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Getting to know your gut

By Datuk Dr MUHAMMAD RADZI HASSAN

Many overlook the importance of keeping the digestive system in good shape, to their collective detriment.

THE average person consumes about one kilogramme of food a day. This means we eat about 365kg of food each year. Despite the huge amount of food we stuff into our guts, the importance of digestive health remains under-appreciated.

According to the Ministry of Health Malaysia (MOH), in 2008, the sixth leading cause of death in MOH hospitals were diseases of the digestive system. We have to remember that the state of one’s digestive system affects one’s overall health and well-being. It not only plays a crucial role in digestion and nutrient absorption, it is also an important part of the immune and nervous system.

Therefore, it is about time we start taking the digestive system seriously.

Did you know that it takes about 10 seconds for the food that you swallow to reach the stomach? – AFP

Guts at work

The digestive system is central in ensuring that the food we eat gets broken down, digested, and absorbed to provide us energy. The food we eat travels through the alimentary canal (the mouth, oesophagus, stomach, the small and the large intestine) and the digestive system’s “accessory” organs (the liver, pancreas, and gallbladder).

·Mouth

Digestion begins even before food enters the mouth. The smell of food stimulates saliva. This is why your mouth waters when you pass by a cookie store. And once you take a bite of the food, saliva production increases.

Saliva, which contains enzymes like amylase, contributes to the chemical process of digestion, which breaks down nutrients into a simpler form, helping make food soft and easy to swallow.

·Oesophagus

From the mouth, food will pass through the oesophagus, which is a 22cm-long tube. The food is pushed down to the stomach through peristaltic movements (a wave-like motion) of the oesophagus muscular wall. Food usually takes up to about 10 seconds to reach the stomach upon swallowing.

·Stomach

You can consider the stomach the food processor of your body. It mixes, churns, and mashes together all the food. While the food mixes, the stomach produces gastric juice, which is essentially hydrochloric acid, to aid digestion.

Typically, food remains in the stomach for four hours. The acidic environment of the stomach (pH1-2) enables food to become a thick liquid that is more easily digested and absorbed.

·Small intestine

From the stomach, food passes into the small intestine. Do not be fooled by the word “small” as your intestines are actually more than six metres long! It is the main site of nutrient absorption.

On the surface of the small intestine are finger-like structures known as “villi”, and on these villi, there are also more needle-like structures. This unique villi structure increases the surface area of the small intestine tremendously, enabling more efficient absorption of nutrients. If you were to stretch out your small intestine, the surface area will be as large as a tennis court!

Absorption occurs when food molecules penetrate the villi into the network of blood capillaries beneath. These molecules will be carried in the bloodstream to other parts of the body for further chemical conversion into nutrients and energy the body needs to sustain life.

·Large intestine

The main purpose of the large intestine is to absorb as much water from the food as possible. The unabsorbed portion forms faeces, which consist of 75% moisture and 25% solids. The faeces is then stored in the last part of the large intestine known as the rectum, and will eventually be passed out in the form of stools.

·Liver

The liver generates bile, a digestive substance that breaks down fats and neutralises food acids. Bile is transferred to the gallbladder for storage.

·Gallbladder

The primary function of this organ is to store bile, which is secreted into the small intestine in the presence of food.

·Pancreas

The pancreas secretes enzymes that chemically break down fats, carbohydrates, and proteins.

The digestive system, however, is not capable of doing all these tasks on its own. For instance, not all foods we consume are digestable. For this reason, the body needs help from others – it needs bacteria.

Legal residents

Believe it or not, trillions of bacteria reside in the digestive system. These bacteria, also known as gut microflora, support good health by aiding the digestive system.

Some beneficial effects of the gut microflora are assisting the digestion process by producing digestive enzymes, and stimulating the production of immune cells on the intestinal lining.

You must love it

The following are some general tips to help keep your digestive system in optimal functioning order.

·Avoid overindulgence

Ensure your meal proportions are just right.

·Regularity is key

Try not to skip meals. Eat on a regular schedule as it helps keep your digestive system healthy. Ensure that your time for breakfast, lunch, dinner, and snacks are around the same time everyday.

·Healthier choices

Discipline yourself. Eat more portions of vegetables and fruits. Fibre helps to prevent constipation and helps to lower cholesterol levels. Avoid foods that are high in fats.

·Stay hydrated

Inculcate the habit of drinking more water, not only to keep yourself hydrated, but also to ensure the food in your gut passes through more easily.

·Avoid bad habits

Habits like smoking and over-consumption of alcoholic beverages interfere with digestion and may lead to stomach ulcers and heartburn, amongst other things.

The brain and the heart are often labelled as “vital” organs in the body. However, without the digestive system, we cannot survive either. In addition, without a digestive system, we would be missing out on one of the major joys of life – food!

Imagine life without the taste of a grilled steak or the taste of warm, moist brownies. Hence, I would like to encourage everybody to develop a better appreciation for digestive health, not only in terms of preventing disease, but also to enhance the joys of living, ie eating all the delicious food that mums or dads, wives or husbands, and girlfriends or boyfriends cook up for us!

This is the first of a series of monthly articles on digestive health. Dauk Dr Muhammad Radzi Hassan is the past president of the Malaysian Society of Gastroenterology & Hepatology.

This article is courtesy of the Malaysian Society is Gastroenterology & Hepatology, supported by an educational grant from the VITAGEN Healthy Tummies Programme.

For a free digestive health booklet or more information, please call 03-5621 1408.

Cervical Cancer Prevention

Sunday November 22, 2009

By Dr MILTON LUM

The prevention of cervical cancer has to be carried out by various measures, all of which are necessary if we are to achieve the success of many developed countries in reducing the incidence and mortality from cervical cancer.

THE prevention of any disease can be primary or secondary. The former involves taking action on the determinants of the disease to prevent it from occurring. The latter involves the early detection of disease, followed by appropriate interventions to prevent its progression.

There has been considerable media publicity about the prevention of cervical cancer in the past six months. Most of it has focused on the human papilloma virus (HPV) vaccine, which has been called a cervical cancer vaccine, although there is no such vaccine available anywhere in the world.

Cervical smears have resulted in a steady decline in the incidence and mortality of cervical cancer in developed countries which have introduced population wide screening programmes.

Yet cervical smears have scarcely been mentioned in the media focus on cervical cancer prevention. This is despite the fact that only 43% of Malaysian women have ever had a cervical smear in their lives (National Health and Morbidity Survey 2006) although cervical cancer is the second most common cancer in women (National Cancer Registry 2003). There is an overuse of cervical screening by women who are younger and/or who are at low risk.

Natural history of cervical cancer

An understanding of the natural history of cervical cancer is helpful in the planning, implementation, and evaluation of any cervical cancer prevention programme.

Cervical cancer begins with changes in the squamocolumnar junction of the cervix where the flat squamous epithelium of the exocervix meets the columnar epithelium of the endocervix. The ratio of the cell nucleus to the cell size is increased in the epithelium in the pre-cancer phase of the disease.

There is a relationship between the induction of these changes and HPV infection. These pre-cancer changes are called cervical intraepithelial neoplasia (CIN). CIN is graded as mild (CIN 1), moderate (CIN 2) or severe (CIN 3). The CIN progresses from mild to moderate to severe disease and then invasive cancer over seven to 20 years. There are usually no symptoms during this progression, which can be detected by cervical smears.

CIN may spontaneously regress or persist. It has been estimated that, if untreated, 70 to 90% of CIN 1 will regress to normal. By contrast, the rates of persistence or progression to invasive cancer among those with CIN 2 and CIN 3 have been estimated at 57% and 70% respectively (Wheeler CM Obstet Gynecol Clin North Am 2008; 35:519-536).

Various risk factors interact and lead to the development of cervical cancer. The risk factors are:

·sexual activity i.e. early initiation of sexual intercourse, multiple sexual partners, number of current or previous sexual partners of sexual partner, all of which increase the risk of HPV infection

·immunocompetency which affects the body’s ability to clear HPV infections

·lower socio-economic status

·high parity (five or more pregnancies)

·smoking

Behavioural interventions

Cervical cancer has a pre-cancerous phase lasting about seven to 20 years before the normal cells change to cancer cells. As the risk factors of cervical cancer are known, behavioural interventions can be taken to prevent its development.

One or more of the following methods can be utilised:

·starting sexual intercourse only when one gets married

·having only one sexual partner

·knowing that one’s sexual partner does not have many sexual partners

·using condoms regularly to prevent the transmission of sexually transmitted viruses like human papillomaviruses (HPV) which play a role in the development of cancer. This is useful when one is unsure whether one’s sexual partner has many sexual partners or whose other sexual partner has cervical cancer. Condoms can be used in addition to other contraceptive methods

·avoiding smoking or reducing the number of cigarettes smoked

Regular pelvic examinations

Regular pelvic examinations and cervical smears would detect most pre-cancerous changes in the cervix. With treatment, the development of invasive cancer would be prevented. Even if there is invasive cancer present, it will be detected at an early, curable stage.

The cervical smear is a screening test that detects pre-cancerous cells. This enables doctors to refer those with abnormal changes in the cervix for further investigation and treatment. It must be emphasised that the cervical smear is not a diagnostic test.

It involves the taking of a sample of cells from the cervix using a brush or spatula. The cells are placed on a glass slide or into a container and sent to the laboratory for microscopic examination.

Cervical smears are recommended for all women, even though if the woman has never had sex. The likelihood of cervical cancer in such women is thought to be low, but it can still occur. Regular pelvic examinations and Pap smears should be done once sexual activity starts. The frequency would depend on the findings and the woman’s risk profile, which the doctor will discuss with a patient.

It is important that the doctor’s advice be carefully followed, especially if there are increased risk factors.

Despite some limitations, cervical smears are 80-90% effective in detecting cervical pre-cancer. Cervical smears together with early detection and treatment can prevent 75% of cervical cancers from developing.

Cervical screening programmes

The use of cervical smears in widespread population screening in several developed countries has resulted in a marked reduction in the incidence of cervical cancer.

The first evidence of its effectiveness of screening came from the Scandinavian countries. The decrease in mortality rates between 1965 and 1982 was greatest in Iceland (80%) where coverage in the nationwide programme was most extensive. The mortality decreased by 25% in Denmark where 40% of the population was covered by organised screening unlike the decrease in Norway (10%) where only 5% of the population was covered.

The introduction of organised population screening in the Canada, United Kingdom (UK), other European countries, Australia, and New Zealand led to a marked decrease in the incidence and mortality from cervical cancer. For example, the introduction of a national call-recall system in the UK in 1988 resulted in a decrease in the incidence and mortality by about 50%, i.e. the incidence of invasive cervical cancer decreased from 14-16 per 100,000 women in 1971 to 10 per 100,000 in 1995 and to eight per 100,000 women in 2005. The number of deaths from cervical cancer has also fallen from 2000 in 1988 to 921 in 2006.

It is generally accepted that participation in the UK cervical screening programme by a woman aged 35 to 64 reduces her cervical cancer risk in the next five years by 60-80% and the risk of advanced cancer by about 90%.

The benefit of screening for women aged 25 to 34 years is more modest whereas screening in women aged 20 to 24 years has little or no impact on the incidence of cervical cancer under the age of 30 years (Sasieni P, Castanon A and Cuzick J, John Snow BMJ 2009;339:b2968).

HPV vaccines

There are two vaccines available. One vaccine acts against four HPV types and the other against two. They prevent the development of HPV infection. As HPV infection is a significant risk factor in the development of cervical pre-cancer, vaccination would prevent some of its development.

It is important that patients and/or their parents are informed that the vaccines provide protection against certain HPV types and not cervical cancer.

They should also be informed that only 5% of oncogenic HPV infections progress to CIN 2 in three years and that less than half of the women with CIN 2 will develop cancer in another 30 years.

The risks and benefits of vaccination have to be considered. It has been estimated that, at maximal efficacy, HPV vaccination will reduce the number of abnormal cervical smears by between 55 to 65% (Diane Harper Curr Opinion in Obstet Gynecol 2009, 21:457–464).

The vaccines are reported to be generally well tolerated with discomfort at the injection site being the most common side effect. There has been no reported discontinuation because of serious vaccine related side effects. However, the cost of the vaccines may limit widespread usage.

Cervical smears and HPV vaccine

HPV vaccination is no substitute for cervical smear screening. Regular cervical smear screening must be continued even after HPV vaccination. It has been estimated that without regular cervical smear screening, the number of cancers prevented by vaccination will be less than the number prevented by regular screening alone.

HPV vaccines are unlikely to benefit women who have already been exposed to HPV 16 and/or 18. It will probably take decades before all women at risk of cervical cancer are vaccinated. A proportion will remain unvaccinated even then. It is unclear the extent to which older women who have been exposed to HPV infection can be protected by HPV vaccination.

Hence, cervical smear screening will continue to play an important role in the early detection of cervical cancer.

The effectiveness of HPV vaccines may not be 100% and even newer vaccines will probably not afford protect against all HPV types. Hence, there will be a continuing need for cervical smear screening in a vaccination era.

It is sad that the current focus on HPV vaccines have relegated cervical smear screening to the back seat.

There are multiple tools available in the prevention of cervical cancers and they are not utilised to the extent that they should be.

Behavioural interventions have an important role to play and they are relatively economical. Yet they are not given the same publicity as that of HPV vaccines.

The misperception of many patients and/or their parents that HPV vaccines are the magic bullets to get rid of cervical cancer has to be addressed by health messages that reflect the reality of cervical cancer prevention.

In short, there has to be greater emphasis by policy makers and healthcare professionals on the proven methods of cervical smears and behavioural interventions if there is to be any significant impact on reducing the incidence and mortality of cervical cancer.

Dr Milton Lum is member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

A Ray Of Light Can Kill Cancer Cells

A ray of light can kill cancer cells without leaving terrible scars - so why are so few offered it?

By Jerome Burne

Last updated at 8:35 AM on 13th October 2009

One of the most frightening aspects of being diagnosed with cancer is that the treatment can be harsh. Youmay be disfigured by surgery or damaged by radiotherapy and chemotherapy.

Imagine your relief, then, to discover that there is a properly tested, officially approved treatment that avoidsthe worst side-effects. Now imagine your anger when you discover that only a very few people can get thistreatment on the NHS.

That's the emotion powering a celebrity-backed appeal, launched last week, to increase the availability of a treatment called photodynamic therapy (PDT).

Cancer cells: PDT is believed to destroy cancer cells  by shining a laser light at them. It avoids scarring and  takes just one treatment

PDT involves taking a drug that becomes active only when laser light is shone on it. Cancer cells absorb the drug and are destroyed when the light, which is carried on a flexible tube that can be put anywhere in the body, is focused on them.

The whole procedure can take as little as half-an-hour and for many patients only one treatment is necessary. Another benefit is that any healthy tissue that is affected grows back normally without scarring.

This isn't just kinder to patients - it's also, remarkably for a breakthrough - cheaper. PDT avoids the risks of  surgery, cuts the use of hospital beds and removes the need for repeated hospital visits required by chemo and radiotherapy.

Indeed, it could save the health care system between one and two billion pounds a year, according to estimates by cancer specialists at University College Hospital, London. But, despite the National Institute for Health and Clinical Excellence (NICE) approving the use of the therapy for cancers such as skin, mouth, oesophagus, head and neck, less than 1 per cent of those who could benefit actually get it.

Skin cancers are the most commonly treated, but even then the numbers are still tiny - only a few thousand of the 76,000 new cases of skin cancer a year receive PDT. The vast majority are treated with surgery, which an involve skin grafts and leave scars.

'All this can be avoided with PDT,' says Colin Hopper, a surgeon at the National Medical Laser Center at University College London. 'It doesn't damage nearby tissue and there's rarely any scarring. It's also far cheaper: surgery can cost £6,000 if reconstructive work is needed compared with £1,000 for PDT.'

If the number of patients receiving the new treatment for skin cancer is low, for other types of cancer it is even worse. Just 300 cancer patients out of more than 300,000 were treated last year. Many are never even told about it or they are told (incorrectly) that it is experimental and doesn't work.

Celebrity supporters: Sir David Frost (left) and Alex Ferguson back PDT

But it's in the treatment of head and neck cancer where the lack of PDT is possibly most keenly felt. These are vulnerable areas and treatment such as radiotherapy can leave patients unable to eat and in pain for months.

For others, surgery can be devastating where it involves the removal of the tongue and voice box.

Virtually all of these horrendous side-effects can be avoided with  photo dynamic therapy, which involves no surgical destruction or burning by radiotherapy.

Even though it was approved by NICE for head and neck cancer six years ago, out of 8,000 operations performed for it last year, just 180 patients got PDT, nearly all at University College Hospital.

Right now, however, the gap between the number of cancer patients who could benefit from it and those who actually get it is huge,' says Colin Hopper.

'It's a criminal injustice that this form of treatment is not available to everyone in Britain,' says musician Robert Plant, who is backing the new campaign. 'I have a friend receiving PDT, but only because we pushed to get it. None of his doctors told him about it.'

So, given its obvious advantages, why is it so little used? Partly it's because some medics consider it experimental on the basis there are no full-scale controlled trials for some of its uses (despite NICE approval for other uses).

Funds for research are a big issue. 'We haven't been able to raise enough money from the traditional routes,' says Dr Stephen Pereira, a gastroenterologist at University College Hospital. 'For some reason, the U.S.

National Institute of Health has been more receptive than British charities and agencies, and it has joint ventures with teams from Harvard Medical School.'

That's not to say there is no funding at all - Cancer Research UK has recently supported a clinical trial on PDT's effect on bile duct cancer as well as helping work at London's Imperial College to develop PDT for other cancers.

But funding is patchy at best. Red tape also plays a part in poor uptake. 'Some health authorities require approval every time PDT is used,' says David Longman, of Killing Cancer, the charity behind the new campaign.

'Then they may refuse it, even though it's cheaper than chemo, because any treatment beyond the norm shows up as an extra expense.'

This is borne out by the experience of Keith Webster, a consultant surgeon at University Hospital, Birmingham. He specializes in head and neck cancers and has been frustrated by having to make a fresh application for PDT for each of his patients.

'This is one of the major centres in the country and yet we have to keep seeking approval,' he says. 'When we say it's appropriate, we should be listened to.'

When this was put to the Department of Health, a spokesman said it was up to clinicians, 'using their judgment, to decide on the most effective treatment, and then for the relevant Primary Care Trust to decide'.

Clinicians and campaigners feel the NHS has been dragging its feet. Two years ago, the Department of Health commissioned a review of PDT - 'but it's not going to be finished for another seven months,' says David' I thought we were getting somewhere, but the lack of urgency by the Department of Health has been astonishing.' Longman.

The Department of Health said: 'We are committed to ensuring that newer treatments are made available as widely as possible, and a review of the evidence will be published in spring 2010.'

The aim of the Killing Cancer campaign is to raise funds to pay for PDT treatment and equipment, and to help fund more research. What makes PDT potentially even more exciting is that it could transform the treatment of nearly all cancers, including those far inside the body.

'We can use fiber optics to put a light down a hollow needle - this enables us to treat solid tumors deep inside the body,' says Hopper. 'Improvements in ultrasound mean we can guide the needle to precisely the right spot.'

This means hard-to-treat cancers such as prostate, lung and pancreas are all within reach.

Indeed, early evidence suggests that PDT may work well with prostate cancer, reducing surgical side-effects such as incontinence and impotence. Later this month, a trial is starting to test the effectiveness of PDT on breast cancer.

What is frustrating is that even though British researchers pioneered PDT, we are falling behind Europe in making it available. By Christmas, Mr Hopper will have trained 40 Italian doctors in how to use it.

'By comparison I've trained a total of 60 British doctors in the past ten years,' he says. 'Soon Italy's use of PDT drugs will be double that in Britain.'

Making sure the therapy is more widely available is one reason Manchester United manager Sir Alex Ferguson is also backing the campaign. 'My mum and dad both died from cancer,' he told the Mail. 'One in three of the magnificent fans watching a match at Old Trafford will also die of it.

'The thought of getting it fills me with dread. I reckon both me and the fans deserve a better deal than is on offer.'

Coping With Joint Pain

A natural sulphur compound appears to be the ideal companion for glucosamine and chondroitin for effective relief of osteoarthritis.

Tomorrow is World Arthritis Day. Afflicting millions worldwide, arthritis is a chronic degenerative disease that can vary in severity. With its widespread prevalence and effect on health and well being, the disease accounts for a significant percentage of doctor visits.

Arthritis is defined as the inflammation of one or more joints and symptoms of the condition include redness, swelling, tenderness, stiffness, pain, and warmth in the affected area. There are over 100 types of arthritis, including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and gout.

Osteoarthritis

Osteoarthritis (OA) is the most common type of arthritis. It is a chronic condition characterised by the breakdown of the joint’s cartilage.

Cartilage is the part of the joint that cushions the ends of the bones and allows easy movement of joints. Healthy cartilage is extremely strong and flexible and allows the joints to move smoothly and painlessly, but in osteoarthritis, the cartilage is damaged, and subsequently wears down. This process continues until little or no cartilage is left in the affected joint, causing bone to grind against bone.

Osteoarthritis typically affects certain joints, such as the hips, hands, knees, lower back, and neck. It occurs more frequently as we age. Before age 45, osteoarthritis occurs more frequently in males. After age 55 years, it occurs more frequently in females.

One needs to supply essential nutrients for the body to build strong, flexible cartilage. Having a strong flexible cartilage is the first step for healthy joints. Hence, with the right nutritional support, osteoarthritis sufferers can rebuilt and regrow their worn out cartilage.

Nutritional support

Glucosamine and chondroitin are two important nutritional compounds used in the treatment of osteoarthritis.

Both glucosamine and chondroitin are natural components of healthy joint tissue. They work by supplying the natural raw ingredients cartilage needs to repair and rebuild itself. They also suppress the natural enzymes that break down cartilage in the first place.

Quick facts:

•Glucosamine is a natural compound that is found in healthy cartilage. It is a normal constituent of glycosaminoglycans in the cartilage matrix and synovial fluid. It is used in the formation and repair of cartilage.

•Chondroitin is the most abundant glycosaminoglycan in cartilage and is responsible for the resiliency of cartilage. It acts as a “water magnet”. The ability of chondroitin to hold water gives rigidity to the cartilage and also enables it to act as a “shock absorber”.

Supplementation with glucosamine and chondroitin helps to relieve joint pains, rebuild cartilage, improve flexibility, lubricate joints, promote healthy connective tissues, and reduce stiffness.

In recent years, studies have shown that two-in-one glucosamine and chondroitin supplements are far more effective in treating moderate-to-severe osteoarthritis than potent anti-inflammatory drugs (celecoxib) or even glucosamine or chondroitin taken separately by itself.

Sulphur this

MSM (Methylsulfonylmethane), a natural sulphur compound with many health benefits, is widely used together in combination with glucosamine and chondroitin for effective relief of joint pains. Many developed nations across the globe such as the US, UK, Europe, Australia, etc regularly observe very positive results in the treatment of osteoarthritis when oral MSM supplements are added to glucosamine and chondroitin nutritional therapy.

MSM is found in the normal diets of humans and almost all other animals. MSM is made up of 34% sulphur, the fourth most abundant mineral in the human body. Sulphur is necessary for the structure of every cell in the body. It is needed for the structural integrity of joint cartilage and connective tissue such as skin, hair, and nails.

Many amino acids, the building blocks of protein, have sulphur as a component. Hormones, enzymes, antibodies, and antioxidants all depend on it. And because the body utilises and expends it on a daily basis, sulphur must be continually replenished for optimal nutrition and health.

The Arthritis Foundation of America recommends starting with a low dosage of 500mg MSM twice a day and increasing gradually to 1,000mg MSM twice a day.