Treating Chronic Gastrointestinal Symptoms with Digital Therapeutics

Treating Chronic Gastrointestinal Symptoms with Digital Therapeutics By E. Dylan Mayer and Emeran Mayer, MD Chronic disorders of the intestinal tract, such as inflammatory bowel diseases (IBD) and irritable bowel syndrome (IBS) are common, affect both children and adults, greatly impact patients’ quality of life and contribute significantly to the economic healthcare burden. About 1.6 million Americans suffer from IBD and the prevalence of these disorders has increased by 200,000 since 2011. Ten to fifteen percent of the US population meet the symptom criteria for IBS. Despite their different disease mechanisms, scientific and clinical evidence point towards alterations in the bidirectional interactions between the brain and the gut, and the important role of the brain in influencing symptom severity.1, 2 The great majority of patients are treated symptomatically with medications which do not always provide satisfactory symptom relief or are limited by side effects. It has been more than 7 years since our group published the results from a small clinical trial on the effectiveness of a psychoeducational treatment program for IBS patients which showed significant clinical benefits.3 A plan to move this treatment program to an online format did not materialize as not enough patients regularly used the internet at the time. A recent large clinical trial from Dr. Jeffrey Lackner’s group at the University of Buffalo show a persistent clinical benefit of a patient-centered cognitive behavior therapy (CBT) approach in IBS patients.4 And our two groups showed in a recent study that CBT not only improves symptoms in IBS, but that this clinical benefit is associated by changes in the brain and the gut microbiome, a finding that qualifies CBT as a biological therapy.5 Even though CBT has been shown to be one of the most effective treatments for IBS patients, the widespread application of CBT in gastrointestinal (GI) disorders is greatly limited by two major factors. Even though it is not a new treatment, there are still a very limited number of CBT therapists with expertise in GI disorders, in particular in non-metropolitan areas. The other issue is that when you do find someone, the duration and cost of traditional face to face CBT has prevented this therapy from being adopted widely. Welcome to 2020 and the age of digital therapeutics. Digital therapeutics or prescription digital therapeutics (PDTs) are clinically validated software treatments prescribed by a doctor and have the potential to greatly improve life outcomes for…

Are Probiotics Good for You?

Are Probiotics Good for You? By Emeran Mayer, MD A recently published report by the American Gastroenterological Association (AGA) on Clinical Practice Guidelines for the role of probiotics in the management of gastrointestinal disorders, based on an in depth Technical Review of the published literature concludes that probiotics have little if any evidence based value in treating digestive diseases (including irritable bowel syndrome [IBS] and inflammatory bowel diseases),1 a statement that is not surprising to somebody who has long followed the scientific debate about probiotics and who gets the question from nearly all of my patients which probiotic is best to take. The only disease populations that the report exempts from their negative assessment were children and adults on antibiotic treatment, preterm infants with low birthweight and patients with pouchitis, a postoperative complication in patients following a colectomy. According to the World Health Organization, “Probiotics are live microorganisms which when administered in an adequate dose confer a health benefit on the host.” This is an ambiguous definition, as it includes both the possible benefits of ingested microbes on gut and overall health in individuals without any specific gastrointestinal (GI) disorder (probably the majority of people who take probiotics), as well as the possible benefits in treating or preventing a specific disease (a small fraction of the overall market). Even though there are a number of clinical trials which have aimed to demonstrate an effect on GI disorders (most of which according to the report have not been conclusive, were of low quality or have been negative), there is a small number of studies which have shown that certain probiotics are effective in reducing common digestive symptoms such as rumbling and abdominal discomfort in otherwise healthy people.2 Unfortunately, for most probiotics such well designed and controlled studies do not exist. Even though I generally agree with the conclusions of the AGA guidelines, there are several important points to consider before we close the curtain on the benefits of probiotics: The same microbes may not be effective in everybody, and based on current knowledge, the effectiveness of a particular microbe is likely to depend on the unique composition and function of the gut microbiome of a particular individual. Until we are able to design custom cocktails of probiotic strains which match an individual’s microbiome, and evaluate the effectiveness in such selected populations it may be impossible to demonstrate significant benefits in clinical…

The Magic Weight Loss Diet Does Not Exist

The Magic Weight Loss Diet Does Not Exist By Juliette Frank and Emeran Mayer, MD Currently, one in three Americans of all ages – over 100 million people – are obese.1 As obesity rates hit peak levels, causing a major public health crisis, many Americans are looking to popular diet programs for a simple solution. There are countless diet recommendations for losing weight and reducing cardiovascular risk factors associated with being overweight such as heart disease, metabolic syndrome, high blood pressure, high cholesterol, and C reactive protein (inflammation in the body). Many popular diets have even been branded and named, promoting theirs to be the “magic key” for a healthy life and perfect body. The great majority of the promoted diets aim to either restrict or reduce the energy-providing macronutrients, e.g. fat, protein and carbohydrates without much consideration of the downstream effect of such diets on the gut’s microbial ecosystem. With one third of Americans dieting, there is high demand for evidence-based studies reporting which popular diet programs are most effective.2 In February of this year thee British Medical Journal (BMJ) released a study with 21 eligible trials with 21,942 patients comparing 14 of the most popular diet programs. Their network meta-analysis quantifies the comparative effectiveness of three dietary macronutrient patterns based on 14 popular diet programs for both weight loss and related cardiovascular risk factors at six and 12 months using the GRADE approach. The BMJ categorized each of the 14 popular diet programs into three dietary macronutrient patterns:3 Low Fat: approximately 60, Fat, % kcal = approximately 10-15, Fat, % kcal = <20 (Ornish, Rosemary Conley) Low Carbohydrate: Carbs, % kcal = <40, Fat, % kcal = approximately 30, Fat, % kcal = 30-55 (Atkins, South Beach, Zone) Moderate Macronutrients: Carbs, % kcal = approximately 55-60, Fat, % kcal = approx 15, Fat, % kcal = 21-<30 (Biggest Loser, DASH, Jenny Craig, Mediterranean, Portfolio, Slimming World, Weight Watchers, Volumetrics) The study measured the effectiveness of each dietary macronutrient pattern to a “usual diet” by comparing its effects on: change in body weight, low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol, systolic blood pressure, diastolic blood pressure, and C reactive protein at the six and 12 month follow-up. At the six month mark they found that low carbohydrate diets, compared to the normal diet, had median difference in weight loss of 4.63 kg or ~10 lbs, a…

Is Frailty Inevitable As We Age?

Is Frailty Inevitable As We Age? By E. Dylan Mayer and Emeran Mayer, MD When people reach their late 60s, many suddenly notice a slow decline in their physical strength, sense of balance, memory and cognitive function, and they realize that they can no longer do some of the things they were able to accomplish easily when they were young a adult. Such a progressive decrease in functions is called frailty, which is generally accompanied by a failure of multiple physiological systems and may include the development of chronic low-grade inflammation, loss of muscle (sarcopenia) and bone mass (osteoporosis), loss of cognitive function, and the increased risk of developing chronic diseases like type-2 diabetes, cardiovascular disease and degenerative brain diseases like Alzheimer’s and Parkinson’s disease. In contrast to physiological healthy aging, frailty is definitely not a necessary consequence of age, and it is preventable as several evidence-based remedies suggest. And we are not talking about remedies promoted by the multibillion dollar pharmaceutical industry which thrives off the consequences of frailty on our health. We are talking about two simple measures everybody can implement into their lives: The First Step Towards Healthy Aging Is Shifting Your Eating Habits The traditional Western diet, has been shown to be detrimental to our health, based on the numbers of people affected by chronic diseases of industrialization including obesity, metabolic syndrome,1 cardiovascular and liver diseases, depression, Alzheimer's, Parkinson’s and some forms of cancer in the US and other developed countries.2 The Western diet is characterized by low intake of fiber and high intakes of animal products, refined carbohydrates, sweets and sugary drinks, which have been shown to increase low-grade immune activation (metabolic endotoxemia).3 A recent publication in the prestigious journal Gut showed that a Mediterranean diet intervention altered the gut microbiome in older people across five European countries, and this was accompanied by reduced frailty and improved health status.4 The gut microbial taxa, which were enriched by adherence to the Mediterranean diet, were positively associated with several markers of lower frailty and improved cognitive function, and negatively associated with inflammatory markers including C-reactive protein and interleukin-17. The diet-modulated microbiome change included an increase in the relative prevalence of several beneficial microbial taxa including Faecalibacterium prausnitzii, Roseburia, Eubacterium, Bacteroides and Prevotella, and these microbial changes were associated with an increase in short/branch chained fatty acid production and lower production of secondary bile acids, p-cresols, ethanol and…

Challenging the Dietary Guidelines on Dairy

Challenging the Dietary Guidelines on Dairy By Juliette Frank and Emeran Mayer, MD Milk has always played an integral part in the Western diet and its high consumption has long been promoted on the concept that milk’s calcium and vitamin D content as necessary aids in development, bone health and prevention of fractures. The current recommended intake of dairy products in the United States for adults and children 9 years and older is three 8 oz (237 ml) servings per day while the average U.S. adult only consumes about 1.6 servings of dairy per day. However, as pointed out by a recent review article in the New England Journal of Medicine by two experts in the field of nutrition and health, Drs. Walter Willet and David Ludwig from Harvard University, there is no substantial evidence supporting health benefits from increased daily consumption, and concerns do exist about adverse health effects from a dairy heavy diet. One of the main focuses of milk’s benefit lies in its believed essential nutritional value for growth and development during early childhood. If breast milk is not available to a child, cow’s milk has long been recommended as a substitute for infant formula, even though neither formula nor cow’s milk contain any of the unique molecules contained in human breast milk, the so called human milk oligosaccharides (HMOs) which are essential for the early development of a healthy gut microbiome. As discussed by Dr. Sanjoy Gosh in a recent Mind Gut Conversation interview, another limitation of factory style milk production is related to the food that the cows are fed. Milk from grass fed cows has a significantly higher ratio of omega-3 to omega-6 fatty acids, which comes with a significant health benefit that large scale, industrial milk production does not have. In large scale dairy production in the U.S. cows have been bred to be pregnant for most of the time they are being milked, leading to higher levels of progestins, estrogen, and other growth hormones. These growth hormones increase the growth rate for children and lead to a higher attained height, which comes with both benefits and risks. An often ignored side product of this unique way of maximizing milk production are the huge numbers of baby cows slated for veal production, with all its ethical implications. Since milk increases height when consumed in adolescence and taller height is highly correlated with hip…