Author: Subhas Ganguli

As a group of concerned physicians and healthcare workers, we have watched with increasing frustration as our healthcare system is overloaded with diseases such as obesity (which has quadrupled since 1990) [l ], diabetes, and coronary heart disease which are the result of an unhealthy diet and lifestyle.

Our profession is poorly equipped to address these factors and it is essential that government get involved by advocating a healthy diet and lifestyle since this has been shown to be highly effective in decreasing the incidence and reversing these diseases. This was clearly shown in Finland which was able to reduce their rates of mortality from cardiovascular disease by 80% as well as their overall mortality by 62% and their cancer mortality rate by 65% with public health interventions [n ].

The next set of Canadian dietary guideline need to be based on the best scientific data and evidence-based data for change. This is the only way to reduce our growing burden of chronic disease with its associated suffering and healthcare costs.

The following points are clearly based on the peer-reviewed scientific literature and are endorsed by us as health care professionals:

The Canadian Dietary Guidelines should:

1. Strongly support the role of a plant-based diet as the best option for obesity and diabetes prevention/treatment since studies show:
   1. A plant-based diet is better than the American Diabetes Association diet in a 74 week randomised controlled trial [c ]. These results were confirmed in multiple other studies [d].
   2. In a large prospective cohort study (e), high animal protein intake was associated with a 49% higher rate of type 2 diabetes; conversely, a high plant protein intake was associated with a 9% lower rate of diabetes.
   3. A meta-analysis of 7 studies (124,706 participants) from around the world showed statistically significant reductions in ischemic heart disease mortality (29%) and cancer incidence (18%) and non-significant reductions in all cause mortality (9%), circulatory disease mortality (16%), and cerebrovascular disease mortality (12%)[f].
2. Strongly support the role of a plant-based diet as the best option for cardiovascular disease prevention and treatment since studies show:
   1. A randomised controlled study showed the angiographic reversal of coronary artery disease with a low fat plant-based diet [h, i].
   2. A plant-based diet improves multiple cardiovascular risk factors [g].
   3. The DASH diet which is high in fruits and vegetables is highly effective in treating hypertension [ ]
   4. There is a clear and significant dose-response relationship between intake of fruits and vegetables and mortality from coronary heart disease (16% reduction), stroke (8% reduction), and cancer (10% reduction). Similar associations were observed for fruits and vegetables separately. Dose-related reductions in risk were observed in all outcomes up to 600 g/day [j].
   5. Separate studies have shown that approximately 45% of cardio-metabolic deaths are due to deficiencies in diet including high sodium, high processed and red meats, high sugar-sweetened beverages, and low in fruits and vegetables [k]
   6. Real world data shows that a plant-based diet is effective in reducing multiple cardiac risk factors
3. Advise lower saturated fat intake as cited in the recent American Heart Association Presidential Advisory on Dietary Fats and Cardiovascular Disease [a ]
4. Encourage a shift to a diet which is lower in fat and refined carbohydrates and sugars since:
   1. A plant-based low fat diet is the ONLY diet which has been shown to reverse coronary artery disease in the majority of patients [ ] on angiography in randomised controlled trials [b ].
   2. A single high fat meal impairs vascular endothelial function while this is not the case with a low fat meal [k]
   3. Substituting fat with processed carbohydrates and sugars does not decrease heart disease [b]
   4. High sugar-sweetened beverage intake is a major cause of cardiometabolic and diabetic mortality [m]
5. Advise the avoidance of processed and ultra-processed foods since
   1. Added sugar intake is strongly associated with cardiovascular mortality [p]
   2. The intake of processed and ultra-processed foods is clearly and strongly linked to energy intake from added sugars (o).

Thank you for your consideration of this submission. We sincerely hope that Canada takes this opportunity to develop a food guide which will best serve the health of our country and serve as a leader throughout the world.

Signed,

Here are some questions which you might want to consider as you try and decide which specialty you would like to end up in:

1. Amount of patient contact
   1. Low: anesthesia, pathology
   2. High: family medicine, psychiatry
2. Patient outcomes
   1. Get better: pediatrics, infectious disease
   2. Don’t: oncology, surgery (depends on area)
3. Salary
   1. I’d suggest you don’t worry too much about this – ‘enough’ depends on your lifestyle which is under your control.
4. Lifestyle
   1. Call – intensity, frequency (note that a group practice can minimise this)
   2. Oupatient vs hospital service
5. Variety of patients
   1. Geriatrics – all old
   2. General internal medicine – more varied
6. Length of training required
   1. I’d suggest you not worry too much about this – more important that you end up happy
7. Balance of thinking vs doing (ie ‘hands on’)
   1. Thinking: Internal medicine, psychiatry, neurology
   2. Doing – procedural: surgery, urology, anesthesia
8. Where you want to end up practicing
   1. Eg urban vs rural
   2. This can be VERY cyclical – eg GI is good now, but was lousy 5 yrs ago.
   3. General Internal medicine is currently in GREAT demand – you can write your ticket & be in any city right now.
9. Importance of Dr-Pt relationship in outcome
   1. High: Family medicine, internal medicine, psychiatry, oncology
   2. Low: Surgery, anesthesia.

Please review this information thoroughly – these are the key questions to ask for each of the following presentations:

Dysphagia

1. 1. Transfer dysphagia is characterized by coughing, choking, or nasal regurgitation. If present ask about cranial nerve symptoms.
   2. Esophageal dysphagia is characterized by sticking further down. The patient often perceives food as sticking higher up than it actually does.
   3. Onset, frequency, intermittent vs progressive
   4. Solids, liquids, both
   5. What happens when food sticks ? Does it pass with repeated swallows ? Do they need to drink water ? Special maneuvers (eg lift arms up). What proportion of the time do they bring it up ?
   6. Have they had to modify their diet ? (Solids & liquids vs mechanincal soft vs liquid)
   7. Zenkers: lump in neck, gurgling sound
   8. Other: weight loss, GERD symptoms (current or past), odynophagia (pain with swallowing), globus (feeling of a constant lump in the throat)

Heartburn/GERD

1. 1. Symptoms
      1. Heartburn – retrosternal burning
      2. Reflux – bitter taste at back of mouth
      3. Other – waterbrash (rare) – fits of oral secretion +/- triggered by reflux
   2. Onset, frequency, progression
   3. Timing: time of day, relation to meals, duration, evening, does it wake the pt.
   4. Treatments: drugs, doses, duration, response
   5. Risk factors: nicotine, caffeine, smoking, chocolate, peppermint, alcohol
   6. Systemic diseases: diabetes, scleroderma, other connective tissue disease, Raynaud’s
   7. Extra-esophageal manifestations: cough, hoarseness, sore-throat, dental erosions, globus, pneumonia

Nausea/Vomiting

1. 1. Onset, frequency, progression, viral illness
   2. Timing: time of day, relation to meals, stress, etc
   3. Characteristics:
      1. food vs gastric secretions/bile
      2. have they clearly seen food from the day before
      3. blood (hematesis
   4. SBO symptoms: acute onset, associated pain, stop passing gas. Suddenly resolves +/- ‘diarrhea’
   5. Complications: lightheaded, hospitalizations, weight loss, proportion of food kept down
   6. Treatments & response
   7. Systemic diseases: diabetes, scleroderma, other connective tissue disease, Raynaud’s
   8. Associated symptoms: diarrhea, headaches, cranial nerve
   9. Need to differentiate from regurgitation which is the non-forceful bringing up of recently ingested food.

Abdominal Pain

P – provocation – meals, movement, bowel movements
P – palliations – treatments & response
Q – quality – dull/sharp, steady/crampy
R – radiation (where does it go to)
S – severity – scale of 1 to 10, effect on their function
T – timing – frequency, duration, course & progression
Associated symptoms: vomiting, passing gas pr etc

Constipation

1. 1. Onset, progression, frequency of BMs (‘anything coming out’)
   2. Character – change in form, scyballous (like pellets)
   3. Straining, digital disimpaction, incontinence, ER visits
   4. Obstructive (strain with no response) vs inertia (don’t get the urge to go)
   5. Associations: blood, melena, pain (? Relieved by BM), nausea/vomiting, weight loss, abuse (physical, sexual, emotional), Raynaud’s
   6. Diet (fiber), fluid, exercise
   7. Treatments & response

Diarrhea & Inflammatory Bowel Disease (Crohn’s & Ulcerative Colitis)

1. 1. Onset, course, progression
   2. BMs: frequency (day/night), consistency, blood (trace, 25%, 50% etc), cramps, tenesmus (feel they need to go, but nothing comes out)
   3. Treatments & response (note dose & duration)
   4. Extra-intestinal manifestations of IBD : painful red eyes, arthritis, low back pain, ulcers (skin, oral)
   5. Risk factors: travel, untreated water, new medications
   6. Steatorrhea: float or sink, how many times need to flush, see oil, smell
   7. Other: surgeries, family history IBD, recent NSAIDs
   8. IBD Rx: Dose, duration, compliance, response, hospitalisations

Abnormal Liver Function Tests

1. 1. Past history, knowledge
   2. Risk factors: Tattoo, acupuncture, IV drug abuse, alcohol, blood transfusion, STDs, multiple sexual partners, cocaine (nasal), herbal products, new medications (even a single dose), travel, family history
   3. Symptoms: jaundice, itching, sleep reversal
   4. Chronic liver symptoms: bleeding, increased abdominal girth

GI Bleeding

1. 1. Eyeball patient +/- orthostatics – are they stable ?
   2. Onset, progression, frequency, last event
   3. Hematemesis, coffee emesis, hematochezia (red), melena
   4. Complications: presyncope (postural lightheadedness), syncope (lost consciousness), chest pain, SOB
   5. Risk factors: ASA, NSAIDs, ‘anti-inflammatories’, coumadin
   6. History: PUD, bleeds, AAA repair, IBD, anemia, any other GI symptoms
   7. OK to scope: symptoms of angina, CHF, need SBE prophylaxis ?

In this section you will find information on various GI diseases and conditions as well as their treatment

Bloating can have many causes.   Most commonly it is due to poorly absorbed carbohydrates.  When these reach the colon, bacteria digest them and cause hydrogen as a byproduct.  There are many different carbohydrates and also many different digestive enzymes to break them down.  A specific deficiency of one enzyme will cause bloating due to maldigestion of the associated carbohydrate.  For example up to 25% of the population is unable to break down lactose, the carbohydrate in milk (also in sour cream, yogurt, ice cream, cheese, cottage cheese, pizza [with cheese], pasta [with cheese] etc.

In order to successfully find the cause of bloating, you will have to sequentially try and eliminate several different carbohydrates to see if they are the culprit.  Just because you can ‘get away with’ eating a particular carbohydrate (eg yogurt), doesn’t rule out maldigestion (ie lactose intolerance).

My suggested approach starts with the most likely causes and moves to the least likely.

1. Stop all smoking, pop, and carbonated beverages for 4 weeks.  If you eat quickly and are done your meal before others, SLOW DOWN.
2. Avoid ALL milk and milk products for 4 weeks.  This includes milk, milk in your tea/coffee, yogurt, cheese (including pizza/pasta etc with cheese), sour cream, cottage cheese, ice cream etc.  If this helps you can use lactaid treated milk and/or use lactaid drops or pills (these digest the lactose for you).
3. Avoid all fruits, fruit juices, and jams for 4 weeks (tests for fructose intolerance).  If this helps you will have to continue to avoid these products as you likely have Fructose intolerance. See here and here for a list of foods to avoid.  You can also use the Monash university FODMAPS app (for iPhone & Android – see here) – go to their food guide and use the ‘filter settings’ at the top right of the screen to select ‘fructose’ and ‘sorbitol’ by moving the bar to the right (red).  You can then use their extensive database of foods to see what is safe to eat.  Further resources are also available: here, & here.
4. Avoid all wheat, wheat products, barley, rye and oats for 8 weeks.  We now realise that there is a disorder of wheat sensitivity (different from celiac disease) which results in bloating.  If you are scheduled to have an upper endoscopy, only start avoiding wheat AFTER your scope.
5. The Australians have done some excellent research on what products tend to cause gas/bloating and have labelled them as ‘F-O-D-M-A-P-S’.  Here is a brief video introduction with more information here.  Books on this subject in the Hamilton Public Library are listed here.  An excellent app for smartphones (iPhone & Android) is also available.  Note that FODMAPS are not bad things – they actually feed your gut bacteria.  So if you respond to a low FODMAPS diet, you should then add high FODMAP foods back one at a time (I’d suggest you wait about a week after adding each back) in the diet in small amounts to identify foods that could be “triggers” to your symptoms.  Thus you only end up having to avoid foods which trigger your symptoms and you keep your gut bacteria happy.  When adding back foods, make sure you start with small quantities.  I recently had a chance to meet Dr Gibson & chat with him.  One point he made is that their understanding of which foods to avoid (ie which are the bad FODMAPS) has evolved in the last few years.  So for this reason I would strongly suggest only using his book/apps since other lists you find on the internet could well be out of date and therefore inaccurate.
6. Although drugs are rarely helpful in this disorder, there are a few over the counter things you can try (I’d suggest you try each 4 or 5 times and continue them if they are helpful): Beano, peppermint (eg real peppermint tea), simethicone (eg Phazyme, Gas-X, Mylanta Gas).
7. Finally, here is a list of foods which MIGHT help.