Indulgences over the holiday season lead many to experience symptoms of indigestion, part of the discomfort that fuels our renewed January focus on exercise and “eating right”. With this in mind, we need to have a discussion about how we as a nation handle GI distress or GERD (gastroesophageal reflux disease) symptoms. Typically, here in the US, there are 2 methods we typically use: 1. The quick way by popping a Tums or Rolaids or 2. The prolonged way by taking PPI’s (proton pump inhibitors) or H-2 blockers on a regular basis (eg. Pepcid AC or Zantac). Both are reliable ways to efficiently feel a little less GI distress.
The immediate relief strategies neutralize the acid that is already in the stomach whereas the longer-acting PPI’s and H-2 blockers actually block or suppress acid production in the stomach. And even though these “longer term” drugs are designed for short term use, the more I inquire about their use with my patients, the more a troublesome pattern emerges. Many of my patients struggling with complex symptom constellations (eg. a non-relaxing pelvic floor, perineal skin issues, gut issues, anxiety, depressive symptoms etc.) describe that they have taken these “digestive aides” continually for years. YEARS! To take care of their indigestion or digestive discomfort that began YEARS ago.
So, this approach is fine, yes? We know acid reflux can lead to esophageal irritation, not to mention pain and nagging discomfort. It can lead to disordered sleep and its associated sequelae. In extreme cases, esophageal irritation could even progress to esophageal cancer. Therein lies the justification for using drugs that suppress or block acid production in the stomach over the long term. Even though long term safe use of these drugs has never been established.
Hmmm. I hope this is cause for pause. It’s true we don’t want GERD or indigestion, yet it remains pervasive. The prevalence of at least weekly GERD symptoms in the US is approximately 20%,3 with overall prevalence estimated up to 30% in the US. 2 This prevalence of GERD is deemed “exceedingly common”, ranking as the most frequent gastrointestinal diagnosis associated with outpatient clinic visits in the US 1. For as frequently as I see these drugs listed on patient intake forms - or forgotten to be listed since it is such a part of one’s routine - I feel strongly that we are dealing with an epidemic I call “indigestion nation”.
Instead of blaming our stomach acid, it’s time for us to start scratching our heads and asking why. Why are so many struggling with digestion? And is there a better way to get a handle on this under-appreciated situation?
Next question: how often is nutrition or food digestibility considered in scenarios involving GERD symptoms, GI upset or indigestion? When I ask my patients about this, the standard answer prevails: they try their best to avoid known triggers including fried and spicy foods. Beyond that, there is little forward thinking in terms of where our collective indigestion originates.
Further, how many health care providers or patients contemplate what long-term acid suppression might look like? I happen to be one of those……so in my pondering, I peeled back layers of my own mental cloudiness on the topic and kept asking questions about basic principles of digestion such as: 'Isn’t our stomach is SUPPOSED to be acidic?' (Answer: it is) and 'What happens if it isn’t?' (Answer: lots of undesirable things). From there, I began connecting the dots and found points of clarity.
How often is the other side of this coin discussed? Is it common knowledge that in order to digest proteins, there has to be acid in the stomach? Is it common knowledge that the acid in the stomach kills or deactivates harmful viruses and bacteria that could otherwise gain access to the rest of our system via the intestinal barrier? The unfortunate answer is no, this isn’t common knowledge nor frequently discussed principles of digestion. Especially not in our conquest to battle indigestion.
We are conditioned to seek the quick fixes to our digestive woes - woes which have increased in prevalence in North America by approximately 50% relative to the baseline prevalence in the early to middle 1990s.1 Our go-to quick (Tums and Rolaids) and long term strategies (Zantac, Pepcid AC) are not without consequences. And I’m not even referring to the recently elucidated serious issue of the H-2 blocker ranitidine (generic Zantac) containing N-nitrosodimethylamine (NDMA)…. a probable human carcinogen. 4
Facts like these will sometimes get us to take notice, however, the more pervasive problem is this: components of our diets have become so difficult to digest, so physiologically incompatible with us, that we forget to examine this issue through such a simple lens. If our diet consists of foods that are difficult to break down or contain substances that can be disruptive to our digestive processes, it’s no surprise our body may reject them or be unable to digest them fully. If our diet consists of foods that are designed for nourishment, naturally pre-digested and ready to assimilate or use by the body for building blocks and fuel, our body will know how to break them down and utilize them fully…..miraculously reducing the digestive burden and improving symptoms of GI distress including GERD and indigestion.
It sounds simple enough.
But in this day and age, the savvy health care provider will do well to learn and appreciate the breadth and depth of this concept and what it means to you as both a consumer of food and one who cares for others who consume food - all of your patients. This understanding -especially for a pelvic rehab provider- is critical to harness. From simple but nuanced concepts one can help prompt remarkable changes. I’ve seen it firsthand innumerable times.
I invite each of you to learn more about this fascinating topic and how it interrelates with so many facets of your patient experiences. Take advantage of the multiple offerings of Nutrition Perspectives for the Pelvic Rehab Therapist across the nation in 2020. Join me at live course events in San Diego, CA on March 20-22; Columbia, MO on July 24-26; Winfield, IL on September 25-27; or Seattle, WA on November 6-8 to take your understanding of the far-reaching effects of digestion to the next level!
1. Richter, J. E., & Rubenstein, J. H. (2018). Presentation and Epidemiology of Gastroesophageal Reflux Disease. Gastroenterology, 154(2), 267-276. doi:10.1053/j.gastro.2017.07.045
2. Eusebi LH, Ratnakumaran R, Yuan Y, et al. Global prevalence of, and risk factors for, gastro- oesophageal reflux symptoms: a meta-analysis. Gut. 2017
3. El-Serag HB, Sweet S, Winchester CC, et al. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut. 2014; 63(6):871–80. [PubMed: 23853213]
4. Mahase, E. (2019). FDA recalls ranitidine medicines over potential cancer causing impurity. BMJ, 367, l5832. doi:10.1136/bmj.l5832
The need for artful incorporation of Hippocrates’ wisdom is great in today’s healthcare landscape. As conversation of nutrition broadens into multidisciplinary fields, his wisdom resonates: first, “we must make a habit of two things; to help; or at least to do no harm”. Second, we must modernize the ancient adage: “let food be thy medicine and let medicine be thy food”. And finally, health care providers will do well to be guided by his insight that “all disease starts in the gut”. Hippocrates’ keen observations during his era, modern science is confirming, hold keys to the plight of our times as we seek to find better ways to manage complex conditions commonly encountered in pelvic rehab practice settings and beyond.
Considered some of the oldest writings on medicine, the “Hippocratic Corpus” is a collection of more than 60 medical books attributed directly and indirectly to Hippocrates himself who lived from approximately 460 to 377 BCE.2 According to the Corpus, Hippocratic approach recommends physical exercise and a “healthy diet” as a remedy for most ailments - with plants being prized for their healing properties. If -during illness states - employment of nourishment and movement strategies fail, then medicinal considerations could be made. This logos - the ancient Greek word for logic - is the art of reason whose relevance today is perhaps more poignant than in ancient times.
In this logos, by making a habit of helping, or at the very least, not harming, it becomes particularly important to identify the unique nutritional landscape that surrounds us. The Hippocratic Oath emanates reason. It is logical that we would seek to practice (healthcare) to the best of our ability, share knowledge with other providers, employ sympathy, compassion and understanding, and help in disease prevention whenever possible.2 One of the most helpful and powerful aspects of rehabilitation is the gift of time we have for meaningful and instructional conversation with our clients. Our interactions with clients can and should address the realm of nutrition as it relates to the health of the mind and body. Because, after all - to help - is why many become health care providers in the first place.
Detailing a “healthy diet” in Hippocratic times was certainly simpler, as the uncontrolled variable of processed foods- as we know them- did not exist. Therefore, we reflect upon the quote: “let food be thy medicine and let medicine be thy food” and acknowledge that this modern food landscape is vastly different 1 than in ancient times. Compounding the issue, our standard logic for helping has gotten somewhat out of order. And both medicine and food carry meanings today reflective of modern times. The issues of poly-pharmacy and the tragedy of medically prescribed unintentional overdoses (or intolerances) remind us of our ‘medicine first’ mentality and the unfortunate reality that medicine is not the cure-all we so wish it could be. Further, not all ‘food’ today is food. Real food sustains and nourishes us. Real food can also heal. We need to celebrate real food for being real food, and champion it’s miraculous ability to support, heal, and transform the human condition.
Finally, health care providers will do well to be guided by Hippocratic insight that “all disease starts in the gut” and to logically extrapolate the opposite: much healing can begin in the gut. It is through this ancient concept that we can organize our modern science and begin to concretely and intentionally help heal ourselves and others from the inside out. Once we understand the key role of digestion and our gut on our health and well-being, the rest is pure logic. We simply need a map for navigation of these universal concepts to go along with our renewed appreciation for the art of reason.
Let Nutrition Perspectives for the Pelvic Rehab Therapist help provide this map. Evolve your nutritional logos into a beautiful and nourishing framework by joining the hundreds of pelvic rehab therapists and other health care providers who have attended Nutrition Perspectives in Pelvic Rehab. Be inspired and empowered on your integrative journey. Live courses will be offered at three sites in 2019: March 1-3 in Arlington, VA, June 7-9 in Houston, TX, and October 11-13 in Tampa, FL!
Fardet, A., Rock, E., Bassama, J., Bohuon, P., Prabhasankar, P., Monteiro, C., . . . Achir, N. (2015). Current food classifications in epidemiological studies do not enable solid nutritional recommendations for preventing diet-related chronic diseases: the impact of food processing. Adv Nutr, 6(6), 629-638. doi:10.3945/an.115.008789
Biography.com https://www.biography.com/people/hippocrates-082216. Accessed January 11, 2019.
A recent article in the Washington Post Health & Science section explored the wonders of dietary fibre in an article called ‘Fiber has surprising anti-aging benefits, but most people don’t eat enough of it’ The article discussed how ‘…Fiber gets well-deserved credit for keeping the digestive system in good working order — but it does plenty more. In fact, it’s a major player in so many of your body’s systems that getting enough can actually help keep you youthful. Older people who ate fiber-rich diets were 80 percent more likely to live longer and stay healthier than those who didn’t, according to a recent study in the Journals of Gerontology’
But what is fiber and why does it matter?
Before we jump in there, let me answer the perennial questions that arise when we, as pelvic rehab clinicians, talk about fiber…’Is it in our scope of practice to talk about food?!’ I think it is fundamental that if we are placing ourselves as experts in bladder and bowel dysfunction, that we also remember that we can’t focus on problems at one end of ‘the tube’ without thinking about what happens at the other end. Furthermore, let me quote the APTA RC 12-15: The Role of the Physical Therapist in Diet and Nutrition. (June 2015): “as diet and nutrition are key components of primary, secondary, and tertiary prevention of many conditions managed by physical therapists, it is the role of the physical therapist to evaluate for and provide information on diet and nutritional issues to patient, clients, and the community within the scope of physical therapist practice. This includes appropriate referrals to nutrition and dietary medical professionals when the required advice and education lie outside the education level of the physical therapist’’
Fiber plays a huge role in so many of the health issues that we as clinicians face daily – constipation is regarded as a scourge of a modern sedentary society, perhaps over-reliant on processed convenience food – this is borne out when we gaze upon the rows of constipation remedies and laxatives in our pharmacies and supermarkets.
Let's take a look at the effects of fiber on breast cancer recovery – what does the research say?
There is growing interest and evidence to suggest that making different food choices can help control symptoms of breast cancer treatment and improve recovery markers – avoiding food with added sugar, hydrating well and focusing primarily on plant based food. Fiber is of course beneficial for bowel health, but may also have added benefits for heart health, managing insulin resistance, preventing excess weight gain and actually helping the body to excrete excess estrogen, which is often a driver for hormonally sensitive cancers. Fiber may be Insoluble (whole grains, vegetables) or Soluble (oats, rice, beans, fruit) but both are essential and variety is best.
In their paper ‘Diets and Hormonal levels in Post menopausal women with or without Breast Cancer’ Aubertin – Leheudre et al (2011) stated that ‘…Women eating a vegetarian diet may have lower breast cancer because of improved elimination of excess estrogen’, but even prior to that, in ‘Estrogen excretion patterns and plasma levels in vegetarian and omnivorous women.’ Golden et al (1982) concluded that ‘…that vegetarian women have an increased fecal output, which leads to increased fecal excretion of estrogen and a decreased plasma concentration of estrogen.’
Fiber may also be beneficial in the management of colorectal cancer, which is on the rise in younger women and men. A recent report by the World Cancer Research Fund International/American Institute for Cancer Research found that eating 90 grams of fiber-rich whole grains daily could lower colorectal cancer risk by 17 percent…and the side effects? A happier healthy digestive system, improved cardiovascular health and a lower risk of Type 2 Diabetes.
Your mother was right – eat your vegetables!
For more information on colorectal function and dysfunction, take Pelvic Floor Level 2A or for a deeper dive on the role of nutrition and pelvic health, why not take Megan Pribyl’s excellent course, Nutrition Perspectives for the Pelvic Rehab Therapist? Physical Therapy Treatment for the Breast Oncology Patient is also an excellent opportunity to learn about chemotherapy, radiation and pharmaceutical side effects of breast cancer treatment, as well as expected outcomes in order for the therapist to determine appropriate therapeutic parameters.
Estrogen excretion patterns and plasma levels in vegetarian and omnivorous women. Goldin BR, Adlercreutz H, Gorbach SL, Warram JH, Dwyer JT, Swenson L, Woods MN. N Engl J Med. 1982 Dec 16;307(25):1542-7.
Diets and hormonal levels in postmenopausal women with or without breast cancer. Aubertin-Leheudre M1, Hämäläinen E, Adlercreutz H. Nutr Cancer. 2011;63(4):514-24. doi: 10.1080/01635581.2011.538487.
There are moments when I pause and realize how far we’ve come in a short period of time, and then others when I’m acutely reminded how far we have yet to go. Our destination is an integrative health care system which addresses nourishment first and early versus last, not at all, or only when all else fails. My mission is to support the concept of nourishment first and early though sharing of “Nutrition Perspectives for the Pelvic Rehab Therapist” through the Herman & Wallace Pelvic Rehab Institute.
After each weekend I teach Nutrition Perspectives for the Pelvic Rehab Therapist, I feel affirmed that this class, this information is vital and at times life-changing for practicing clinicians. And every time I teach, participants share that they take away much more than they expected. It’s a course that makes accessible complex concepts to entry level participants while offering timely and cutting edge integrative instruction to the advanced clinician eager to incorporate this knowledge into their practice. Supportive literature is woven throughout the tapestry of the course.
After the most recent live course event, a participant shared with me a letter she received from a patient in 2016 who mentions the lack of nutritional attention during her cancer treatment. I want to share with you the essence of this letter:
“In October 2015, I was diagnosed with cancer. The following December I started treatments of radiation and chemotherapy. I really appreciate all the fine employees who helped me through care and treatments. Every clinician I came across, whether a doctor, nurse, phlebotomist, radiation and chemo teams, and my PT, were all exceptional in showing care, concern and knowledge.
However, one area I felt was lacking in was nutrition. I was frequently offered a standard hospital-issue protein drink. When offered, I explained that I would not take it due to it containing high fructose corn syrup (HFCS). I asked if they knew that HFCS was like putting and accelerant on a fire? I received a smile and a nod of head as to say they understood.
I was also offered soda pop to wash down bad tasting medicines/ liquids I was to take. I opted to just down the medication without chasing it as I didn’t want to exacerbate my condition. While taking chemotherapy, I was offered snacks containing HFCS and other non-nutritive so-called foods.
I was also offered limited entree choices, but there were plenty of pies, cakes, jellies, and other non-nutritive foods to choose from. All Items I would not consider for a cancer diet or even a healthy diet. I finally took a picture of the menu selection sheet as I thought no one would believe such a thing could happen.
I received excellent care throughout your system with the exception of nutrition . I would ask that you take a look at making menus with truly healthy options as well as giving patients options that do not contain ingredients that feed the cancer.”
While this letter addresses an inpatient issue at one regional health system, it correspondingly brings into focus the irony present in the vast majority of health care settings across the nation from inpatient to outpatient settings: there is a profound lack of clarity about what it means to be nourished, especially when we are at our most vulnerable.
I cannot claim “Nutrition Perspectives” will solve our nation-wide problem, however, I am certainly encouraging a movement towards a collective understanding of the imperative fact that food is medicine - powerful medicine - and we must as front-line practitioners harness what this understanding can offer. Pelvic rehab practitioners are uniquely positioned to process this information and begin immediately sharing it in clinical practice.
Like many providers, this same participant shared with me that upon receipt of this letter two years ago, she struggled to make progress with what and how to offer nutritional information - mainly because of the overwhelming nature of the subject, and also because of the conflicting and oftentimes confusing information traditionally shared with the public. After attending Nutrition Perspectives, she said “I cannot even begin to describe how much your course has met ALL my hopes for helping clients!….I had struggled to put something together and here it all is - so unbelievably grateful.”
And that’s what this course is all about - empowering you as you broaden your scope of knowledge in a way that teaches you not facts, but deep understanding. Once that foundational understanding is laid, this grass-roots effort will progress like putting an accelerant on the integrative movement. Soon we’ll see the inclusion of nourishment information as first-line practice, and the lives impacted in a positive way will continue to grow.
Please join me at the next opportunity to share in this live experience with other like-minded clinicians. Nutrition Perspectives for the Pelvic Rehab Therapist will be coming to Denver, CO September 15 & 16, 2018!
When it comes to discussing nutrition with our clients in pelvic rehab, it is normal to initially feel both uncertain and perhaps a bit overwhelmed at the prospect of delving into this topic. Yet we know that there must be links, some association between nutrition and the many chronic conditions we encounter. Gradually, over the last several years, a cornerstone of my practice with patients in pelvic rehabilitation has become providing nutritional guidance.
I was both humbled and immensely grateful when many of my colleagues and peers attended Nutrition Perspectives for the Pelvic Rehab Therapist (NPPR) in Kansas City last March. In the following months, our clinics underwent a significant change in the types of discussions occurring with our patients. By embracing concepts presented in NPPR, a continuous stream of patient stories developed about lives having been touched by this shift. For many, “one small change” made a very big difference or served as the catalyst to many more positive lifestyle changes. Simply placing a high priority on re-thinking health situations through the lens of nourishment has been a very important shift, one that can occur across the spectrum of pelvic rehab practitioners if we choose to answer the call to “do what’s necessary”.
Learning the essence of a topic outside our comfort zone is not easy, yet in present time is necessary for providers trying to grapple with how to wrap our professional minds around what we know in our hearts to be true: the effect of nourishment on health is profound. This brings to mind the resonating wisdom of Francis of Assisi:
“Start by doing what’s necessary, then do what’s possible;
and suddenly you are doing the impossible.”
At this crossroads in our health care system we know that nutrition matters. We must start by doing what’s necessary: acknowledging our role in helping patients along their path to a better life through less pain, ease of movement, normalization of function, and healing. With commitment to our patient’s well-being, we too must commit to investigating the realm of nutrition and rehabilitation. Next, we can strive to do what’s possible. NPPR can serve as a springboard for professionals ready to develop programs incorporating sound nourishment principles in relation to both specific conditions in pelvic rehab and general health and well-being. Finally, we may - in a few short years - realize that suddenly we are doing the impossible; integrating these vital principles as standard care in rehabilitation.
Please join us in White Plains, NY March 31-April 1, 2017 for Nutrition Perspectives for the Pelvic Rehab Therapist. Whether you are just beginning to integrate nutrition and its correlates to pelvic rehab or are already well on your way along this path, you will come away with both a strong understanding of how food affects function along with tools you can immediately begin sharing with the clients you serve.
Honestly, I have never noticed Curcumin on any of my patients’ lists of pharmaceuticals or supplements, but I will be certain to look for it now. Curcumin is the fat-soluble molecule that gives turmeric its yellow pigment, and it is best absorbed with the addition of black pepper extract. Patients often complain non-steroidal anti-inflammatory medicines (NSAIDs) tear apart their stomachs, so newer studies showing positive results with the use of an herb sound promising, even for pelvic health.
A 2015 study by Kim et al. researched the inhibitory effect of curcumin on benign prostatic hyperplasia induced by testosterone in a rat model. Benign prostatic hyperplasia (BPH) is common among men and has a negative impact on the urinary tract of older males. Steroid 5-alpha reductase converts testosterone into dihydrotestosterone (DHT), and this increases as men age and may have negative effects on the prostate gland. Because of the side effects of conventional drugs (like finasteride) to inhibit steroid 5-alpha reductase, the authors wanted to determine if curcumin could play a protective role in BPH. They divided 8 rats into 4 groups after removal of testicles: 1) normal, 2) BPH testosterone induced subcutaneously, 3) daily curcumin (50mg/kg orally), and 4) daily finasteride (1mg/kg orally). The group receiving curcumin had significantly lower prostate weight and volume than the testosterone induced BPH group, and curcumin decreased the expression of growth factors in prostate tissue. The authors conclude curcumin may be a useful herb in inhibiting the development of BPH with fewer side effects than conventional drugs.
In the urology realm, Cosentino et al.2016 explored the anti-inflammatory effects of a product called Killox®, a supplement with curcumin, resveratrol, N-acetylcysteine (NAC) and zinc. When benign prostatic hyperplasia (BPH) is not treated with drugs, a surgical intervention can be executed called a transurethral resection of the prostate (TURP); or, for bladder cancers, a transurethral resection of the bladder (TURB) can be performed. Either surgery generally requires administration of NSAIDs post-operatively for inflammation, urinary burning, or bladder spasms or to prevent later complications such as urethral stricture or sclerosis of the bladder neck. This open controlled trial involved Killox® tablet administration to 40 TURP patients twice a day for 20 days, to 10 TURB patients twice a day for 10 days and to 30 BPH patients who were not suited for surgical intervention once a day for 60 days. The control group received nothing for 1 week post-surgery, and 52.5% of TURP and 40% of TURB patients required NSAIDs to treat burning and inflammation the following 7 days. None of the Killox® treatment groups had post-operative or late complications except one, and none suffered epigastric pain like those using NSAIDs. The authors concluded Killox® had significant positive anti-inflammatory and analgesic effects on the patients and could be used as a safe alternative to NSAIDs by physicians.
Although “just” an herb, the use of curcumin should be supervised by a healthcare professional who understands proper dosage and any possible contraindications for a particular individual. The curcumin needs to be in a form that can be easily digested and used effectively by the body. Ultimately, it is exciting to learn about an alternative to gut-wrenching NSAIDs, making curcumin a noteworthy anti-inflammatory option for patients.
Nutrition plays an important part in patient wellness and rehabilitation. There are many reasons to consider diet when designing treatment regimens and you can learn all about them in Megan Pribyl's Nutrition Perspectives for the Pelvic Rehab Therapist course. Your next chance to take this course is March 31 - April 1, 2017 in White Plains, NY. Don't miss out!
Kim, S. K., Seok, H., Park, H. J., Jeon, H. S., Kang, S. W., Lee, B.-C., … Chung, J.-H. (2015). Inhibitory effect of curcumin on testosterone induced benign prostatic hyperplasia rat model. BMC Complementary and Alternative Medicine,15, 380. http://doi.org/10.1186/s12906-015-0825-y
Cosentino, V., Fratter, A., Cosentino M. (2016). Anti-inflammatory effects exerted by Killox®, an innovative formulation of food supplement with curcumin, in urology. Eur Rev Med Pharmacol Sci. 20: 7, 1390-1398. http://www.ncbi.nlm.nih.gov/pubmed/27097964#