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Identifying and Achieving Digestive Health
Leo Treyzon, MD
University of California, Los Angeles
David Geffen School of Medicine
While other kinds of health - cardiovascular health, bone health, mental health - are widely discussed, digestive health is rarely mentioned, partly because many people consider the topic embarrassing, and partly because even physicians lack a universal definition of good digestive health. Yet we all know what it means. I am reminded of Justice Potter Stewart's 1964 definition of pornography: "I know it when I see it."
The American Gastroenterology Association offers the following: "Good digestive health indicates an ability to process nutrients through properly functioning GI organs, including the stomach, intestines, liver, pancreas, esophagus and gallbladder. Most people who are in good digestive health are of appropriate weight and do not regularly experience symptoms like heartburn, gas, constipation, diarrhea, nausea or stomach pain. Eating a nutritious diet is needed to maintain a healthy digestive system and may prevent and treat certain digestive diseases." Defining digestive health is complicated by the fact that everyone is different. Normal laxation is different for different people. Furthermore, cultural norms are also important considerations.
Good digestive health may be defined by the absence of symptoms of functional gastrointestinal (GI) disorders. The Rome Multinational Working Teams (Rome II) has classified more than 20 functional GI disorders related to any of five anatomic regions: esophageal, gastroduodenal, biliary, bowel and anorectal. These disorders may vary in their clinical features, but all are characterized by chronic or recurrent symptoms attributed to the gastrointestinal tract. They may relate to abnormalities in motility or afferent sensitivity as modulated by the central nervous system.
Prevalence and Costs of GI Diseases
GI and liver diseases are extremely prevalent and inflict a heavy physical and economic burden. Each year there are 135 million cases of non-food-borne gastroenteritis, 76 million cases of food-borne illness, 19 million cases of gastro-esophageal reflux disease (GERD), and 15 million cases of irritable bowel syndrome (IBS). It is difficult to estimate the effects of these diseases on morbidity, mortality, and economic burden, but it is important to do so in order to set priorities to reduce the burden of illness. This information shapes the research agendas of government, industry and private foundations and can be used to evaluate and modify the resource allocations of agencies that fund research or pay for health care services.
The estimated direct health care costs for all GI diseases in 1998 were $85.5 billion; for the 17 most common GI diseases these costs were $36 billion. Examples include:
- GERD - $9.3 billion
- Gall bladder disease - $5.8 billion
- Colorectal cancer - $4.8 billion
- Peptic ulcer disease - $3.1 billion
The direct cost of GI diseases by category is estimated to be:
- Chronic GI disorders $4.8
- Liver disease $1.4
- Acid-related $12.4
- GI infection $7.3
- Pancreas & gallbladder $7.8
- GI cancers $7.3
There is evidence that people with GI diseases have more physician visits for all causes and have more disability from work and school than people with no bowel symptoms. According to the U.S. Householder Survey of Functional Gastrointestinal Disorders, people with IBS are significantly more likely to see physicians for non-gastrointestinal complaints (3.9 vs. 1.7 physician visits per year) as well as for gastrointestinal complaints (1.6 vs. 0.1 physician visits per year). Another population study found that the odds of incurring medical charges was 1.6 greater for persons with IBS when compared to healthy controls, and the median annual health costs were $742 for persons with IBS vs. $429 for others.
The U.S. Householder Survey also found that people with IBS had almost three times more illness-related work and school absenteeism in the previous year than people with no bowel symptoms (13.4 vs. 4.9 days), and a higher proportion of the IBS group (11.3%) was too sick to work or go to school than the group with no bowel symptoms (4.2%).
Beyond the economic costs, the quality of life of individuals is also affected by the severity of their digestive symptoms.
Achieving Digestive Health Promotion
Webster's dictionary defines "prevention" as "the act of keeping from happening." With this definition, almost all activities in medicine could be defined as prevention. After all, clinicians' efforts are aimed at preventing the untimely occurrences of death, disease, disability, discomfort, dissatisfaction, and destitution. The fact remains that although more prevention is practiced today than ever before, physicians still spend most of their time diagnosing and treating rather than preventing disease.
Three types of prevention are possible, based on when in the course of disease interventions are made.
Primary prevention keeps disease from occurring at all by removing its causes - for example, counseling patients to eat a healthy diet to prevent colorectal cancer; stop smoking, eat foods low in saturated fats and cholesterol and high in fiber and exercise appropriately to prevent heart disease; and engage in safe sexual practices to prevent hepatitis B.
Secondary prevention detects disease early, when it is asymptomatic, so that early treatment can stop it from progressing. Examples include colonoscopy for adenoma detection and fecal occult blood tests for colorectal cancer. Most secondary prevention is done in clinical settings, and all physicians, especially those caring for adults, undertake secondary prevention.
Tertiary prevention refers to clinical activities that prevent further deterioration or reduce complications after a disease has declared itself. Tertiary prevention is particularly important in the management of patients with fatal disease. Here the goal is not to prevent death but to maximize the amount of high-quality time a patient has left. Examples include ASA to prevent adenoma or cancer recurrence and COX inhibition for established colorectal cancer.
Most doctors are attracted to medicine because they look forward to curing disease but, in fact, most patients would prefer never to contract a disease in the first place — or, if they cannot avoid an illness, they prefer that it be caught early and stamped out before it causes them any harm. To accomplish this, procedures are performed on patients without specific complaints so as to identify and modify risk factors and thereby avoid the onset of disease, or to find disease early in its course so that with intervention patients can remain well. Such activity is referred to as health maintenance or the periodic health examination.
Screening, the identification of an unrecognized disease or risk factor, is of fundamental importance in health maintenance. It separates apparently well-feeling persons who have a risk factor or a disease from those who do not. However, deciding upon the best and most appropriate screening for each patient is not always easy. When considering what to do routinely for patients who have no specific symptoms for a given digestive disease, the clinician must first decide which medical problems or diseases he or she should try to prevent. This statement sounds so straightforward that it doesn't need saying, but the fact is that many preventive procedures, especially screening tests, are performed without a clear understanding of what is being sought. For example, physicians performing routine checkups on their patients frequently order an electrolyte panel, when a urinalysis might be used instead to search for any number of medical problems, including diabetes.
It is necessary to decide which, if any, GI conditions are worth screening for before undertaking a test. Three factors are important in deciding what condition to include in a digestive health examination: the burden of suffering caused by the condition, the quality of the screening test, and the effectiveness of the intervention for primary prevention. The following criteria apply to all types of screening tests, including the history, physical examination, laboratory tests and procedures:
Simplicity and low cost. An ideal screening test should take only a few minutes to perform, require minimum preparation by the patient, depend on no special appointments, and be inexpensive.
Safety. It is reasonable and ethical to accept a certain risk for diagnostic tests applied to sick patients seeking help for specific complaints, but less risk is acceptable when the same tests are applied to well patients without specific complaints. Screening tests are not always completely benign. They can cause serious physical harm in the rare patient, either because of complications of the screening test itself or because of adverse consequences of subsequent tests or treatment.
Effectiveness of treatment. Screening is only as good as what you can do with the information. A particularly difficult dilemma faced by clinicians and patients is when a person is known to be at high risk for a condition, but there is little or no evidence that early treatment is effective. What should the physician and patient do? For example, people with Barrett's esophagus (a condition in which the squamous mucosa in the distal esophagus is replaced by columnar epithelium) run a 30- to 40-fold greater risk of developing esophageal cancer than persons without Barrett's esophagus. However, there is little evidence regarding the effectiveness of screening such people with periodic endoscopic examinations followed by early treatment if cancer occurs. There is no easy answer to this dilemma, but if physicians remember that screening will not work unless early therapy is effective, they can weigh carefully the evidence about therapy with the patient. If the evidence is against effectiveness, they may hurt rather than help the patient by screening.
Risk of a false positive result. False-positive tests can cause psychological damage or worse. At the worst, patients may undergo harm from adverse consequences of subsequent tests or needless physical trauma from unnecessary treatment.
Acceptance by both physician and patient. It is important that the clinician have solid evidence about how much good and how much harm health promotion activities accomplish, and discuss the options thoroughly with the patient.
Digestive Health Maintenance
Digestive health maintenance is accomplished at three levels: the physician, the community and the individual.
Physicians should understand the conceptual basis and content of the periodic digestive health exam and incorporate it into the ongoing care of a patient. Colorectal risk factors should be routinely assessed in patients presenting for annual physical exam. Screening instruments must be established. All patients should be advised about healthy digestive-related behaviors, regardless of their risk. Physicians should be prepared to answer patient questions about a range of concerns, from performing stool occult blood testing annually to incorporating fiber and antioxidants into the diet.
Prevention at the community level is also effective and in some cases has been the best solution to a public health problem, for example fluoridation of drinking water to prevent cavities. A community level intervention that might be useful in digestive health maintenance would be immunization to prevent gastroenteritis in children. Sometimes combinations of clinical and societal measures can be effective. Clinical efforts can complement community-wide programs, such as smoking cessation programs led by doctors coupled with public education, regulations and taxes help prevent teens from starting to smoke.
Finally, patients themselves must be involved in prevention. Patients must be inquisitive and take an interest in their digestive health. They should become familiar with basic risk factors and warning signs of disease, ask questions and not be afraid to raise the topic of digestive health.
Looking to the Future
Clearly, digestive diseases are prevalent and incur large physical and economic burdens. Digestive health, like other aspects of health, deserves attention. Part of the barrier to achieving digestive health promotion is the culture of medicine itself, which is oriented toward cure more often than prevention. This is changing, but slowly. Research expenditures for prevention in the area of digestive health are very worthwhile, because prevention is preferable to treatment from every perspective.
We must keep advancing research into particular diseases but with a focus on preventive strategies. Prevention must become a bigger part of medical education. Immediate steps that can be taken include further research with evolving analytical methods such as database analysis, economic analysis, HRQOL studies and surveys.
Long ago, in 1135, Maimonides wrote, "Live sensibly. Among 1000 people only one dies a natural death. The rest succumb to irrational modes of living." Our challenge today is to figure out how to integrate preventive medicine principles and findings in order to achieve rationale modes of living.
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