The brain-gut connection

By Cathy Gulli - Thursday, November 6, 2008 at 12:00 AM - 10 Comments

In the coming year, a team of researchers from Canada and the U.S. will begin a study to determine the best way to treat the worst gut problems, including severe diarrhea, gas, bloating, nausea and “chronic constipation where you have excruciating cramps [that feel] like labour pain,” says Brenda Toner, a psychologist and co-head of social equity and health research at the Centre for Mental Health and Addiction, who is leading the investigation. But they won’t be looking at antacids, laxatives or enemas. The most effective remedies may be ones normally prescribed for mental illness: antidepressants or talk therapy, or both. “What I’ve been trying to do is put the mind and the body back together,” says Toner, who heads the women’s mental health department at the University of Toronto.

This surprising study is the latest research acknowledging the connection between anxiety or depression and gastrointestinal problems. “Most of us, when we’re under stress, respond with a GI symptom,” says Toner, up to 70 per cent of people, in fact. Think about how sick to your stomach you felt before that big meeting or when you were worried about someone you love. Gut discomfort is one of the biggest reasons people miss school or work, second only to the common cold. And for people whose pain is persistent, which is typical because many GI disorders are chronic, the psychological impact can be devastating. “The brain-gut interaction is a prominent one,” says Nicholas Diamant, a gastroenterologist and professor of medicine at the University of Toronto, who is working with Toner on the study. “There are a lot of things about gut symptoms that impact patients in a mental way,” he explains, which “will not only affect their mood but also their behaviours—whether they go to work or out to socialize.”

The physical pain is real and dogged. “On bad days it feels, literally, like somebody has taken a knife and stabbed it in my lower left side and is dragging it across my stomach,” says Jeffrey Roberts, 47, who has suffered from irritable bowel syndrome since he was a teenager. The symptoms fluctuate between diarrhea, constipation, nausea and cramps. Roberts, who lives in Toronto, is also lactose intolerant and was diagnosed with Crohn’s disease on his 40th birthday. The gut discomfort has forced him to reschedule a family trip to Disney World and cancel an Italian romantic getaway with his wife.

One of the most famous victim of eviscerating GI pain was Kurt Cobain, who hauntingly foreshadowed his own death when describing how gut symptoms sent him into a downward spiral: “It had been building up for so many years that I was suicidal. You know, waking up starving, forcing myself to eat, barfing it back up . . . just crying at times, ‘Urgh, I’m in pain all the time.’ ”

On top of the physical distress, Roberts says he and others like him suffer mental and emotional symptoms. (Cobain’s proof.) Anxiety and depression begin to creep in. “You worry that people see you as a hypochondriac,” he says, “as if it’s all in my head.” Some sufferers feel hopeless, which is a common reaction to chronic pain. Even the practical aspects of living with a major gut problem—always needing to know there’s a bathroom nearby, for example—can wear people down. ‘‘I don’t know anything that is more distressing for a patient,” says Diamant, a senior scientist at Toronto Western Research Institute, “than to fill their pants full of poop at the grocery store.”

The body, of course, reacts to stress in all kinds of ways. The cardiac system may respond with a hastened heartbeat; the vascular and nervous systems may cause a migraine headache. “But the gut seems to be the one [system] that’s more sensitive,” says William Paterson, a neurogastroenterologist and research chair at Queen’s University in Kingston, Ont. The gut includes everything from the salivary glands, the pharynx and esophagus to the stomach, intestines and anus, plus organs like the liver and pancreas. It’s huge and complex. “There are more nerves in the wall of the gut than there are in the spinal cord,” says Paterson, past president of the Canadian Association of Gastroenterology. It’s so responsive that scientists often refer to the gut as the “little” or “second” brain.

Feeling the burn

By Nancy Macdonald - Thursday, November 6, 2008 at 12:00 AM - 5 Comments

When Cooper Olsen was four weeks old, he started to projectile vomit. Soon, he was crying through every feeding: “He’d arch his back, throw his head back and scream,” says his mom, Julie, who lives in the affluent L.A. bedroom community of Valencia. “Then he’d gulp from the bottle and cry.” It went on like this—gulp, scream, gulp, scream, gulp, scream—“over and over again,” says Julie, who works in the L.A. office of a New York-based consulting firm. After one horrible night, “over three hours of constant, bone-chilling screaming,” she and her husband, Bob, a pilot with a large U.S. airline, took Cooper to the hospital; by then, he’d stopped gaining weight. There, a doctor diagnosed him with gastroesophageal reflux disease, commonly known as “GERD.” Since he started taking Prevacid, Cooper’s become a different baby.

Yes, chronic reflux, that almost quintessentially Auntie May disease, is now hitting North Americans at every age. Indeed, the uptick of diagnoses in kids and babies is “really scary,” says Seattle physician Tom Vaughan, an expert on acid reflux and professor at the University of Washington. Two decades ago, it was almost unheard of. Now the use of proton pump inhibitors (PPIs), the strongest acid-blocking drugs, for infants like Cooper—who might once have been dismissed as “colicky”—has soared by 750 per cent in the U.S. in the past decade; a range of reflux drugs have been approved for use in kids under age 11. This year, a lime-flavoured, “kid’s-strength” version of the GERD prescription drug Nexium will hit the market. “More and more kids are being treated with PPIs and getting anti-reflux surgery,” says Dr. Douglas Corley of Kaiser Permanente Hospital in Oakland, Calif. “And no one has any idea what the long-term effects are.”

Unfortunately, ignoring the symptoms—which for kids can include coughing and tummy aches—has its perils too, notes Gail Attara, executive director of the Canadian Society of Intestinal Research. Six years ago, at age nine, her son was diagnosed with acid reflux. “He didn’t feel the effects of reflux,” says Attara—“or he wasn’t expressing it.” She took him to the doctor because she couldn’t figure out why he had such terrible breath: “He’d never had a cavity. He ate well, and was healthy in every other way. Somehow, his esophageal sphincter was open,” she explains, “and it was letting [stomach acids and] those odours up.” After being on acid suppressant medication for one day, she says, his breath was “as sweet as when he was a baby.”

The numbers among children mirror a wider trend; researchers say GERD, which only appeared in medical literature in the 1930s, may be on its way to becoming the epidemic of our times. Almost everyone has heartburn now and again, often after pigging out at Thanksgiving or Christmas. But chronic reflux—caused when digestive acids routinely splash the upper chest or throat—affects close to six million Canadians at a cost of $670 million to the health care system every year. Drugs to combat it are among the most-prescribed pills in North America, neck and neck with those used to treat high blood pressure, cholesterol and asthma. And the incidence of reflux is increasing by five per cent a year, according to a 2007 study in the journal Clinical Gastroenterology and Hepatology. The rest of the world, meanwhile, is following our lead: Europe is roughly 10 years behind North America in the incidence of GERD; Asia is 10 years behind them, says Dr. Ernst Kuipers, chair of the department of gastroenterology at Erasmus University in the Netherlands. “It’s the downside of development,” says Kuipers.

One issue that researchers, led by microbiologist Martin Blaser of New York University, have narrowed in on is the eradication of Helicobacter pylori, a once-common bacteria known to cause ulcers and stomach cancers. It turns out H. pylori—which has been virtually eliminated from industrialized countries—may have been protecting the body from GERD; it did this by slowing or decreasing the production of acid, particularly with age, says Kuipers. “As rates of H. pylori go down, GERD rates go up,” he says. “We think that relationship is causal.”

Gut wrenching

By Kate Lunau - Thursday, November 6, 2008 at 12:00 AM - 3 Comments

There’s nothing wrong with being polite. Saying “please” and “thank you,” using the turning signal, holding the door for a stranger—these are all good things. There’s such a thing, though, as being too polite, especially where our health’s concerned. Even in the doctor’s office, many Canadians are reluctant to talk about their “gas, diarrhea or bloating,” says Dr. Richard Fedorak, president of the Canadian Digestive Health Foundation. “You don’t go out for dinner and discuss that with your guests. It’s fine to discuss your high blood pressure or your diabetes, but you don’t discuss your gas.”

We might hesitate before airing our stomach problems in public, but they’re more common—and sometimes more serious—than most people think. Earlier this year, Scienta Health, a medical clinic in Toronto that specializes in preventative care, provided Maclean’s readers with its Q-GAP test, an online quiz developed by Scienta with 75 questions on topics ranging from sleep patterns to sex drive, to help people note symptoms that could point to underlying health problems. (The Q-GAP test is now available again at macleans.ca/howhealthy.) Over 14,000 people completed the test anonymously. Of all the symptoms identified, indigestion, heartburn, acid reflux, bloating and passing gas were among the most prevalent (of nine categories used in the test, gastrointestinal symptoms were second only to emotional health concerns among both men and women).

People tend to assume these problems are just part of the aging process, or maybe the result of last night’s spicy meal. But that’s a mistake, says Dr. Elaine Chin, co-founder and chief medical officer at Scienta Health. “Your gastric system is your input. It’s the first line of bringing nutrients into your body,” which is critical to the immune system, she says. “When the conveyor belt is screwed up, that’s where other problems start.” It’s not just a quality of life issue. An upset stomach can be a red flag for anything from poor diet to a heart attack. “We just ignore it, because we think we can’t do anything about it,” Chin says. That approach could be doing more harm than good. Continue…

Eradicating a bad bacteria

By Kate Lunau - Thursday, October 9, 2008 at 12:00 AM - 0 Comments

The town motto of Aklavik, an Arctic hamlet huddled at the Mackenzie River Delta in the Northwest Territories, is “Never Say Die.” So when the close-knit community of 600 noticed an alarming trend—a high number of people were getting sick with stomach cancer—they decided to act. “In the past, we hardly ever buried anyone except elders. The graveyard wasn’t touched for so long,” says child-care worker Annie Buckle, 54. Now, “there’s a new gravesite. You’d be surprised by the dates [on the headstones].” Buckle says she lost her mother to stomach cancer last year.

The culprit, residents believed, was a common bacteria: Helicobacter pylori. The spiral-shaped bug, which lives in the human stomach or intestine, is a major cause of gastric cancer and peptic ulcer disease. (Gastric cancer is the second most common cancer among Inuit men, but ranks 10th overall for Canadian men.) So, the community invited a medical team from Edmonton and Yellowknife to investigate. In February, 27 doctors, nurses and researchers descended on Aklavik, surveying 314 people and endoscoping 193. Among 255 people given a breath test for H. pylori, 57 per cent came back positive. Buckle was one of them: she took a preventative 10-day course of antibiotics to rid herself of the bug. All who tested positive, symptomatic or not, will be offered treatment.

Humans have lived with H. pylori for over 50,000 years. Now, across the developed world, it’s rapidly going extinct. A century ago, it’s thought that nearly everyone had it in their stomachs; today, thanks to clean water, better hygiene and antibiotics, just five per cent of people born in the 1990s do, according to one U.S. study. (The bacteria, which is transmitted orally or fecally, is more prevalent in rural and developing areas.) The bene?ts of eradicating H. pylori have been great. “Ulcer disease is going away; stomach cancer is going away,” says Dr. Martin Blaser, chair of the Department of Medicine at the New York University School of Medicine, whose work was instrumental in linking H. pylori to gastric cancer. But as those ailments disappear, “new diseases are rising,” he adds.

And the loss of H. pylori could be partly to blame. A growing body of research suggests the bug might not just cause ulcers and cancer—it could actually prevent some diseases, too. As H. pylori is wiped out, a host of health problems are on the rise: more than half of the population in Canada is now overweight or obese. Over 15 per cent of kids aged four to 11 suffer from childhood asthma. Six million Canadians have gastroesophageal reflux disease (better known as GERD), when stomach contents splash up into the esophagus. Could the much-maligned bacteria actually protect against these conditions? Blaser believes it might. “If the world is more complicated than what was originally proposed, then so be it,” he says. “The question is, what’s the truth?”