Author: Subhas Ganguli

General Patient Information

This page has general information for patients.

  1. Oral Iron Replacement.
  2. Information on other diseases
  3. Information on special diets
    1. Dumping syndrome diet
  4. Gastroparesis
  5. See also:
    1. Darnall Medical Library – gastroparesis, FODMAPS, IBS, gas/bloating
    2. Viral Hepatitis Page
    3. Mount Sinai – GI Disease Page
    4. Mayo Clinic – Diseases & Conditions
    5. NIH Health Information – Homepage, Medline Plus
  6. Information on Specific Tests
    1. 24 Hour Urine Collection (eg copper)

Treating Iron Deficiency

Iron deficiency is a common disorder and can have many causes.  Most patients are treated with oral iron because it is generally effective, readily available, inexpensive, and safe.  However side-effects (especially from the gut such as nausea, vomiting, discomfort, diarrhea, and constipation) are quite common (1) and are related to the dose of iron administered.

There are many iron formulations (see table) and there are a range of frequencies of reported side-effects.

It is generally not a good idea to use enteric-coated or sustained release capsules as the iron in them is released too far down the gastrointestinal tract to be well absorbed.  There is some evidence that taking iron every other day may result in better absorption.

Elemental iron will make your bowel movements dark or black so don’t worry if that happens.  Some pharmacies keep their iron behind the counter, so ask if you don’t see it on the shelves.

Suggested Approach to Taking Oral Iron (1,2):

  1. Start with 1-3 pills per day of ferrous sulfate/gluconate/fumarate (as recommended by your doctor).  
    1. Do not take with food which decreases absorption
    2. Do not take with calcium supplements or milk, dietary fiber, tea, coffee, or eggs which decrease absorption.
    3. Do not take with antacids (you can take them two hours before or four hours after antacids).
    4. Iron is best taken along with vitamin C which increases absorption.  You can do this by taking your iron with a half glass or orange juice or with 250 mg of ascorbic acid (vitamin C).
  2. If you have side-effects try the following:
    1. Lower the dose (ie number of pills per day)
    2. Take your pills every other day
    3. Make dietary modifications (take iron with food or milk – while this decreases absorption, at least you will be getting some iron intake).
    4. Switch from a tablet to a liquid which will allow you to start with a lower dose which can be gradually increased (eg ferrous sulfate).  Some doctors recommend washing your mouth with water after a dose to avoid potential staining of tooth enamel.
  3. In a large review (1), the best-tolerated form of inorganic iron was iron protein succinylate – the only formulation of this that I was able to find is called ‘Iron Protein Plus’ from Life Extension.  You can get it by mail-order from the USA (here) or from a Canadian supplier (here) 
  4. If you can’t tolerate the above formulations some of my patients have found less side-effects with the following (often available at health food shops):
    1. Heme iron (an organic form of iron) – multiple brands including Proferrin (available on Amazon.ca) 
    2. Vegetarian liquid ferrous gluconate by Salis (eg Floravit, Floradex)
    3. Organic plant-derived iron (Pranin Iron) – see Amazon.ca

For patients who fail the above approach (this has to be documented in the chart), intravenous iron therapy MAY be an option. However this is expensive and not covered in Ontario unless the following conditions are met:

  1. You are younger that 25 OR older than 65
  2. If you are between the ages of 25 to 65 you MAY get coverage IF YOU ARE ALREADY ENROLLED IN THE TRILLUM DRUG BENEFIT PROGRAM. To learn more about the program and apply for coverage, see here.

References

  1. Tolerability of different oral iron supplements:a systematic review. MJ Cancelo-Hidalgo et al. Curr Medical Research & Opinion 2013:29(4):291-303.
  2. Treatment of Iron Deficiency in Adults M Auerbach UpToDate 3/2020

Liver Patient Referrals

This page describes the process for referring liver patients with NASH (fatty liver) for a nutrition optimisation consultation with Dr Ganguli.

  1. Please explain to patient that consultation is to assist them in making changes in their diet (to a plant-based diet) to help with their liver disease.
  2. Please give information sheet to patient and explain that after reviewing the information on the sheet they need to call the number on the sheet so that an appointment can be booked for them to be seen.
  3. Please send Dr Ganguli a consultation request via Oscar (ie brief [1 line] note asking me to see the patient)
  4. Please send a tickler to ‘Ganguli, Subhas’ so that I am aware
  5. My staff will then make sure the patient has all the info they need etc.

ACLM 2019 Exam

This page is for those preparing for the 2019 American College of Lifestyle Medicine exam in October 2019.

I have had a chance to chat with Dasha (ACLM education person) & Dr Herzog (head of ABLM) – both made it pretty clear that the Board Review book is key in preparing for the exams. My thought was that a very good way to work together would be to divide the Board Review Book into sections among us and make questions to test our knowledge on each section (which we would all have access to).  Please order this book ASAP as it take 2 weeks to ship.

Please note that a new version of this came out in March 2019 & that it takes 2 weeks to ship.

Having looked at some of the ways available to make questions that we could all access, one of the better platforms is Brainscape.com  (1 min overview video here). with an overview of this resource in the comments below.  While there are alternatives, I don’t think they will work because they won’t let us share and update our questions (see here).  See this link on how to add cards. I will set up the decks and give each person access to them so that they can add cards for their assigned section of the Board Review Course.

The best way to reach me is via Facebook messenger or Email (subhasganguli@gmail.com).

Crohns and Ulcerative Colitis

Here is a 20 minute talk by a British gastroenterologist about the role of diet in Crohn’s disease:

Below are some useful links to learn more about your disease:

  1. Crohn’s & Colitis Foundation of Canada
  2. Crohn’s & Colitis Foundation of America
  3. Mayo Clinic IBD Information
  4. Database to look up information about drugs here.

Click here to learn about medications commonly used in Crohn’s and ulcerative colitis and their side-effects.

While the role of diet in Crohn’s & Ulcerative Colitis is currently unclear, it is POSSIBLE that avoidance of emulsifiers and highly processed carbohydrates such as maltodextrin could be helpful in preventing disease.  However until further studies are done, clear recommendations for patients cannot be made. Here is an excellent article about the probable role of processed foods in IBD and how to avoid them.

Here is an excellent article about food additives which may make our gut leaky. Also see the following videos:

  1. Preventing Crohn’s Disease with Diet (6 min)
  2. Are Emulsifiers like Carboxymethylcellulose and Polysorbate 80 safe ? (5 min)
  3. Ultra-Processed Junk Food Put to the Test (8 min)

Medications used in Crohn’s and Ulcerative Colitis

Below is a list of medications commonly used for Crohn’s and ulcerative colitis with information on their side-effects:

5 ASA (mesalamine, Asacol, Pentasa, Salofalk)

Side-effects: 5 % worsening of colitis, renal failure (< 1/1000)

Metronidazole (Flagyl)

Side-effects: vomiting if take alcohol, nausea, altered taste, dark urine.  Chronic use may result in peripheral neuropathy (permanent)

Prednisone  (steroids)

Side-effects:Risks of longterm use include osteoporosis, cataracts, avascular necrosis (< 1 in 10,000 but may need hip or knee replacement).  Click here to use FRAX – a tool developed by the World Health Organisation to predict your 10 year risk of a bone fracture.

Azathioprine (Imuran), 6 mercaptopurine

Side-effects: Pancreatitis (3-5%, rarely fatal), liver test abnormalities, lymphoma (1:1000), ongoing risk of bone marrow suppression (if you have a fever for more than 6 hours, do NOT take another pill until your blood count is checked).

A recent publication also looked at the risk of non-melanoma skin cancer in patients treated with azathioprine in 14,527 patients with a follow-up of 8.1 years (median).  There was an overall twofold increased risk in developing non-melanoma skin cancer which increased with duration of use.  The rate (per 1000 person-years) was 3.7 for non-users versus 5.8, 7.9, 8.3, 7.8, and 13.6 for the 1st, 2nd, 3rd, 4th, and 5th year of thiopurine use.  Implications of this include the use of sun-protection and consideration of regular (? annual) review by a dermatologist. Another publication confirmed that the risk was 1.85 times baseline (P<0.05).

A prospective cohort study of 19,486 French patients followed for a median of 35 months showed a significantly increased hazard ratio of developing lymphoma of 5.28 (P<0.01).  The rate of lymphoma per 1000 patient years was 0.26 in those who had never received the drug and 0.90 in those who had.  Thus the increased risk was 0.64 per 1000 patient years.  In other words if a person took the drug for 50 years, there would be a 1 in 31 risk of getting lymphoma.

Cyclic Vomiting Patient Tips for Travelling

  1. Be prepared. The more you can feel prepared for the travel, the eventuality of an episode and what to do if you have one, the less anxiety you have about it. Anxiety is not our friend. Prepare for what you can. Feel good knowing you are prepared. Lessen your anxiety knowing you’re ready for anything.
  2. Motion sickness aids. A good number of CVS sufferers also struggle with motion sickness. It can be a trigger for some. See 1f a motion sickness aid would be beneficial.
  3. Seabands. You can get these at almost any pharmacy and they fall under the category of motion sickness aid, but are also good for nausea. These can be also be used with the other motions sickness aids when you do theme parks!
  4. Temperature control. Some sufferers do not do well in the heat. Use the cooling towels to keep coot when you have to be out in the heat. Others are the opposite. They need heat. So pack a heating pad or one use hot packs for relief.
  5. Salty snacks. With motion sickness comes nausea. Pack the salty snacks and keep the nausea at bay.
  6. Peppermint. Pack the peppermint. Peppermint gum, peppermint chapstick, chase away the nausea without anyone knowing that you are struggling. Ginger is helpful as well.
  7. Vomit bags. Buy the ones on Amazon that absorb the liquid. This makes for discreet disposal later. Some travel with Zlplocs just in case.
  8. Be prepared for possible ER or admission. Check for possible hospital affiliations ahead of time and see If you will need to take your medical records or just a letter from your Doctor for treatment options should you require care.
  9. Rest. Fatigue is a common struggle and during travel can be more of a concern than you may be used to. Plan to take more frequent breaks and rest when you need to.
  10. Make sure you are keeping an eye on your triggers We know it’s vacation, but food triggers and sleep or chemical triggers can sneak up on you.

Adapted from CVSA Code Summer 2017 Newsletter