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New Treatment for Irritable Bowel Syndrome (IBS)

Doctors have finally shown that most cases of Irritable Bowel Syndrome are caused by an overgrowth of bacteria in the upper intestines (Digestive Diseases and Sciences, May 11, 2012;57(5):1321-1329). IBS affects more than 30 million North Americans. It is characterized by recurrent belly pain, bloating, gas, and diarrhea or constipation or both. Earlier studies showed that IBS can often be controlled by taking rifaximin, an antibiotic that is not absorbed into the bloodstream.

In this new study, researchers passed tubes down the esophagus and into the upper part of the small intestine (duodenum) to collect cultures for bacteria. They found large amounts of bacteria in the small intestines of the participants who had IBS. The IBS sufferers were far more likely to have diabetes and/or to take medication to shut off stomach acidity. Diabetes weakens your immunity to make you more susceptible to all types of infections, and the acid in your stomach helps protect you from intestinal infections.

THE NORMAL INTESTINAL TRACT: When you eat, food passes down your esophagus and into your stomach. Then it passes through more than 20 feet of small intestine and five feet of large intestine (colon). You absorb most of your food in your small intestine and a lesser amount in your large intestine.

THE SMALL INTESTINE: In your small intestine, food is broken down into carbohydrates, fats, and proteins. Then cells in your small intestine produce thousands of chemicals called enzymes that break down carbohydrates into sugars, proteins into amino acids, and fats into fatty acids. Of all carbohydrates, your small intestines allow only four simple sugars (glucose, fructose, galactose and mannose) to be absorbed into your bloodstream. Of all proteins, only single amino acids and chains of amino acids can be absorbed. Of all fats, only fatty acids are absorbed.

THE CAUSE OF GAS: Any carbohydrates that cannot be broken down into one of the four single sugars are not absorbed in the small intestine. Instead, they pass to your large intestine, where bacteria ferment them. Fermentation produces gas, which is normal. This fermentation is supposed to occur only in your large intestine.

BACTERIA IN YOUR INTESTINES: The large intestine is loaded with bacteria, but the rest of your gastrointestinal tract has relatively few bacteria. You are not supposed to have large amounts of bacteria in your small intestine. When a person has bacteria in the small intestine, unabsorbed carbohydrates are fermented there, producing significant amounts of gas. This causes cramping and burning because the gas stretches the small intestine. The gas can also push the intestinal contents rapidly toward your large intestine to cause diarrhea, and the carbohydrates fermented in your upper intestinal tract can clump together to make you constipated.

TREATMENT BASED ON THIS NEW UNDERSTANDING OF IBS:
• Avoid foods with added sugars, sugared drinks, and foods made from flour (bakery products and pastas) because these foods are the ones that are most easily fermented by bacteria to cause intestinal gas.
• Eat a high fiber diet. Your diet should be loaded with raw or lightly cooked vegetables, fruits, whole grains, beans, nuts and seeds. These foods contain many natural antibiotics to limit bacterial overgrowth in the small intestine. They also contain plenty of soluble fiber that is fermented primarily in the colon, and insoluble fiber that helps to prevent constipation.
• If you take medications to shut off stomach acid to treat belching and burning, check with your doctor to see if you can stop taking them. Stomach acid inhibits the growth of bacteria in the upper intestinal tract. Shutting off stomach acid encourages bacteria to grow in the small intestine.
• Ask your doctor if you would benefit from taking rifaximin 200mg three times daily for three days, then a maintenance dose of 200 mg daily for several weeks. Rifaximin is an antibiotic that is not absorbed into your bloodstream.
• Check for intestinal parasites. If you have them, your doctor may prescribe paromomycin 500mgs three times a day and/or doxycycline 100mgs twice a day for a week.
• Avoid other antibiotics, if possible, because they can change your normal intestinal bacteria.

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Salt Restriction Fails to Lower High Blood Pressure in Most People
This week, Gary Taubes wrote an article in the New York Times, stating correctly that there is no good evidence that restricting salt intake reduces high blood pressure significantly or prevents heart attacks (June 2, 2012). If you read my newsletters or listened to my radio show, you know that I have been saying this for more than thirty years. High blood pressure is best managed by eating large amounts of fruits and vegetables; losing excess weight; eating less saturated fat, particularly in red meat; and exercising every day.

Most doctors who believe that a low-salt diet lowers high blood pressure base their argument on the INTERSALT project, published in 1988, which showed that populations that have very high salt levels in their urine also had a high incidence of high blood pressure; and on the 2001 DASH-Sodium study, a 30-day trial of salt restriction (N Engl J Med, January 4, 2001, 201;344:3-10). The DASH study showed that eating significantly less salt can lower high blood pressure a little bit, but it did not show that salt restriction prevents heart attacks or strokes.

THE DATA: Research shows that restricting salt can lower high blood pressure slightly, but there is insufficient evidence that it prevents heart attacks, strokes or premature death (Cochrane Database of Systematic Reviews, Published Online October 5, 2011).

Excess salt intake can cause your body to retain excess water which can raise your blood pressure temporarily. However, middle-aged people who start an exercise program lose their tendency to develop high blood pressure when they take in extra salt (Journal of Human Hypertension, May 2006).

Researchers at Albert Einstein College of Medicine showed that people on low-salt diets are actually more likely to suffer heart attacks than those on high salt diets (Journal of General Internal Medicine, June 2008). They analyzed data from the Third National Health and Nutrition Examination Survey (NHANES III) of American adults. Dr. Hillel W. Cohen, lead author of the study, stated, "Our findings suggest that for the general adult population, higher sodium is very unlikely to be independently associated with higher risk of death from heart attacks."

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Salt Restriction Can Cause High Blood Pressure in Exercisers
Serious exercisers can be harmed by the broad recommendations for all people to restrict salt intake. If you do not exercise, you are not likely to sweat very much and you do not need very much salt. On the other hand, if you exercise vigorously, you sweat and lose a lot of salt. When you don't have enough salt, your adrenal glands put out large amounts of aldosterone, which constricts arteries and raises blood pressure; and your kidneys put out large amounts of renin that also constricts arteries and raises blood pressure (Clinical Autonomic Research, 2002;12(5):353-357). Furthermore, without the extra salt that you need, you will not recover from your hard bouts of exercise and you will be more likely to be injured or tired all the time.

SALT IS THE ONLY MINERAL YOU NEED DURING EXERCISE: Dr. James Gamble spent World War II studying the mineral needs of soldiers fighting the Japanese in the Pacific. He concluded that the only mineral soldiers and athletes need in large amounts is sodium, common table salt. They do not need extra potassium, magnesium, calcium or trace minerals. To this day, nobody has improved on his data and recommendations. His lectures on this topic were presented to Harvard Medical students right up to the time of his retirement in the 1960s {Gamble JL, Extracellular Fluid, A Lecture Syllabus, Harvard University Press. Cambridge, Massachusetts 1958}.

SYMPTOMS OF SALT DEFICIENCY: If you are a serious exerciser and you suddenly are not recovering from your workouts as fast as you usually do, a common cause is loss of salt. Symptoms of salt deficiency include muscle weakness, soreness and cramps, loss of strength and tiredness. Get a blood test for sodium on the day after a hard workout. If your blood sodium is below 132 mmol/L, you need more salt.

HOW SALT DEFICIENCY HAMPERS PERFORMANCE: Not taking in salt when you exercise for more than two hours can prevent you from retaining the water that you drink. It can also block thirst, so you may not know that you are dehydrated. Thirst is a late sign of dehydration. You lose water during exercise primarily through sweating, and sweat contains a far lower concentration of salt than blood. So during exercise, you lose more water than salt, causing the concentration of salt in the blood to rise. You will not feel thirsty until the concentration of salt in the blood rises high enough to trip off thirst osmoreceptors in your brain, and it takes a loss of two to four pints of fluid to do that.

SALT HELPS YOU RETAIN FLUID: You need to take salt to retain the fluid you drink while exercising. If you lose two pints of fluid, you can replace it with two pints of water if you also take salt, but if you don't take salt, it can take four pints of fluid to replace two pints of sweat because the water you drink will pass out through your kidneys. In one study, female competitive distance runners took in drinks with different concentration of salt during a four-hour run (British Journal of Sports Medicine, 2003;37(4). Ninety-two percent of those who took in plain water with no additional salt developed low blood levels of salt.

FITNESS DOES NOT REDUCE SALT LOSS: A study from Spain shows that being fit does not reduce the concentration of salt in sweat (European Journal of Applied Physiology, November 2011). A person who exercises in the heat can lose far more than 4000mg of salt. So in spite of the fact that most serious exercisers get a lot of salt from the large amounts of foods that they eat, they can still become salt deficient.

SALT BEFORE COMPETITION: Taking salt just before competition improves performance (Medicine and Science in Sports and Exercise, January 2007; Clinical Journal of Sport Medicine, January 2007). Athletes who took extra salt had larger blood volume and greater endurance. Salt makes you thirsty earlier so you drink more, and salt in your body holds water so you have more water available to meet your needs.

SALT FOR LONG ENDURANCE EVENTS: You can keep yourself fresh during extended exercise by eating foods with salt and drinking frequently, before you feel hungry or thirsty. Once you are weakened by loss of fluid or salt, it becomes very difficult to regain your strength. When an athlete competes in events lasting more than three hours, he or she should replace salt (sodium) at the rate of 700 mg/hour.

Commercial sports drinks help to increase endurance with their caffeine, sugar and salt content, and, to a lesser degree, protein (The Physician and Sportsmedicine, April 2010). Most sports drinks do not contain adequate amounts of salt for long-term exercise, because very salty drinks taste awful. When we cycle for more than three hours on very hot days, we eat salted potato chips and drink ordinary soda.

CASUAL EXERCISERS SELDOM SUFFER FROM SALT DEFICIENCY: The North American diet contains up to 10 times your minimal salt requirements. Salt is added to almost all prepared foods, so if you doubled or tripled your salt losses through sweating, you would still not be deficient because you are already taking in far more salt than you need.

HYPONATREMIA: Taking in large amounts of fluid without also taking in salt dilutes the bloodstream, so that the concentration of salt in the blood is lower than that in brain cells. This can cause fluid to move from the low-salt blood into the high-salt brain causing the brain to swell which can cause seizures and death.

More on hyponatremia

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Recipe of the Week:

Clementine-Quinoa Salad

You'll find lots of recipes and helpful tips in The Good Food Book
- it's FREE

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June 10th, 2012
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About the Author: Gabe Mirkin, MD

Sports medicine doctor, fitness guru and long-time radio host Gabe Mirkin, M.D., brings you news and tips for your healthful lifestyle. A practicing physician for more than 50 years and a radio talk show host for 25 years, Dr. Mirkin is a graduate of Harvard University and Baylor University College of Medicine. He is board-certified in four specialties: Sports Medicine, Allergy and Immunology, Pediatrics and Pediatric Immunology. The Dr. Mirkin Show, his call-in show on fitness and health, was syndicated in more than 120 cities. Read More
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