Whole Health Library

_{tTG IgA = transglutaminase IgA
DGP = deamidated gliadin peptide antibody
HLA = human leukocyte antigen (DQ2/DQ8 = chromosome locations)}

Jake had negative tTG IgA, DGP and no evidence of malabsorption or a history of autoimmune disease. To see if he may have NCGS, you suggest that he consider doing an elimination diet (ED) with a particular focus on gluten. He refrains from eating gluten for 3 weeks to see if his symptoms improve. Using one’s own body as a laboratory to test sensitivity to a food protein can be both diagnostic and therapeutic. It is still the gold-standard test for diagnosing food sensitivity. For more information, refer to the “Testing to Assess the Gastrointestinal Ecosystem” Whole Health tool.

Elimination Diets

As reviewed in Figure 1, if there is a food protein that is triggering an inflammatory response through a disrupted intestinal barrier, removing this food can help reduce the intestinal permeability. This is an important part of improving the GI ecosystem. It is important to realize that a food sensitivity is different than an IgE mediated food allergy. A known food allergy must strictly be avoided to prevent a serious allergic reaction. A food that the body has become sensitized (not allergic) to needs to be removed to help the intestinal permeability heal. But once the barrier function and the GI ecosystem improve, it is possible that the body may be able to tolerate this food again.

It is also important not to create a fear of food. The gut-mind, mind-gut connection is so powerful that sometimes when people have such a positive response in symptoms by removing one food group, they can inappropriately attach fear and avoidance to other foods that may not actually be causing an inflammatory response. For example, maybe someone has a fight with a loved one and then eats a tomato, and the result is abdominal cramps and watery diarrhea. The fear that the mind attaches to the food can trigger symptoms that can result in a slippery slope of multiple food intolerances that can result in malnutrition and overall a poor health outcome.

Please refer to the following resources on elimination diets:

• “Elimination Diets” Whole Health tool
• Chapter on elimination diets, Integrative Medicine 4^th Edition, by David Rakel (2017).[52]

The FODMaP diet

Jake’s fondness for “white foods” suggests that he may also benefit from the FODMaP diet, which is often considered a second-line approach after adhering to general dietary guidance. White foods are rich in bleached white flour, which converts to simple sugars in our digestive system. The FODMaP Diet is an acronym for Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyol sugars. These particular sugars are not easily absorbed and thus go through the process of fermentation when exposed to microbes in the gut.

To put this into a context that is easy to understand, think of brewing beer. The combination of a sugar (malt) and a microorganism (yeast) causes the production of gas (fermentation). The same thing can happen in the gut. If our diets consist of an excessive amount of sugar, particularly those types that are difficult to digest, the sugar mixes with bacteria and yeast in the gut and produces a gas that can cause bloating and pain. An excessive amount of these specific sugars in the diet can also encourage the growth of yeast and bacteria that sustains the gaseous process. Foods to avoid in the FODMaP diet have shown to trigger an osmotic fluid shift into the lumen of the intestine, which worsens symptoms in those with diarrhea-predominant IBS.[53] This may explain the findings in one study where the FODMaP improved symptoms by 50% for both diarrhea and constipation-predominant IBS, but only reduced stool frequency for IBS that was diarrhea-predominant.[54] Now that we have a better understanding of the pathophysiology of how certain sugars can worsen GI symptoms, we can treat the symptoms by modifying the diet.

These mechanisms also help to explain why some people’s GI symptoms significantly improve after taking an antibiotic. The antibiotic reduces the amount of bacteria needed to ferment dietary sugars. However, as discussed above, we need these healthy bacteria for many reasons, and using antibiotics to treat irritable bowel syndrome (IBS) has benefit that may be short-lived. The nonabsorbable antibiotic, Rifaximin, reduced the bacterial growth in the GI tracts of IBS patients by 70%, with a small benefit (10%) over placebo.[55] A 10-day course costs about $600. Since Rifaxamin is only mildly effective relative to placebo, may worsen the GI ecosystem, and is expensive, nutrition is a better initial and long-term therapy.

For more information, go to the “The Low FODMaP Diet” Whole Health tool.

Modified FODMaP. The FODMaP diet can lead to a significantly lowered intake of fiber from fruits and vegetables, which could lead to micronutrient deficiencies and adversely affect the microbiome. Although it has not been extensively studied, some people may benefit from a “modified FODMaP diet,” which allows for continued intake of some higher FODMaP foods. Consider starting by having patients significantly reduce their FODMaP sugar load by avoiding dairy, wheat, rye, high-fructose corn syrup, honey, and polyol sugars. If this does not work, one can consider doing the full FODMaP diet.

Fiber

Regular consumption of fiber is a foundational nutritional requirement for optimal gastrointestinal health. Soluble fiber is a source of nutrition for the gut microbiome and also maintains the healthy intestinal mucous layer needed for bacteria to survive and support healthy gut immunity.

Fiber is beneficial for the following reasons:

• Fiber slows the glycemic index of carbohydrates. This is why it is much better to eat an orange in fruit form and not just drink orange juice. The fiber in the whole orange slows the absorption of the sugar within the juice. Slowing the absorption of sugar results in fewer insulin spikes and decreased insulin resistance.
• It inhibits the absorption of cholesterol. Plants are not only rich in fiber but also in plant stanols and sterols—plant cholesterols that humans cannot make. When eaten in plant form, cholesterol absorption is inhibited. Eating a diet that is specifically high in fiber, plant sterols, soy, and nuts has been found to equal the cholesterol-lowering effects of 20 mg of the drug lovastatin.[57]
• Soluble fiber absorbs water and stimulates satiety. One tbsp of soluble fiber (e.g., psyllium or ground flaxseed) placed in 8-10 oz of water and consumed before meals can help with weight loss by filling up the stomach. This not only reduces postprandial sugars and cholesterol absorption, but it also causes a person to eat less during the following meal. Soluble fiber is an ideal therapy for a diabetic who wants to lose weight while lowering cholesterol and blood sugar levels.
• Fiber stimulates peristalsis of the GI tract, reducing constipation and helping with regular evacuation.
• It binds to hormones such as estrogen and helps with their excretion. This may have a beneficial influence on hormone-sensitive cancers (e.g., breast and prostate cancers).[58]
• It provides an excellent source of nutrition for the bacteria in the gut; in other words, it is a prebiotic.
• Fiber stimulates mucus production along the GI tract.

Strategies to improve fiber intake. The American Dietetic Association (ADA) recommends eating at least 21-38 grams of fiber each day (varies depending on age and sex). Most people will get this if they eat 6-8 servings of vegetables and fruit daily. The following foods are considered good sources of soluble fiber:

• Oat bran
• Guar gum
• Dried beans and peas
• Apples (with their skins)
• Seaweed-based foods
• Flaxseeds

An important note: “Whole grains” are often considered by consumers to be a fiber surrogate, though the fiber content of whole grains various widely by grain and type of processing.[59]

A good rule of thumb to optimize one’s fiber intake is to examine food labels and determine the “total carbohydrate to fiber ratio.” A ratio of less than 10 is good, and a ratio of less than 5 is ideal. For example, if a serving of cereal has 20 gm of total carbohydrates and 4 gm of fiber, this ratio is 20/4=5—an excellent choice.

If it is difficult for someone to get enough fiber by eating multicolored whole foods, you can recommend a supplement, such as one of the following:

• Guar gum. Dose is 5-10 gm a day or 1/2 tsp in juice or water before each meal 3 times a day. Low-cost guar gum is available online through websites such as Amazon ($2.50 for 8 oz).
• Psyllium (Metamucil). This is available in many forms, including powder, capsules, and wafers. Dose is 1/2 tsp in juice or water before meals or 1 tbsp daily.
• Ground flaxseed. Advise patients to buy the seed form of flax, which stores well. They can use a coffee grinder to prepare a week’s worth. Store flaxseed in the refrigerator, because once it is ground and the oils are released, it spoils quickly. Dose is 1 tbsp on food twice daily. It works well to sprinkle flaxseed over salads and in smoothies. Flaxseed is a good source of both fiber and omega-3 fatty acids.
• Methylcellulose (Citrucel) (. The dose is 1 tbsp in 8 oz of water or juice 2-3 times daily.
• Oat bran/oatmeal. You might recommend eating a bowl of this with fruit each morning.

Jake has a disordered sleep-wake cycle. He reports that he often has trouble falling asleep due to racing thoughts. This disruption in the circadian rhythm is associated with worsening GI symptoms. As with many components of the Circle of Health, the benefits often go both ways. Not only does improving sleep improve GI function, but improving GI health also improves sleep.[60] A poor sleep-wake cycle triggers inflammatory cytokines that can exacerbate inflammatory bowel disease (IBD) and disrupt GI immunity.[61]

Poor sleep can also result in lower melatonin levels. Melatonin reduces acid reflux by increasing the tone of the lower-esophageal sphincter and reducing acid excretion.[62][63] It makes sense that melatonin would have these effects. When we lie horizontally to sleep, reflux is more likely to occur, because gravity is no longer directing acid out of the stomach. Melatonin counteracts this, and it also reduces the intestinal permeability caused by nonsteroidal anti-inflammatory drugs (NSAIDS) in animal models.[64] Some individuals who have gastroesophageal reflux disease (GERD) and are bothered by symptoms when they are supine may benefit from a low dose (0.5-3 mg) of melatonin at bedtime. For more information on improving the sleep-wake cycle, refer to the “Recharge” Whole Health overview.

Hearing a Veteran’s unique story and understanding more about what provides meaning and purpose in his or her life is a key part of the Whole Health approach. This exploration helps us break out of the find-it, fix-it model and redirects our focus toward the fundamental question of why each Veteran wants their health in the first place. This is relevant for all health conditions, including those of the GI tract. Understanding Mission, Aspiration, Purpose (MAP) —“what matters most”—helps clinicians co-create an optimal treatment plan based on individualized goals and can enhance self-efficacy. Jake wants to be able to support his family—this gives his life meaning. If this fact is not held at the center of his Personal Health Plan, it is unlikely Jake will make the necessary changes to align with this goal.

When patients were asked if they felt their physician should ask about their spiritual health, 83% answered yes.[65] Among those who wanted to discuss spirituality, the most important reason for discussion was to enhance physician-patient understanding (87%).[65] Patients believed that information concerning their spiritual beliefs would favorably affect physicians’ ability to encourage realistic hope (67%), give medical advice (66%), and positively change medical treatment (62%).[65]

Two studies illustrate the dynamic interaction of the gut ecosystem, mind, and body. A study of women, who were given a probiotic drink and then underwent functional MRI scanning of the brain, showed that the women given the probiotic drink had changes in the parts of the brain that process emotions and sensations. These areas of the brain were not stimulated in the control group who did not consume the probiotic.[66]

A fascinating mouse study involved a probiotic, Lactobacillus rhamnosus, and its effects on mouse behavior. Researchers fed one group of mice a broth rich in the probiotic, while another group of mice received broth without it added. The mice given the probiotic broth not only had more explorative activity, but also had less anxiety and fewer signs of depression. Mice from each group were placed in water to elicit a fear of drowning. Mice that were given the probiotic not only were able to swim longer, but they had less anxiety and lower levels of the stress hormone, cortisol. Researchers repeated the same experiment with mice that had severed vagus nerves; the findings were not reproduced.[67]

These studies suggest that the bacteria in our guts may influence emotional behavior and sensation. It would seem that the pathway in which this information is conveyed is through the vagus nerve. The vagus nerve is the super-highway of communication between the mind and the gut, and the gut and the mind. Information flows between the two in both directions. Just as bacteria may be able to influence our mood, our mood can also influence the gut.

Some consider the gut to be the body’s “second brain.” The intestinal tract actually contains more serotonin than the brain. It has been shown that when the mind perceives stress, the mast cells are activated along the enteric nervous system. They can exacerbate inflammation, worsening intestinal permeability (as noted in Figure 1). A study in rats demonstrates this nicely. One group of rat pups was separated from their mothers after birth. These highly stressed rat pups were found to have significant intestinal permeability as compared to the control group, which were not separated from their mothers. The highly stressed rat pups were fed supplements that included docosahexaenoic acid (DHA, an omega-3 fatty acid), arachidonic acid (ARA, fat found in breast milk), fructooligosaccharides (a prebiotic) and the probiotic lactobacillus. When the stressed rats were given these supplements, their intestinal permeability healed.[68]

As is common in the culture of medicine, we often want to focus on the magic “fix” that comes from outside the living being, giving less attention to self-healing that comes from within. It might be tempting to focus on the supplements needed to help the gut barrier heal, forgetting that putting the rat pups back with the mothers facilitates healing from within without the need for the external “fix.”

Ideally, when able, it is best to recruit the self-healing mechanisms of the body. It is also important to have tools to help move it along in the healing direction. One tool worth exploring involves metaphor, discussed under the Therapeutic Disclosure section that follows.

Therapeutic disclosure

We have two ears and one mouth, to be used in that proportion. Our empathic listening is likely one of our most-effective therapeutic tools.

Watch for nonverbal cues. During a visit with a patient, watching for nonverbal clues (such as welling up of the eyes), allows us to understand how gentle questioning may help someone discuss what truly matters to them.

Listen for metaphor “It’s eating me up inside.” “She is breaking my heart.” Listening for metaphor in a patient’s story can be a helpful. A memorable patient with proctalgia fugax (painful rectal spasms) once stated, “My boss is a pain in the ass.” After this stressor was explored and brought into her conscious awareness, her pain resolved without the need for medications. Medications would only have treated the symptom, not its cause.

Metaphor can help us understand the relationship between the mind and the body. Lord Chesterfield said, “I find, by experience, that the mind and the body are more than married, for they are most intimately united; and when one suffers, the other sympathizes.”

Getting something “off your chest” encourages disclosure of information that the body must work hard to keep suppressed. This work on the part of the body is thought to cause dysregulation of the autonomic nervous system (ANS) and the hypothalamic-pituitary axis (HPA), leading to elevated cortisol and immune suppression.[69] James Pennebaker, a leading researcher in this area, demonstrated this by monitoring the physiologic effects of disclosure in individuals connected to polygraphs. Once a person confessed to something he or she did wrong, the ANS returned to a more balanced state, with a reduction in heart rate, blood pressure, skin conductance, and respiratory rate.[70]

Consider recommending journaling.. Writing about emotional events is often referred to as journaling (summary of science for expressive writing therapy), and the process of expressing weighted emotions as disclosure. Many of the studies on journaling divide study participants into three groups. One group writes about an emotionally charged event, one writes about trivial topics (such as time management), and the third is the control group, who do not write at all. No study has found benefit to writing about time management. In contrast, writing about emotionally charged events has been found to do the following:

• Speed wound healing[71]
• Improve lung function in asthmatics by 20%,[72] and improve functional disability in adolescents with asthma[73]
• Improve disease severity (inflammation) by 28% in people with rheumatoid arthritis[72]
• Improve memory function with less intrusive thoughts in college students[74]
• Reduce number of visits to the infirmary in inmates of a psychiatric prison[75]
• Improve marital satisfaction in Veterans returning from Iraq and Afghanistan[76]
• Increase rates of smoking cessation in young adult smokers[77]
• Reduce physical symptoms and number of cancer-related medical visits in women with breast cancer[78]

No one has to read what is written. The therapeutic benefit comes from expressing the emotions in a way that enhances a sense of control and understanding. A patient can even consider burning the writings and letting the wind carry the ashes away to add ceremony and closure to the process.

Researchers have started to analyze what it is about journaling that is most strongly associated with improved health. [79] Key ingredients were threefold:

1. The writing tells a story with a beginning, middle, and end.
2. In creating the story, the writer develops insight into how the event influenced their life and uses words such as realize and understand. The writing demonstrates a sense of optimism with the use of more positive words.

The writing changes to reflect less social isolation. As the story evolves, there is a change in the use of pronouns from first person singular (me, I) to second person pleural (we, us).

Precautions. As with many therapies that have beneficial effects, there are precautions to remember with therapeutic disclosure. The body often keeps emotions repressed for a reason. If they are brought out when the individual is not yet ready to deal with them, the process can backfire. In dealing with Veterans, who have a high prevalence of PTSD, it is particularly important to keep this in mind.

Following are some points to keep in mind when exploring emotional stressors:

• Disclosure of past emotional events is most likely to occur within a trusting relationship. It is important to offer support for further processing if needed. Collaboration with a licensed counselor or therapist is beneficial.
• If the individual is not ready to discuss or write about emotional events, do not push.
• Be careful not to allow past events to create guilt. There is no evidence to support the often-misguided belief that past stressful events themselves cause disease. It is the individual’s reaction to an event that plays a role, and guilt only exacerbates the problem.

Clinical Hypnosis

Clinical hypnosis is a method of deliberately using verbal cues to induce an altered state of awareness for a targeted therapeutic indication. These verbal cues can enhance relaxation, the ability to generate imagery, and focus. Evidence supports the use of either Gut-Directed Hypnotherapy (GDH) or audiotape hypnotherapy, and one trial found these to be equally effective for IBS with response rates of 50%-75%.[80] GDH is more resource-intensive than a self-directed audiotape, requiring 8-12 sessions that are ½-to 1-hour long. Several studies showed that clinical hypnosis seems to have consistent positive effects on IBS, with an estimated 25%-73% improvement in bowel symptoms, psychological distress, and quality of life that lasted over a year after treatment was completed.[81][82][83] In refractory cases referred to a GI clinic, an uncontrolled prospective study of 204 individuals found that 81% received benefit; 71% of these continued to have benefits 5 years later.[84] Although larger randomized trials need to be done to verify the effectiveness of clinical hypnosis, its safety and potential benefit makes it a worthwhile therapeutic option. It also remains unclear how this intervention compares to other interventions.

For self-guided hypnosis audio resources, go the Health Journeys website. For a copy of a script you can use for yourself or with patients to ease abdominal pain, refer to the “Balloon Self-Hypnosis Technique for IBS and Abdominal Pain: A Guide for Clinicians” Whole Health tool.

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) focuses on identifying behaviors and thought patterns, as well as negative emotions that hinder progress toward one’s self-defined goals. This mind-body modality has the most robust evidence base for improvements in function. [85][86] Some data suggests that online delivery may be as effective as live delivery, which may allow systems to greatly expand this often underutilized service. [85]

A number of nutritional supplements are used to treat GI conditions. They can be categorized as those most useful for the upper GI tract and those most useful for the lower GI tract. This is not an exhaustive list, but it includes those that have the most evidence and historical use supporting benefit.

The upper GI tract

Melatonin

If someone has reflux symptoms that get worse upon lying down, melatonin can be a useful tool. Melatonin may promote the secretion of gastric bicarbonate, protect the gut barrier from NSAIDS, and improve the activity of the lower esophageal sphincter by inhibiting nitric oxide.[62][63][64] Given that endogenous melatonin peaks in the evening, this may be one way that one’s innate physiology help to minimize gravity-dependent reflux. Supplementing with melatonin may not only help with sleep initiation, but it may be as effective as a low dose PPI in treating GERD. Dose: 3-6 mg, 30-90 minutes before bedtime. [87][88]

Licorice

A demulcent, or mucilaginous, botanical medicine can be used as mucoprotection of the esophageal mucosa, soothing irritated tissues to promote healing. For example, licorice (Glycyrrhiza glabra) is a well-known demulcent botanical used for GERD, gastritis, and duodenal and peptic ulcers. For long-term use, it should be prescribed as deglycyrrhizinated licorice (DGL) in order to avoid the side effects of one of its phytochemicals, glycyrrhizin, also called glycyrrhizic acid. The prolonged use of decoctions or infusions of dried, unprocessed licorice root can cause hypertension, hypokalemia, and edema, due to glycyrrhizin’s mineralocorticoid effects. The common dosage is 2-4, 380 mg lozenges before meals.[89][90]

Slippery Elm

Slippery elm (Ulmus fulva) root bark powder is another useful demulcent for GERD. Mix 1-2 1-2 tbsp of the powder with a glass of water and take after meals and before bed. Advise patients to carefully titrate the proportions, as the preparation can be very thick and difficult for some people to tolerate; to increase its palatability they can add sugar or honey to sweeten it slightly. Most sources describe this botanical as very safe, though the hydrocolloid fibers may bind simultaneously administered medications and decrease their absorption.[89]

Marshmallow

Marshmallow (Althea officinalis) is another mucilaginous herb for GERD symptomatic relief. Its demulcent properties also make it useful for pharyngitis, wound healing, cough, and bronchitis. The dose is 5-6 gm (about 2-3 tbsp) daily, in divided doses, as an infusion of the leaves or root. As with slippery elm, there may be a decrease in absorption of orally administered drugs taken simultaneously with marshmallow.[89]

Chamomile

Chamomile (Matricaria recituta) is well-known for its mild sedative actions and for its anti-spasmodic effects on the GI tract. In GERD, it is used as a non-demulcent anti-inflammatory. Chamomile is most commonly used as a hot-water infusion (tea) of 1-3 gm (about 1 tbsp) of the flowers, steeped in a cup covered with a saucer, and taken 3-4 times daily.[89] Chamomile is generally well-tolerated, though individuals allergic to other plants in the daisy family (Asteraceae) may experience an exacerbation of their allergic symptoms with consumption of chamomile.[91]

Combination botanical products

Iberogast® is a product that includes Clown’s mustard, German chamomile, angelica root, caraway, milk thistle, lemon balm, celandine, licorice root, and peppermint leaf. A meta-analysis supported its use in the treatment of dyspepsia, showing a reduction in epigastric pain, cramping, nausea and vomiting compared to placebo.[92] The usual dose is 1 ml, 3 times daily. Usually well tolerated, it may cause nausea, diarrhea, and skin rash in some people.

The Lower GI tract

Probiotics

The bacteria within the mucus of the intestinal wall play a key role in the permeability of the tight junctions of the enterocytes. The gut flora interact with toll-like receptors (TLRs) that are the gatekeepers in helping distinguish which antigens are helpful or harmful[93], and composition of the gut flora directly influences intestinal permeability.[94] There is growing data showing a potential therapeutic benefit of probiotics in the treatment of IBS.[95][96][97][98][99] The most positive single-species studies for IBS have shown the specific strain Bifidobacterium infantis (B. infantis) 35624 at a dose of 10⁸ colony-forming units (CFUs) to be the most effective.[100][101] However, multispecies probiotics seem to provide superior relief when used for at least 8 weeks and should contain Lactobacillus and at least one of either Streptomyces or Bifidobacterterium species.[98]

In one meta-analysis, the number of people who needed to be treated (NNT) with probiotics to have one person experience improvement was found to be as low as four. .[102] Probiotics have significant favorable effects on abdominal pain, bloating, and bowel movement difficulty, especially in those with the diarrhea subtype.[99][103]

While using probiotics can be helpful, it remains unclear if they provide long-term benefits beyond several months. Some studies suggest that they do not, and other studies suggest that they may possibly worsen symptoms after 3-4 months.[104] Therefore, using probiotics during times of worsening symptoms, while incorporating other modalities, may be the best approach.

Peppermint

Peppermint is one of the most commonly used supplements for lower abdominal spasms that are common in IBS. Its main active ingredient is menthol, an antispasmodic. It works best to treat spasms that lead to abdominal pain as opposed to treating distention and flatulence. It has also been shown to improve diarrhea, constipation, urgency, and incomplete defecation.[105] One systemic review showed response rates in those using peppermint oil of 79% for abdominal pain, 83% for abdominal distention, and 73% for flatulence.[106] These findings are as good as those for pharmaceuticals—if not better—and peppermint oil has fewer side effects. In fact, the number needed to treat (NNT) is 2-3, making this possibly the single, most effective intervention for IBS.[107]

L-glutamine

Glutamine is a nonessential amino acid utilized by rapidly growing cells. The enterocyte lining of the GI tract contains one of the most rapidly reproducing cells of the human body, and depletion of this protein can result in continued disruption of intestinal integrity. Research of L-glutamine has focused on severely ill individuals in the intensive care setting who develop increased intestinal permeability that leads to enteric derived septicemia. The breakdown of the intestinal barrier allows pathogenic bacteria into the blood stream resulting in sepsis.

This can be prevented by supplementing with L-glutamine, which maintains the integrity of the intestinal barrier and reduces the incidence of gut-derived infections.[108] Glutamine appears to have the most benefit when inflammation is present despite the depletion of nutritional stores.[109] It reduces inflammatory cytokine release within the bowel wall[110] and increases heat shock protein, which protects enterocytes from injury.

There is limited research on L-glutamine and IBS, but due to its safe side effect profile, a short course of therapy (5 gm BID for 2 weeks) may prove helpful in those patients suspected to have increased intestinal permeability. Since meat is the key nutritional source for glutamine, vegetarians may be at greater risk for deficiency.

Zinc

There is preliminary human data demonstrating that zinc has benefit in helping preserve intestinal integrity. In a randomized crossover trial, 10 patients were given 37.5 mg of prophylactic zinc to see if this would prevent the loss of intestinal integrity when given the medication indomethacin. There was no loss in intestinal integrity in those given zinc, but there was a three- to fourfold increase in intestinal permeability when zinc was not used. The group treated with zinc also had a 75% reduction in gastric and small bowel injury and 50% less villous shortening.[111] In vitro data is also supportive.[112]

Since zinc deficiency is one of the most common mineral deficiencies in the Western diet,[113] a short trial of supplementation (20-35 mg daily for 14-30 days) may prove helpful. Zinc is necessary for appropriate immune function of the GALT and is deficient in those with IBS, although this may be secondary to zinc loss from diarrhea.[114]

Chinese Medicine and Acupuncture

Acupuncture is one of many therapies used within Chinese medicine (CM). It has a history of more than 2,000 years of use. Chinese medicine is a holistic system encompassing acupuncture, herbal medicine, nutrition, meditative practices (qi gong), and movement (tai chi). CM is based on the belief that health is maintained by balancing two opposing forces, yin and yang. Yin is the cold, slow or passive force and yang represents the hot, excited, or active force.[115] Yin and yang balance is managed by qi, the body’s vital energy source, believed to flow in channels throughout the body. Disease results from an imbalance of yin and yang with resultant blockages in the free flow of qi. The goal of CM modalities is to restore and maintain the balance of yin and yang. Acupuncture stimulates points on the body, usually with needles, altering the flow of qi attempting to achieve this balance. Even though acupuncture represents one piece of CM, it often is practiced as an independent therapy.

For more information, refer to the “Acupuncture” Whole Health tool.

Acupuncture can help with pain and peristalsis of the GI tract in those with GERD or IBS.

Acupuncture may have clinical efficacy for GERD based on three possible mechanisms. Acupuncture may stimulate GI motility and decrease acid secretion via the vagus nerve and other parasympathetic pathways. Acupuncture also may increase esophageal sensory thresholds, which decrease in those with GERD. A recent meta-analysis of 12 small, heterogeneous trials showed that acupuncture improves quality of life and decreases recurrence of symptoms, and that the combination of acupuncture plus pharmaceuticals is more effective than either alone.[116]

Acupuncture may also be more effective than doubling the dose of a PPI in those with persistent symptoms on standard-dose PPIs.[117] It can also be helpful for allowing patients to transition off a PPI. Stopping a PPI can lead to rebound hyperacidity. For more information, refer to the “Coming off a Proton Pump Inhibitor” Whole Health tool. In the case of IBS, randomized controlled studies have not shown a clear benefit of acupuncture in reducing symptoms or severity or in improving quality of life. However, a few Chinese trials have shown that acupuncture may be more beneficial than antispasmodic medications. It may be that individuals who prefer acupuncture as a treatment modality, or have greater expectations of improvement with acupuncture, will benefit more from acupuncture than medications.[118][119] In many studies, quality of life improves in both treatment and sham acupuncture groups. Given that acupuncture has a favorable benefit-to-risk ratio, it may be worth considering, though cost and accessibility must also be taken into account.[120]

After going through the Personal Health Inventory (PHI), Jake was able to self-reflect on the areas that he feels are the most important to work on for his long-term health. He realized that he was not where he wanted to be with his personal development and emotional and nutritional health. The process of going through the PHI helped trigger insight, which aided in the facilitation of a personalized, proactive, patient-driven therapeutic process. It also helped him see that family support and his spiritual life are important for supporting his mission toward health.

Jake’s main goal is to find a job to support his family. Assisting him with that will help reduce the stress that can exacerbate GI symptoms. He will be referred to a PACT social worker who can connect him with vocational resources, such as a counselor to help him identify his vocational interests and strengths, workshops on skill building and networking, resume-writing resources, a job-hunting support group, and/or sources of job-postings.

In taking Jake’s nutritional history, it became evident that he enjoys a lot of “white food,” such as breads and pasta. He also notices that his symptoms worsen when he drinks beer. All these foods are rich in gluten, which could be triggering sensitivity along his GI lining. After a trial of meeting basic healthy eating guidelines (with a focus on fiber), he can be encouraged to do an elimination diet, staying off gluten for two weeks to see if this reduces the frequency of his stools. For more information on how to use this tool, refer to the “Elimination Diets Whole Health tool.

If an elimination diet proves helpful, Jake would have two possible courses of action. Some clinicians might choose to challenge him again with gluten to see if his symptoms worsen again, while other clinicians might have him stay off the gluten for 3-4 months as he works on improving the health of his GI ecosystem. Ideally, once intestinal permeability improves, he could slowly start eating small amounts of foods containing gluten again. If he has no benefit from the elimination diet, trying the FODMaP diet could help reduce his symptoms.

To improve the GI environment, a Whole Health strategy would include the following recommendations.

Personal Development

Connect Jake to resources that may increase his likelihood of finding rewarding work and that will provide support throughout the job-seeking process. This will help reduce his stress and fear about not being able to provide for his family.

Food & Drink

• Encourage Jake to meet with a nutritionist to improve his nutrition. He should be encouraged to include more vegetables, fruits and fiber. He should also be introduced to fermented foods (yogurt, sauerkraut, miso, tempeh, kefir) which can increase beneficial gut bacteria.
• Supplement with a soluble fiber, such as psyllium or guar gum: 1 tbsp in 6-8 oz of water daily. Using a soluble fiber with less water (6 oz instead of 12 oz) can reduce stool transit time, reducing the frequency of stools.
• Supplement with a probiotic of 10⁸ CFUs that contains both lactobacillus and bifidobacteria. Take both probiotics for 8 weeks.
• Make sure Jake is getting good sources of omega-3 fatty acids in his diet (fish, nuts, fruits), zinc (green leafy vegetables, peanuts, eggs), and glutamine (meat). If he doesn’t get enough of these through his diet, consider supplementing with 1,000 mg of EPA and DHA essential fatty acids in the form of fish oil, L-glutamine (5 gm daily), and zinc (20-30 mg daily) for 4 weeks.

Power of the Mind

Refer Jake to the team’s psychologist, who will first explore the stressors of his experience in Afghanistan through CBT. Then, explore other therapies that can recruit the mind as a therapeutic ally. These may include journaling, Guided Imagery, and/or Gut-Directed Hypnotherapy.

“Digestive Health” was written by David Rakel, MD and updated by David Lessens, MD, MPH (2014, updated 2020).”References