NMT 150 - IBS & GERD Past Paper PDF

Putting it Together - Week 10 NMT 150 - IBS Dr. Ellen Wong, ND - Toronto Campus  Learning Objectives Discuss the treatment approach for chronic conditions...

Putting it Together - Week 10 NMT 150 - IBS Dr. Ellen Wong, ND - Toronto Campus  Learning Objectives Discuss the treatment approach for chronic conditions and weighing symptom management versus root cause treatment Practice using electronic resources to support design of management plan Practice creating a treatment plan that: Is comprehensive with evidence-informed rationale Meets requirements of informed consent Balances patient wants that may differ from doctor’s Incorporates dietary, lifestyle and natural health products (with rationale for selection) based on patient’s needs and lifestyle Picture: decorative, woman's hands typing on laptop Picture: decorative, various plants in leaf an powder form Therapeutic Order Considerations Small Group Discussion How might you interpret the therapeutic order in this case? Discuss in groups of 4-5: 15 minutes Therapeutic Order Considerations This conversation can be applied to almost all chronic conditions within the naturopathic world Will depend on the severity of patient presentation, patient lifestyle and their needs and wants Find balance between addressing underlying causes and managing symptoms Will require having honest conversations about the nature of chronic condition (IBS) May take a while to manage May take a while to figure out triggers Does patient have any upcoming situations where her fluctuations symptoms will cause stress Picture: decorative, woman holding paper faces, orange coloured one smiling, pink one indifferent, green one in discomfort Diagnosis Considerations Picture: decorative clear brain with multicoloured paint spraying out of the top Diagnosis Considerations IBS is a diagnosis of exclusion What conditions might you rule out? ROME IV criteria Hot Topic: Food sensitivity testing Why is it so controversial?  Picture: decorative, group of students talking at table with books and laptop Small Group Discussion How might you explain this to a patient in a way that is easy to digest AND respects that this is something the patient specifically wanted to do? Practice explaining to a patient in pairs: 10 minutes Picture: decorative, green pill and orange pill, cut open kiwi and orange Symptom Management Considerations Picture: decorative, group of young adults smiling at each other and talking Small Group Discussion Let’s pretend the patient says they 1st want to manage their symptoms Design a treatment plan using dietary, lifestyle and natural health products (with rationale for selection) based on patient’s needs and lifestyle Discuss in groups of 4-5: 20 minutes  Picture: decorative, various vegetables and fruit, nuts and seeds, meat and eggs Symptom Management - Dietary Low FODMAP diet PMID: 20659225, PMID: 28625832, PMID: 27725652, PMID: 29159993 What are some things that would be important to share with the patient when you remove foods from their diet? Side effects? Benefits to treatment? Pro: eliminates symptoms in a lot of patients, rapid response (2-6 weeks), the diet is the test, no fee, no waiting for results Cons: less effective in IBS-C, unlikely to maintain long- term, nutrient deficiencies, social isolation History of disordered eating? Picture: decorative, man with face on laptop and a large rock on his face to represent stress Symptom Management - Lifestyle Stress management What is the cause of stress? Co-management of anxiety and/or depression Side effects? Benefits to treatment? Picture: decorative, peppermint leaves Symptom Management - NHP Peppermint Oil - abdominal pain, “cramping”, QOL PMID: 26721531, PMID: 19507027, PMID: 17420159 Why is QOL important? “A majority of patients would give up 10–15 years of life expectancy for an instant cure for their condition” PMID: 11346322 One of the most common reasons for work or school absenteeism, second only to the common cold People with IBS miss 3-4 times as many workdays annually as the national average of 5 days Side effects? Benefits to treatment? Picture: decorative, spoon with various pills in it Symptom Management - NHP Bifidobacterium (or L.plantarum 299v or mixed strain probiotics) - reduction of symptoms - severity of pain, distension, dissatisfaction with BM, IBS interference in life Study issues: variability of strains and doses methodology industry based studies short-term magnitude of overall benefit in positive studies is modest Side effects? Benefits to treatment? Post-Abx IBS Picture: decorative, glasses on top of a notebook, and other table top decor (candle and plant) Chronic Management Considerations Picture: group of students gathered together at desk all looking at one laptop Small Group Discussion Design a treatment plan using dietary, lifestyle and natural health products (with rationale for selection) based on patient’s needs and lifestyle Discuss in groups of 4-5: 20 minutes  Picture: decorative, french fries, onion rings, ketchup, soda, cheeseburger with lettuce Chronic Management - Dietary Assuming we removed some food, how long do we do this for? When can we re-introduce it? Wheat products (30% reduction? PMID: 26096570) Dairy (lactase persistence - PMID: 30388735) Fried food Beans and legumes Caffeine: tea, coffee, and other caffeinated beverages Packaged and processed foods: chips, cookies, pretzels, and processed meats Artificial sweeteners and sugar alcohols, chocolate Alcohol Cruciferous vegetables: broccoli and cauliflower Garlic and onions Cultural & lifestyle considerations Sauerkraut - PMID: 30256365 reduction in the total IBS-SSS score Picture: decorative, wooden hand holding lit candle Chronic Management - Lifestyle Hypnotherapy - PMID: 24901382 CBT - PMID: 30971419 Meditation + CBT - PMID: 36362745 Decrease symptom severity and QOL Journalling - PMID: 33826992 deepest thoughts and feelings about their IBS - reduce self-rated pain and healthcare utilization Picture: decorative, Japanese zen garden with path of rocks Chronic Management - Lifestyle Management of anxiety and/or depression Anxious trait IBS responds better to CBT Stress management: identifying stress origin Cause disrupt gut flora the same way antibiotics can, just not the same immediate level Do not ignore stress management Do NOT ADD TO THEIR STRESS Hormonal influence? Stats Canada: Among women, IBS is most prevalent during menstruation years, most severe after ovulation & before menses Women with IBS are 3x more likely to receive a hysterectomy than women without IBS Picture: decorative, various jars and containers of supplements and powders Chronic Management - NHP Vitamin D - esp if low Vit D levels Psyllium fibre Consider iron deficiency - menstruating women, vegan / vegetarian, athletes Picture: decorative, garden with various coloured flowers, and trees, winding path and mountains in the distance Chronic Management - Other Acupuncture - results are heterogenous; frequent sessions needed, symptoms may return after cessation of treatment Exercise - r​​esults are heterogenous; may improve symptoms and QOL effect on mood related concerns Putting it Together - Week 11 NMT 150 - GERD Dr. Ellen Wong, ND - Toronto Campus  Learning Objectives Continue discussion of management of chronic conditions Practice discussing gut-brain connection to patients Practice using electronic resources to support design of management plan Practice creating a treatment plan that: Is comprehensive with evidence-informed rationale Meets requirements of informed consent Incorporates dietary, lifestyle and natural health products (with rationale for selection) based on patient’s needs and lifestyle Picture: decorative, woman's hands typing on laptop Picture: decorative, concept sketch of stomach, person with stethoscope in background Diagnostic Considerations Diagnostic Considerations GERD is mainly a symptom based diagnosis Most commonly due to inappropriate lower esophageal sphincter relaxation lack of compelling evidence that GERD is caused by H.pylori Commonly "test by treatment" of PPI Patients may have already tried OTC antacids Gastroscopy (and further investigations): absolute indications - heartburn with red-fags (bleeding, weight loss, dysphagia, vomiting, FHx of GI cancer) persistent symptoms after PPI trial for 4-8 weeks BID high-risk for Barrett's Esophagus - male, >50yoa, white, tobacco use, obese, long history of symptoms Picture: decorative, paper napkin with written "your gut feeling" Therapeutic Order Considerations Small Group Role Play Organize into groups of 4-5 Within your group, get into pairs (or group of 3) Scenario 1 - 15 minutes Scenario 2 - 15 minutes Picture: decorative, various vegetables, fruit, nuts, seeds, and chocolate Management Considerations  Picture: decorative, glass of alcohol with cigarette in ashtray Risk Factors >50yoa Smoking Frequent NSAID or aspirin use Obesity Low socioeconomic status Alcohol PMID: 28232473 Sleep deprivation can worsen symptoms (PMID: 31701607 - very small study) Picture: decorative, group of students in discussion Small Group Discussion Points of discussion: Dietary recommendation Lifestyle recommendation NHP recommendation "Are PPIs dangerous? I heard that it decreases my absorption of nutrients? Which ones? Should I take a supplement? Groups of 4-5 30 minutes Picture: decorative, examples of fried, fatty foods, chocolate and pastries Dietary Management Common Food Triggers EtOH Caffeine (including tea) Tobacco Fatty or fried foods Chocolate Mint Spicy foods / spices Citrus Tomato (ketchup) Low FODMAP diet similar (PMID: 34051134) Of note: removal of food triggers treats symptoms, not underlying cause Picture: decorative, dog lying on back on yellow sofa Lifestyle Management If living with obesity: weight loss If nocturnal symptoms: elevate head of bed Small meals Reduce / avoid late night meals / eating Avoid lying down soon after eating Picture: decorative, drawing of human outline with macaroni outlining connection between brain and stomach Lifestyle Management - Con't Gut-Brain Connection Regulation Communication between the CNS and ENS Links cognitive and emotional centers of brain to the digestive system Previously: CNS affects ENS; now - ENS affects CNS too Stress management - mindfulness, meditation CBT Hypnotherapy Picture: decorative, wooden ladle with various supplements NHP Management Melatonin (PMID: 20082715) very small study 3 mg qd before bed; 8 weeks Artichoke leaf (PMID: 14653829) GERD with functional dyspepsia Associated biliary concerns 640 mg tid; 6 weeks specific formulations DGL (Deglycyrrhizinated Licorice) lots of rat studies may be useful if GERD in addition to H.pylori (PMID: 27614124) and peptic ulcer disease (several very old studies) Picture: decorative, hand holding pill Let's Chat About PPIs TL;DR: nutrient deficiencies may occur if: long-term use of PPI; baseline / borderline deficiency (either because of diet or underlying health concern) Mostly observational studies B12: higher doses of PPI (>1 pill/day) for >2yrs Vitamin C: if also positive H. pylori Picture: decorative, hand holding pill Let's Chat About PPIs Calcium + Fracture risk: 2010 - FDA added "warning"; removed in 2011 risk may increase if higher dose of PPI or >1yr (or both) studies: renal failure patients on dialysis or severe hypochlorhydria Iron: decrease in hemoglobin, hematocrit and MCV PPI > 1 yr no recommendation for iron supplementation Picture: decorative, hand holding pill Let's Chat About PPIs Magnesium: PPI > 1 yr Severe hypomagnesemia - usually other underlying health conditions Other medications can decrease Mg as well subclinical insufficiency PRIMARY PREVENTION OF CVD NMT150 FORM TEAMS OF FIVE Create a shared version of document on Moodle for your team; this will be a reference for you … Assume you have done a reasonable assessment and feel confident that this is uncomplicated; nothing is immediately urgent; no makers of HTN or dysglycemia; no evidence of peripheral arterial disease, CHF; kidney function is fine, etc... Articulate therapeutic goals Most scenarios of sub-optimal body composition and metabolic sequelae are related to “lifestyle;” Find a review that outlines these factors, and create a concept map to illustrate them Any limitations/biases with this approach? The importance of healthy lifestyle behaviors in the prevention of cardiovascular disease Social Determinants of Cardiovascular Disease Rosenthal T, Touyz RM, Oparil S. Migrating Populations and Health: Risk Factors for Cardiovascular Disease and Metabolic Syndrome. Curr Hypertens Rep. 2022 Sep;24(9):325-340. doi: 10.1007/s11906-022- 01194-5. Epub 2022 Jun 15. PMID: 35704140; PMCID: PMC9198623. Münzel T, Hahad O, Sørensen M, Lelieveld J, Duerr GD, Nieuwenhuijsen M, Daiber A. Environmental risk factors and cardiovascular diseases: a comprehensive expert review. Cardiovasc Res. 2022 Nov 10;118(14):2880-2902. doi: 10.1093/cvr/cvab316. PMID: 34609502; PMCID: PMC9648835. Jacobsen AP, Khiew YC, Duffy E, O'Connell J, Brown E, Auwaerter PG, Blumenthal RS, Schwartz BS, McEvoy JW. Climate change and the prevention of cardiovascular disease. Am J Prev Cardiol. 2022 Sep 11;12:100391. doi: 10.1016/j.ajpc.2022.100391. PMID: 36164332; PMCID: PMC9508346. PREVENTION = MITIGATION Identify current best practices for primary prevention of cardiovascular events; what are the first line strategies recommended? Overlay these on your concept map https://www.sciencedirect.com/science/article/pii/S003306202100133X?via%3Dihub#f0005 Split into one of the five following areas Work with members of other teams to complete the tasks; document your findings … citations, full-text preferred, and summary of key findings, as well as interpretation/reflections: 1. Movement 2. Diet 3. Weight loss 4. Healthy psychology and lifestyle 5. Pharmaceuticals and natural health products (NHPs) TAKE A BREAK RECONNECT WITH YOUR ORIGINAL TEAM Share what you learned with your group members; practice explaining as though they were your patient. 2 min each (!) GEN ER AT E A N I N I T I A L P L A N F ROM A N I N FOR MED CON S EN T P ERS P EC T I VE When you have your plan, come write it on the board Yu E, Malik VS, Hu FB. Cardiovascular Disease Prevention by Diet Modification: JACC Health Promotion Series. J Am Coll Cardiol. 2018 Aug 21;72(8):914-926. doi: 10.1016/j.jacc.2018.02.085. PMID: 30115231; PMCID: PMC6100800. Riggs DW, Yeager RA, Bhatnagar A. Defining the Human Envirome: An Omics Approach for Assessing the Environmental Risk of Cardiovascular Disease. Circ Res. 2018 Apr 27;122(9):1259-1275. doi: 10.1161/CIRCRESAHA.117.311230. PMID: 29700071; PMCID: PMC6398443. Social Determinants of Cardiovascular Disease "15-minute city" work, school, entertainment, and other activities are reachable within a 15-min walk of the home involves the creation of a city of villages and a return to more traditional city design encourages more physical activity through active transport likely to reduce urban inequalities and health inequities will also reduce the need for long distance travel and thereby reduce CO2 emissions, and air pollution and noise levels Translation of French words: apprendre = to learn; travailler = to work; partager et réemployer = to share and reuse; s’approvisionner = to supply oneself; s’aérer = to get some fresh air; se cultiver, s’engager = to subdue, to be committed; se soigner = to nurse oneself; circuler = to be on the move; se dépenser = to wear oneself out; bien manger = to eat well; chez moi = at home. www.micaeldessin.com. If a patient is skeptical, or preferring passive management, how might you navigate this? Explain to your patient why active self-care is relevant. NATUROPATHIC THERAPEUTICS – PUTTING IT TOGETHER WEEK 13 AUTHOR: DR. ZEYNEP URAZ, ND LEARNING OBJECTIVES Active learning session to review, consider, and apply this week’s material Practice talking about sex with patients Review potential causes of sexual dysfunction and erectile dysfunction Collaborate with colleagues, and learn from each other’s perspectives Review considerations for a comprehensive Naturopathic treatment plan as relevant to this week’s case REVIEWING THIS WEEK’S CASE KEY FEATURES OF THE CASE History of cardiovascular disease risk (high cholesterol, family history) Chose not to take statins several years ago Has returned with some new risk factors for cardiovascular disease risk Has a new concern of erectile dysfunction TODAY’S FOCUS Manage hypertension and erectile dysfunction with lifestyle approaches using best evidence HYPERTENSION HYPERTENSION Primary vs secondary hypertension Target value depends on patient’s overall risk factors SEXUAL AND ERECTILE DYSFUNCTION TAKING A SEXUAL HISTORY ASK ABOUT SEX Taking a sexual health history Let’s practice: https://nationalcoalitionforsexualhealth.org/tools/for- healthcare-providers/asset/Sexual-Health-Questions-to- Ask-All-Patients.pdf Practice asking about “practices, pleasure and problems” TREATMENT GOALS? OBJECTIVELY ASSESSING OUTCOMES Hypertension – using correct in-office method Erectile dysfunction – using standardized, validated questionnaire International Index of Erectile Function https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/ii ef.pdf TREATMENT GOALS Taking the opportunity to discuss diet and lifestyle changes in the context of a patient-important outcome Reducing long-term risk of cardiovascular disease GOALS FOR GROUP WORK: Identify Treatment goals (for each condition) (2-4 goals total) Propose treatment plan with supported rationale for treatment (Look to the evidence!) (see resources slide) Type out the treatment plan as you would for a patient Role-play: Take a sexual history QUESTIONS TO ANSWER Does combining lifestyle and dietary recommendations (non- pharmacological interventions) with pharmacological interventions have an additive impact on blood pressure? What is the expected reduction in BP for each dietary/lifestyle intervention? Name two strategies to help with adherence to your recommended recommendations QUESTIONS TO ANSWER Which 2 clinical scenarios is the use of pharmacological treatment alongside pharmacologic treatment recommended? RESOURCES https://www.ahajournals.org/doi/10.1161/CIR.00000000 00000678 (see section 4.4 “Adults with Hypertension”) https://www.auanet.org/guidelines-and- quality/guidelines/erectile-dysfunction-(ed)- guideline#x8057 (see guideline statement 7) THANK YOU.