PLAN diet and lifestyle modification, drugs and bariatric surgery Requires long term care and multidisciplinary approach and education Developing world : a challenge,childhood obesity, effect of globalisation and FDI Predictive factors for maintaning wt loss

17. Nutrition diet and obesity – Energy intake less than expenditure wt loss of.5 to 1 kg per week requires calorie deficit of 500 to 1000 cals per day with no changes in physical activity diet <800 cals not recommended – Low fat vs low CHO diet long term results ? – Low glycemic load diets/high protein diets/high fibre diets – Potential adjunctsdietitians/eating breakfast/adding dietary fibres

18. GLYCEMIC INDEX OF INDIAN FOODS

19. Lifestyle changes and obesity – Physical activity – Behavioural modification and counselling – MAINTENANCE OF WEIGHT REDUCTION Eating low fat fibre and protein rich diet Self monitoring Physical activity Wt loss of more than 2 kg in 4 wks Expending up to 2500 cals per wk Patients belief and behavioural modification

20. FEW FACTS FOR OBESITY Will nuts cause wt gain10 almonds(75 clavs one samosa(165 cal), 8cashew(85)vs idli(150),20 peanuts(90)vs4 glucose biscuits(140),16 pista(88)vs 4 marie bis(100) Role of soybean/omega3fatty acids foods/nuts/fruits/green vegetables Role of calcium/iron/B complex/Vitamin amin A,C, E/phosphorus Role of weighing machine in obesity Keep ur waist below 37 inches in male and 31.5 inches in female

21. WDHD theme four key GI symptoms--- heartburn, abdominal pain/discomfort, bloating and constipation Common troubling but not disabling symptoms Cultural differences effect the prevalance Causes, type of treatment and response effected by dietary, lifestyle, cognitive, emotional /behavioural/psyhcosocial factors

22. PATIENT FACTORS – Age/gender – Lifestyle- smoking/alcohol/diet pattern, exercise, sleep, stress, travels – Culture related to food/diet – Health literacy- self care capacity – Health status – Psychosocial factors/family history – Prescription/non prescription medications – Dietary supplements – Efforts to relieve symptoms

23. HEART BURN GERD / Functional – Definition- site/type/timing /description – Atypical features- cardiac/pulmonary – Alarm features – new onset age>50 to 55 yrs, GI bleeding, dysphagia, unintentional wt loss…. – Other features which exclude self care – symptoms >3 mo, continuing after 2 wks of therapy, symptoms suggestive of cardiac pain, continuous N/V/diarrohea

24. Management of heart burn – Occasional symptoms by antacids – Avoid chocolate coffee, alcohol, smoking, carbonated drinks, mint, fried/fatty foods, citrus fruits/juices, tomato products, garlic/onions, spicy foods – Elevating head of the bed – Small frequent meals, avoiding food or liquids three hours before lying down – Avoid medications like OCP, NASID’s,TCA etc – ROLE OF PHYSCIAN/SPECIALIST

25. ABOMINAL PAIN/DISCOMFORT – Definition—chronic/recurrent, assoc. symptoms – IBS like features – Food intolerance--- FODMAPS’s, lactose, fructose – Alarm features– wt loss, gi bleeding, lab abn., new onset, asso. with inability to pass stool/gas – Management -- dietary and lifestyle modifications, symptom based OTC medications – role of SPECIALIST

26. BLOATING – Definition – vague, includes flatulence, frequent burping, abdominal rumbling, – Has a diurnal pattern -- worse in evenings – Causes are complex, in Upper GI– aerophagy, in LGI it is fermentation – Usually benign causes difficulty in relation too work/recreational/social activity, increase in sick days, physicians visit – Alarm features – bleeding, anemia, wt loss free fluid

27. CONSTIPATION – Definition – Alarm features – D/D from IBS abdominal pain – Self care strategies Not miss Bfast gastrocolic reflex max Include fibre rich food fruits/legumes veg. whole grain and seeds gradually increase fibre in diet Fruits rich in pectin apples strawberries lychees and pear Drink water,avoid fried foods and alcohol and caffeinated, sugar rich beverages, decrease intake of refined sugar Exercise avoid stress improve sleeping patterns Do not ignore urge to pass stool and optimal toilet sitting position Minimise use of medications use simple bulking agents