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Matters of Prostate Cancer Survivorship

Who’s a survivor?  You are, if you are trying to get your life back after a diagnosis of prostate cancer.

 

            Survivor.  What does that word bring to mind?  (Besides, of course, the name of the rock band whose song, “Eye of the Tiger,” went double-platinum in 1982 and was the theme of “Rocky III.”)

            There are more prostate cancer survivors now than ever before.  More men are being cured of localized disease, and more men are living longer with advanced cancer than ever before.  This is great news!  It also means that, as men live longer after treatment for prostate cancer, they have new things to deal with – which brings us to the evolving area of cancer survivorship.

             Survivorship is basically the day-to-day effort to live your best life during or after treatment for localized cancer, or between and in the midst of treatments for more complicated disease.  It’s such a big part of cancer treatment now, in fact, that medical centers are devoting significant resources to it.  One of them is Dana Farber, where medical oncologist Alicia Morgans, M.D., will soon become the new Medical Director of Cancer Survivorship.

The criteria for survivorship used to be a lot more strict, she notes.  “The old-fashioned definition would say that patients living with cancer are not survivors” – that a true survivor could only be someone whose cancer has been cured.  That has changed.  “Now, anybody living after a diagnosis of cancer is a survivor and deserves to have the best quality of life possible.”

Good news: for many men recovering from treatment or living with prostate cancer, help is available.  But it may be up to you to ask for it, if your doctor doesn’t address it specifically.

Note:  Here is where your spouse, partner, family or friends can help.  Those who love you may be aware of some things that you might not have noticed, and their insights can help your doctor take better care of you – if you say it’s okay for them to talk about it.

“Men are stoic, and may not feel comfortable admitting a weakness or vulnerability, or they may not have the words to describe what they’re going through,” says Morgans.  “Or, they may not perceive a problem, but their caregivers or loved ones may.  Raising their concerns – with the permission of the patient – to the doctor can be very helpful.”  This is especially true, she adds, in cases where the patient is experiencing “psychological distress, depression, anxiety, and may not recognize it.  Sometimes the caregiver can say, ‘You don’t realize it, but you’ve had a really short temper.’ Or, ‘You may not recognize it, but you’re sleeping all day, and you’re not eating.’Or, ‘Your cancer is controlled, but your behavior is very different, and you seem really down.’  We may not perceive these changes as being different or outside our norm, but if they’re empowered to speak (with your permission!), your caregiver or family members can really help reflect back to us more accurately what’s happening with you.”

While visiting the doctor, phone a friend!  If it’s not possible for a family member to be there at the appointment, no problem!  “We can often call or conference a loved one in,” with Zoom, FaceTime, or through the medical center.  There are also “electronic ways,” Morgans adds, for loved ones to communicate with the doctor.  You can write an email to the doctor, using the patient’s portal – or even your own.  “In many systems, caregivers can have an account that’s connected to the patient.  I have many patients whose spouse has an adjacent account.  Others just use the patient’s account.”

Be sure to identify yourself, that this is the patient’s daughter, spouse, or friend.  “Don’t represent yourself as the patient if you’re not the patient.”  This does happen, Morgans says.  “Sometimes wives will get on there as the patient, and you know it’s the wife: women tend to talk a lot more than men!  I’ll see a long description, and write back, ‘Is this John’s wife?’”  The information is still appreciated, she adds.

“If there’s something they think the doctor needs to know, and if they’re empowered by the patient to speak to us, the caregiver or spouse can intervene in a meaningful way.”

Sexual Health

Sexual health is “one of the most underrecognized issues” for prostate cancer patients and their partners.  One big reason why is that men just don’t want to talk about it, either because they keep hoping it will get better, or they just decide to be stoic and carry on.  “Even though we have a roadmap for how to address these issues after surgery or radiation, we often lack the support system,” says Morgans.  “There are way too few sexual health counselors specifically dedicated to helping men recovering from prostate cancer.”  And yet: “This is an area of high interest to many patients.  Sexual health affects their personal experience, their mood, energy, everything they do.”  It also affects the health of their partners.

Although this is the issue many men wish would just go away, what they need to do is just the opposite of hoping for the best:  be proactive.  If you had surgery and you haven’t already had this discussion with your urologist, find out what you can do for penile rehabilitation.  This may include pills such as Viagra, Cialis, or other PDE5 inhibitors; vacuum devices for stretching the penis to protect against scar tissue formation; in-office or at-home treatment with a small TENS unit to stimulate nerve regeneration and help with return of urinary control; penile injection; or a penile implant.

Don’t suffer in silence!  Don’t listen to anyone, yourself included, who thinks, “Your cancer has been cured. Just be happy with that.”  There are many steps you can take to recover your sexual health – but they won’t happen if you don’t ask for help.

Intimacy: This is not the same as sexual health, but men on ADT and their partners still need intimacy.  If your oncologist or medical center does not provide counseling in this area, ask for a referral to a sexual health counselor, and keep this in mind: you are not alone, whether you’re the patient or his partner.  There are thousands of couples dealing with this issue, as well.  Your doctor also may be able to recommend support groups, online and affiliated with local medical centers.

Fighting Back on ADT

ADT will try to affect your overall health, but here’s the good news:  you can fight back, Morgans.  Arm yourself with what it might do, and you will be better able to protect yourself against its tactics.  So here, in no particular order, are some of the things ADT might affect, and countermeasures you can take:

Bone health:  Prostate cancer can affect your bones, and so can ADT, in different ways.  Treating prostate cancer in the bones not only protects them, it can improve survival!  ADT raises your risk of osteoporosis – but not only is this treatable, it’s not a “done deal” that every man on ADT will develop it!  “Avoiding fractures is so important,” says Morgans.  “Men who have fragility fractures (due to osteoporosis) can lose their mobility and independence, and can have some major changes in their lives until those fractures are repaired.  If we simply follow the guidelines we already have on how to care for bone and prevent osteoporosis, we can improve those outcomes pretty dramatically.

“A lot of the complications associated with ADT are absolutely things that we can address head on, try to prevent and to reverse; for instance, we have effective therapies to counteract bone thinning and lower the risk of fracture and complications from weak bones.  Many of the known side effects of ADT are not necessarily inevitable.”

Your risk of cardiovascular disease:  Here’s some good news:  A new drug, Orgovyx (relugolix), was approved in December 2020 by the FDA for men with advanced prostate cancer, based on results of the Phase 3 HERO study.  It lowers testosterone, but it works in a different way.  It’s also administered differently – a once-daily pill instead of a shot – and it has a significantly lower risk of major adverse cardiovascular events compared to Lupron (leuprolide).  If you have cardiovascular risk factors, such as high blood pressure, high cholesterol, a family history of cardiovascular disease, diabetes or pre-diabetes, if you’re overweight or if you smoke: heart disease needs to be on your radar, because ADT can make it worse. “Multiple studies have shown that men who have cardiovascular risk factors, particularly if they are not addressed, have higher rates of complications and even death on ADT,” says Morgans.  But treating these risk factors with diet, exercise, and medication if needed, can “improve overall survival and also quality of life.  When your body is healthier, you feel better.”

Note:  For just about every category on this list, exercise is one of the answers.  Men on ADT who exercise lower their risk of having cardiovascular and cognitive effects, developing insulin resistance, diabetes or pre-diabetes, obesity, and high blood pressure.  “All of these are modifiable risk factors,” says Morgans.

Depression:  “Depression is highly treatable,” says Morgans.  “This is important, because evidence suggests that men treated with ADT do have higher rates of depression than men who have prostate cancer but are not receiving ADT.”  But depression is underdiagnosed and undertreated in men on ADT, she adds, “perhaps because of reticence to ask for help, or a perceived stigma with mental illness,” or perhaps because it has crept up, and the patient hasn’t recognized that there’s a problem.  This is where friends, family and caregivers can help.  Depression can affect sleep, appetite, and memory, as well.

Cognitive changes:  ADT can cause cognitive decline and dementia.  However, this is more complicated than it sounds, Morgans notes.  For one thing, symptoms of depression can be mistaken for cognitive decline, and can improve with antidepressants and exercise.  For another, there are multiple forms of dementia, including vascular dementia.  “If that risk is increased because of ADT, then a medicine that reduces the risk of major adverse vascular events could feasibly lower the risk of dementia, as well,” although this remains to be proven in large-scale studies. In general, “what’s good for the heart is good for the brain,” and taking steps to improve your cardiovascular health will help protect your cognitive function, too.  “We also have strategies and mental tricks to help improve memory, and even medicines that may slow the progress of Alzheimer’s.”  The key is to tell your doctor, and get further evaluation and help if needed.  “The choice of therapies may help, as well,” Morgans notes. “In multiple ongoing studies, some really interesting MRI data suggests that there may be differences in some distribution of blood flow in the brain” between androgen-targeted medicines, “including one study with darolutamide that has just launched.”

Hot flashes:  “At its basic level, ADT is lowering testosterone, which keeps men’s bodies functioning in a way they’re used to,” says Morgans.  “Just as we see when women go through menopause, there are widespread changes.  The constellation of symptoms is much broader than just the effects of ADT on the prostate cancer cells themselves.”

Among the most annoying and persistent – and undertreated – are hot flashes, which “can affect mood, sleep, and cognition,” says Morgans.  A novel approach on the horizon is a “wearable,” she adds.  It’s like an Apple watch, and can be linked to your phone.  The basic idea is to stimulate the autonomic nerves on the wrist, with a cool sensation.  “PCF is actively engaged in supporting work that can potentially improve quality of life and reduce hot flashes in men on ADT.  This is an area with much room for improvement, where attention is needed, and pharmacologic therapies aren’t as effective as we wish.”

For now, treatment with antidepressants may help; so can exercise.  Many men seek relief of symptoms with holistic treatments, including relaxation therapy, hypnosis, cognitive-behavioral therapy, and acupuncture.

In addition to the book, I have written much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

 

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New Marijuana Studies: Pot Hurts Your Brain

marijuana fieldBefore we start this discussion, please hear these words:  this is not about your right to smoke marijuana.  I don’t care if you spend every waking moment high as a kite, as long as you don’t operate heavy machinery or endanger anyone else.  I do not care.  That’s not my business.

However, I’m worried about your brain, because scientists are worried about it.  I also worry that some states have gotten so caught up in the political correctness of marijuana that they have fast-tracked legalizing it without fully understanding the science of what it does, and the biggest thing it does is reduce the circulation to every cell in your body, including the brain.  New studies have linked using marijuana to a higher risk of dementia, depression, and even schizophrenia.

The part of the brain that marijuana particularly seems to affect is the hippocampus, which is the same region of the brain that’s damaged in Alzheimer’s disease.  Wait a minute, hippo-what?  Let’s backtrack a minute, and:

Get to Know Your Hippocampus!

Actually, there are two of these in the brain, so technically it’s “hippocampi.”  There’s one on the right side, and one on the left, roughly over each ear, about an inch and a half inside your head.   

When you make a new memory, it happens in your hippocampus.  When you file that memory away in your brain and assign emotions to it, that happens in your hippocampus.  When you smell fresh oranges and think of that box of fruit your grandfather used to send your family at Christmas:  that happens in the hippocampus.  When you see an ad for “White Linen” perfume and think of the crush you had on your high school math teacher, who used to bathe in the stuff:  that happens… you guessed it.

Now, within the hippocampus, there are different compartments.  One handles spatial memories; in fact, when scientists studied London cab drivers, who have to commit the intricate labyrinth of 500-year-old city streets largely to memory, they found a connection to growth in the rear part of the hippocampus. 

marijuana bagsThe hippocampus is where, when you sleep, you process all the stuff you saw and felt during the day, and then you ship it off to your brain’s equivalent of the warehouse where they put the Ark of the Covenant after Indiana Jones found it – long-term memory.  The hippocampus is the triage area.  It’s short-term memory we’re talking about here, people. 

So, what happens when the hippocampus is damaged?  Well, autopsy studies of people with amnesia have shown damage to the hippocampus.  Damage here is linked to problems remembering names and events.  Dates, too. 

Is there any redundancy – a failsafe against damage, since we have two hippocampi?  Well, not exactly, because they’re specialized.  Damage to the left hippocampus can affect your ability to come up with the right words, and damage to the right can affect your ability to process visual information.

Cell degeneration in the hippocampus is connected to the onset of Alzheimer’s.   

Hold that thought.

Risk of Alzheimer’s

Marijuana causes abnormally low blood flow to virtually every part of your brain.  In a study published in the Jan. 12, 2017, issue of the Journal of Alzheimer’s Disease, scientists at Amen Clinics in California looked at the brains of more than 26,000 patients at American neuropsychiatric clinics between 1995 and 2005.  Of these, nearly 1,000 were pot smokers. 

All of the marijuana users had abnormal blood levels in the brain, particularly in the same regions of the brain affected by Alzheimer’s, namely the hippocampus.  They used SPECT imaging to show the brains of marijuana users compared to controls (people who did not smoke pot), and the difference was striking.   Every single pot smoker had “significantly lower blood flow” in the right hippocampus compared to the controls.  Even the investigators were surprised.  Lantie Elisabeth Jorandby, a psychiatrist and one of the study’s co-authors, said when the paper came out, “What struck me was not only the global reduction in blood flow in the marijuana users’ brains but that the hippocampus was the most affected region, due to its role in memory and Alzheimer’s disease.  Our research has proven that marijuana users have lower cerebral blood flow than non-users.”  The study’s authors concluded, “The most predictive region distinguishing marijuana users from healthy controls, the hippocampus, is a key target of Alzheimer’s disease pathology.  This study raises the possibility of deleterious (harmful) brain effects of marijuana use.”

In a blog post (http://www.amenclinics.com/blog/amen-research-marijuana-affects-blood-flow-brain/) the study’s authors talk about their findings.  There are also images of two brains (one from a marijuana user, and one from the control group) and it’s kind of like looking at a fresh piece of fruit vs. one that’s been in a dehydrator and put into some trail mix.  “Our research demonstrates that marijuana can have significant negative effects on brain function,” the investigators wrote.  “The media has given the general impression that marijuana is a safe recreational drug, this research directly challenges that notion.  Several studies of perfusion imaging in marijuana users have shown similar results compared to ours. A small … PET study in a sample of 12 marijuana users used a randomized clinical trial design to examine brain perfusion before and after marijuana use. The study results found frontal, temporal and occipital lobe hypo-perfusion (lower than normal blood flow) – all findings concordant with our study.”

In previous posts here at Vital Jake, we have talked about the importance of cerebrovascular health in preventing dementia.  Good blood flow to the brain is really important.  Trust me, you want good circulation up there, and there are ways to do this, which we’ve talked about in previous posts.   If you exercise and eat right and do all the things that have been proven to help reduce your risk of dementia – and then smoke pot, you might be wasting all that effort.

Risk of Schizophrenia

In a landmark report released by the National Academies of Sciences, Engineering, and Medicine, scientists said what we don’t know about marijuana “poses a public health risk.”  And yet, 28 states and Washington, D.C., have legalized marijuana for medical use, and eight states and D.C. have legalized it for recreational use. 

marijuana budThe report also said there is strong evidence to link using marijuana to the likelihood of developing schizophrenia and other causes of psychosis, with the highest risk among the most frequent users.   

The Royal College of Psychiatrists issued a statement that says, “There is growing evidence that people with serious mental illness, including depression and psychosis, are more likely to use cannabis or have used it for long periods of time in the past.  Regular use of the drug has appeared to double the risk of developing a psychotic episode or long-term schizophrenia.”

Now, you may wonder, does marijuana actually cause these problems, or are people who are prone to depression and/or schizophrenia trying to self-medicate, to find some relief of their symptoms?  That’s a reasonable question.

It appears that marijuana is more likely to be the cause than the cure.   Australian scientists followed 1,600 adolescents, aged 14 to 15, for seven years.  They found that “while children who use cannabis regularly have a significantly higher risk of depression, the opposite was not the case – children who already suffered from depression were not more likely than anyone else to use cannabis. However, adolescents who used cannabis daily were five times more likely to develop depression and anxiety in later life.”

Other studies show that the risk of schizophrenia or bipolar disorder appears to be dose-related, especially in adolescents.  Australian scientists found that adolescents who smoked pot were more likely to develop a psychotic illness, and to develop it about 2.7 years sooner, than those who did not.  These kids may also have a genetic predisposition to a psychiatric illness; so it may be that the ones who developed problems had a lower threshold for damage.  Would they have developed it without the marijuana use, however?  Nobody knows.

Risk of Depression

In another imaging study of 48 people, published in the Proceedings of the National Academy of Sciences, scientists showed that smoking marijuana increases the risk of depression, anxiety, restlessness, and other “negative” emotions.

They showed it in an interesting way, by looking at how the brains of study participants – pot smokers and controls – reacted to dopamine, the “feel-good” neurotransmitter (brain chemical) that affects your emotions, your movements, your ability to sense pleasure and pain, to learn, to pay attention, and to think.  Dopamine affects your mood, your sleep, and your memory, too.   

Dopamine is also part of your brain’s reward system.  Eat a sugary snack: get a hit of dopamine.  Do cocaine:  get a hit of dopamine. 

The ADHD drug Ritalin, a stimulant, raises the levels of dopamine in the brain, too, and this is what the researchers used in the study.

The pot smokers met the criteria for marijuana “abuse or dependence.”  That is, they smoked a lot of pot.  In personality tests and brain scans, the pot smokers had “significantly blunted” responses to dopamine compared with controls.  They were more lethargic, apathetic, anxious, and depressed.  Psychiatrist Nora Volkow said the scientists believe dopamine has a “downstream effect” in another area of the brain called the striatum, where your motivation comes from.

The study’s authors expressed their concern that “moves to legalize marijuana highlight the urgency to investigate effects of chronic marijuana in the human brain.” 

They used the word “urgency” because they are worried that people may be doing themselves significant harm.   

Here are some things to think about:

Another study from Imperial College London found that long-term pot use destroys dopamine.  Dopamine levels decline as we age, already; they also decline in Parkinson’s disease. 

People who already have a history of depression might not be ideally suited for marijuana.

People with a higher risk of stroke (high blood pressure, high cholesterol, prior heart disease, a history of TIA, or cerebrovascular disease) should not use marijuana because it will almost certainly diminish circulation even further and this could make them more likely to get dementia.

©Janet Farrar Worthington

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How to Age Well, Part 2

This is the second part of a series on aging well. – Janet

It all makes sense, but sometimes we need to hear this stuff anyway.  Eat right, get vaccinated, and get some sun, because Vitamin D protects your body and helps prevent cancer.  This is from How to Age Well, Part 1.   Part 2 is about how we all need to get off the couch, mentally as well as physically.

Jeremy Walston, M.D., a gerontologist at Johns Hopkins, co-directs the Biology of Frailty Program and is co-principal investigator of the Older American Independence Center.  He has spent his career studying how we age.  In addition to many studies on specific aspects of aging, he has looked at what healthy older people have in common — at what they eat and don’t eat, and how they live – and has come up with some practical tips.  I recently interviewed Walston for Breakthrough, the magazine for the Johns Hopkins Center for Innovative Medicine.

Here’s more of what he had to say:

Keep Moving

exercise“Stay active as long as possible,” says Walston.  “Don’t sit for long periods of time, especially in the late afternoon or evening.  Studies show that those are low-activity times for many people, so it’s good to try to boost your activity during those times.”  Go for a walk after dinner.  Walking is good; in fact, you should walk a lot, or do some aerobic activity – there’s plenty to choose from. 

Just a few examples include taking a Zumba or Jazzercise class, riding a bike, swimming or doing water aerobics, hiking, jogging, or dancing.  In addition to getting cardiovascular exercise, “it’s also important to do exercises that help you stay flexible, that help your balance and gait, and that help strengthen your muscles.  Don’t forget your shoulders,” which are important for maintaining core body strength and higher levels of function.  And if you have an “orthopedic issue,” like knee or hip trouble, address it.  “It is essential to maintain your mobility as long as possible.”  This may mean that you need a knee or hip replacement – but it also could be something as simple as starting to use a cane.

However, while you’re staying active: 

Don’t Fall

balanceThe body literally takes a hit when you fall.  Many older people, who otherwise have been doing pretty well, take a turn for the worse after a fall.  Just being laid up for a few days, or even longer, can be difficult for the elderly because they tend to lose strength quickly. 

The best way not to fall is to be aware of the risk, and do your best to prevent it, says Walston.  “Things that can make you fall include not watching your medication; vision problems; weakness in the lower extremities; and balance and gait problems.” 

One huge risk factor is easy to fix:  “low lighting and a cluttered living area.”  Make sure your rooms are well lit – that you not only have enough lamps or ceiling lights, but that the bulbs are high-powered enough so you can see where you’re going.  And go after the clutter.  It doesn’t take much – maybe a stack of books or magazines that slips over, or a puzzle left by a grandchild on the floor – to make a walkway treacherous. 

Sometimes, you’re so used to looking at clutter that you don’t see it.  This is why Walston recommends bringing in an independent party – a friend or relative who is not used to your home, who can see potential trouble spots you haven’t noticed.

You can lower the odds of falling, as well, by working on your balance.  Tai Chi is a great way to do this, and many community centers offer classes (another bonus: taking a class helps you stay connected – see below).  Weights and exercises can also help your legs get stronger. 

Keep your mind active, too

puzzle“Cognitive risk factors include diabetes, elevated lipids, and high blood pressure,” says Walston.  Medications can keep all of these problems in check.  Even if you are currently being treated for these, it’s good to go the doctor for “tune-ups” every so often, to make sure you’re still on the right dosage.   

But other things can affect how well you’re thinking and functioning, too, and they may not be what you’d expect:

Poor hearing:  If you don’t feel connected, you may tend to withdraw from the conversation, smiling politely, not engaging, because you don’t know what people are saying.  This is bad.  “Get a hearing aid if you need one.”  It won’t just help your hearing; it will help your brain.

Personal note: I find this especially poignant.  There’s a feedback loop between our brain and the world.  We need stimulation to keep our brain going.  If we withdraw and isolate ourselves, we don’t get that feedback, and this hurts us mentally.  If all you need to do to help stop this from happening is get a dang hearing aid, swallow your pride and go get one!  Do it for your brain.

Physical inactivity:  Being active affects every part of your body.  It helps your heart work better, helps your lungs get more air, strengthens your muscles, and helps your brain work better.  Many studies have shown that older adults who are active are less likely to get dementia and Alzheimer’s. 

Depression:  If you are depressed, you are going to be withdrawn, you may not eat or sleep very well, and you may not get enough exercise.  All of these can affect your cognitive skills. 

Addressing all of these risk factors is good “cognitive protection,” says Walston.  And one of the most important ways to protect your brain is to stay active is to “interact with others more frequently.”  Stay connected.  Talking to people — volunteering, interacting with others in church, clubs, or other groups, being around family or friends – is good medicine. 

This is the second part of a series on aging well. To read part one click here. 

©Janet Farrar Worthington

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Can Your Gut Bacteria Make You Depressed?

Mr. Rogers' Neighborhood

Gene J. Puskar/Associated Press

If you’re old enough to remember Mr. Rogers, you might remember him singing the happy little song, “So, who are the people in your neighborhood, in your neighborhood, in your neighborhood… they’re the people that you meet when you’re walking down the street.  They’re the people that you meet each day.”

This isn’t Mr. Rogers’ neighborhood.  It’s a lot smaller, but there are some interesting characters here.  They are bacteria, also called gut flora, or microflora.

The microflora in the gut are way more important than anyone realized even a few years ago.  This microbiome is made up of communities of bacteria and other organisms.  Tiny changes here can have big effects — not only on our digestive tract, but on our emotions.

Cynthia Sears, M.D., professor of medicine at Johns Hopkins Medical Institutions, is the director of the Scientific Advisory Board of the new Johns Hopkins Food, Body & Mind Center.  (I wrote about some of the research going on at this center in a recent post.)  In addition to finding links between diet and disease, scientists at the Center, particularly Sears, are studying the role of good and bad bacteria in making us sick and keeping us healthy.

Sears has focused on the many interactions between the gut’s microflora – the little ecosystems of bacteria that live and die down there in without our ever knowing about it – and our health.  I recently interviewed her for Breakthrough, the magazine for the Johns Hopkins Center for Innovative Medicine.  Rapidly expanding evidence, she told me, suggests “that the complex communities that we carry with us, which are on every surface of the body, are essential to health.  But they’re also associated with disease” — both right there in the gut, and distantly.  “They influence liver function, the function of the deep tissues, the enteric nervous system.”  They may also contribute to heart disease, pancreatic conditions, and be linked to our mood and to psychiatric disorders, as well as our weight.  “This concept is amazing,” she says, “particularly the idea that they can influence our mood and how we function in life.”

So, imagine that you have depression, and a doctor has put you on an antidepressant.  And it’s not really helping that much.  Then imagine that a doctor tells you, “the problem could be in your gut.”  This discussion is still pretty new, Sears says, but “our hope is that we will be able to identify the bacteria that produce the right metabolites, the ones that make you feel better,” to change how the microbiome functions.  “So if the microbiome has bad molecules, that we could modify it or treat it in such a way that you get good molecules and change the balance.”

Good bacteria

Photo Credit: sahilsajjad via Compfight cc

I asked her if this might one day eliminate the need for antidepressants.  Probably not, Sears says.  “But there are a lot of people who probably don’t fit into classic psychiatric criteria, who don’t feel well.  So this idea that we can use food and possibly ‘good’ bacteria to modify function and make someone feel better, and help turn someone’s life around, is very intriguing.”

Fermented Foods and Probiotics

Is there anything you can do to help clean up the neighborhood of bacteria in your gut?  Well, yes:  You can eat fermented foods, which contain probiotics, or you can take supplemental probiotics.  The problem with probiotics is that they are not regulated as drugs by the FDA, and there is a lot of variability in quality and effectiveness.  Similarly, there is a surprising lack of definitive, scientific journal-published research absolutely proving that fermented foods are helpful to your health.  However, that said, there is a lot of anecdotal evidence that they are.  The fermented items listed below, eaten in moderation, are not harmful to your health.  You may want to give them a shot for a couple of weeks, and see if you feel better with them in your diet.

Sauerkraut.  It’s fermented, hip, it’s happenin’ — check out the gourmet varieties (like Wildbrine’s Arame Ginger) of sauerkraut in the refrigerated section at upscale grocery stores — and it’s been around since the 4th century B.C.  First of all, it’s cabbage, and cabbage is already good for you, just raw out of the garden.  It’s in the family of cruciferous vegetables, along with broccoli and cauliflower, which have long been shown to help prevent cancer.  But the fermentation process brings some new chemicals to the table, including: isothiocyanates, which counteract carcinogens and help the body remove them; glucosinolates, which activate the body’s anti-oxidants; and flavenoids, which help protect artery walls.  Sauerkraut has few calories.  However, if you eat too much of it, it can cause diarrhea.  Again, moderation in all things.

Kombucha.  Fermented black tea.  Again, we’re starting with something that is already good for you; tea is rich in antioxidants.  Fermented black tea delivers a load of probiotics to your gut.  In addition to aiding digestion, these beneficial bacteria boost the immune system and can relieve irritable bowel symptoms, yeast infections, and other problems.  In one study, rats given kombucha had higher levels of “good” HDL cholesterol, a finding linked to a lower risk of cardiovascular trouble.   FloraStor, a commercial probiotic that’s used to treat C. difficile colitis, was isolated from kombucha.  A study from India found that a form of kombucha was just as effective as the drug, omeprazole (Prilosec), in healing stomach ulcers.  (Note: If you have an ulcer, I wouldn’t chuck Prilosec and start drinking kombucha.  For one thing, the kind you get might not have the kind of bacteria these scientists studied; also, how much would you need to be drinking every day, and for how long?  Ideally, as fermented foods become more popular, they will be better studied and their benefits will become a lot more clear.)

file5321333011701Yogurt.  Look for the words, “Live and active cultures.”  These are probiotics, and besides increasing the number of good bacteria in your gut, they can help reduce symptoms of irritable bowel syndrome, and also can help improve symptoms of inflammatory bowel diseases, such as Crohn’s and ulcerative colitis.  Greek yogurt has more protein than traditional yogurt; it takes longer to digest and can help you feel full longer — which, in turn, can reduce the need for snacks between meals, so as a bonus, it may help you lose weight.

 

 

In addition to the book, I have written about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org.  The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  I firmly believe that knowledge is power.  Saving your life may start with you going to the doctor and knowing the right questions to ask.  I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease.  Many doctors don’t do this, so it’s up to you to ask for it.

©Janet Farrar Worthington

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What You Eat and How You Feel

gut ache

Ever had a gut feeling?  Felt butterflies in your stomach?  Maybe gotten a little crampy or needed to make an emergency trip to the bathroom during times of stress?

Now, let’s look at this from the other end, so to speak:  Maybe you’ve been feeling anxious or depressed.   Maybe you feel bad, and you don’t know why.  Maybe something in your diet is making you feel this way.

Maybe what you eat is making you sick.

There is an intimate, intricate link between the brain and the gut that scientists are just beginning to understand.  Questions are being asked and investigated that, frankly, nobody thought of even a few years ago, because the connections weren’t there yet.  That is changing.

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Here are some fun facts you should know about what scientists call the gut-brain axis:

  • You have as many neurons (nerve cells) in your gut as you do in your spinal cord.
  • These intestinal nerve cells crank out 90 percent of your body’s serotonin and half of its dopamine. Both of these powerful neurotransmitters help the mind stay calm and focused and are natural anti-depressants.
  • If you go to a doctor for irritable bowel symptoms (such as alternating diarrhea and constipation) or dyspepsia (uncomfortable fullness or pain in the upper abdomen, heartburn, or other digestive problems), you are likely to be prescribed one of the same drugs used to treat anxiety or depression. Doctors don’t really understand why these “brain” drugs work on the gut, but they know that they help make symptoms better.
  • As many as 40 percent of people who go to the doctor with gastrointestinal problems suffer from irritable bowel syndrome and gastroparesis (the stomach muscles or the nerves that drive them stop working, and food doesn’t move out of the stomach the way it should) – conditions that involve the enteric nervous system.  This is the massive highway of nerve cells lining the muscular walls of your esophagus, stomach, intestines, and rectum.
  • These nerves control peristalis, the conveyor-belt series of muscle contractions — think of toothpaste being squeezed through a tube — essential for swallowing, for digestion, absorption of food, and for pooping (literally, movement of the bowels).
  • These enteric nerves also affect immune responses and inflammation.
  • Changes in our mood can also affect everything in the gut.

Is there really a food-mood connection?  Here’s a good example:  An estimated 1 in 133 Americans have celiac disease, an autoimmune disease in which the body attacks the small intestine (this can be diagnosed with a blood test).  The culprit is gluten, which is in wheat.  If you have celiac disease and you don’t change your diet, and you get an upper endoscopy, if you are lucky, it will likely show a telltale “cobblestoning” of the small intestine – damage to the villi, tiny, fingerlike oars that help the small intestine absorb the nutrients in your food.  This damage is reversible.  Within a few weeks of going gluten-free, these little dudes come back and your small intestine can do its job again.  If you are not lucky, a biopsy to the small intestine will show that the celiac disease has caused cancer, and this is not good.

Am I saying you have celiac disease if bread gives you a belly ache? No, but bear with me:  One, a lot of people test negative for the disease itself, but notice they feel bad when they eat bread or pasta.  They feel bloated, maybe a little cranky; maybe they also get headaches.  They also feel better when they eliminate gluten from their diet.  They may have gluten intolerance, which is not the same as celiac disease, but responds well to a change in diet.  Two:  People with celiac disease who give up gluten notice a lot of other changes in their lives.  They may put on muscle mass, because their body was starving from the inside; no matter how much they ate, they weren’t absorbing the good nutrients, because their small intestines didn’t function right.  They also tend to realize, with great surprise, that they have felt bad for years; they just didn’t know why.  And here’s the kicker: Their mood improves.

Celiac disease can cause depression, irritability, and anxiety, but can get better with a diet change.

What I want you to think about is this:  If it can happen with one gut disease, it can happen in other problems involving the gut and/or diet.  Food affects mood.  Maybe you have a food allergy or intolerance that you didn’t know about.  The nerve cells in the gut affect your mood.  It’s the opposite of those ads for Las Vegas:  What happens in the gut does not necessarily stay in the gut.

Food, Body & Mind

“The gut has its own brain,” says Pankaj “Jay” Pasricha, M.D., gastroenterologist and neuroscientist, director of the Center for Digestive Diseases at Johns Hopkins Bayview Medical Center, and co-director of the new Johns Hopkins Food, Body & Mind Center.  At this center, the science is a fusion: it’s Gastroenterology, Neuroscience, Microbiology, Immunology, and Psychiatry.  They’ve got a bunch of doctors and scientists working together to figure out just how important a role the gut plays in diseases that seem like they wouldn’t trouble the intestines – diabetes, heart disease, depression, anxiety, even cancer.

I have interviewed Jay Pasricha several times for the Johns Hopkins Center for Innovative Medicine’s magazine, Breakthrough.  At the Center, he says, many of their patients come to them by way of a rather long road.  Basically, they’ve been through a lot — medicines that may not have worked, for example, or doctors who may have addressed one of their problems without realizing the whole body was involved.  Pasricha told me that his research involves multiple aspects of the gut-brain axis.  He is very interested in the pancreas, in exploring “how the gut can be a signal that drives metabolic disease,” he says, and “finding the mechanism by which gastric bypass surgery relieves insulin resistance and diabetes.” Pasricha has also shown in mouse models of diabetes that there is remodeling of the enteric nerves that help control insulin production; he believes that a new approach to treating diabetes — by changing the way the nerves signal to each other — may be on the horizon.

Enteric nerves

Exactly how the brain in the gut relates to the “big brain” is what Pasricha and his colleagues are working hard to find out, testing the potential of never-before-recognized molecular targets for treatment of nausea, abdominal pain, and other symptoms that may arise when mind-gut pathways go awry.   “The treatment of motility disorders (like irritable bowel disease and gastroparesis) really requires the art as well as the science of medicine, because every patient responds differently,” notes Pasricha.  “In fact, there are very few effective treatments, and what works for one person might not be very helpful for another,” which is why he believes that entirely new avenues of treatment might make a huge difference in care.

But better treatment for motility disorders is most likely just the tip of the gut-brain iceberg, Pasricha believes. The enteric nerves almost certainly play a role in obesity, diabetes, in pancreatitis; they may even be involved in Alzheimer’s disease, some forms of cancer, and other diseases that aren’t usually thought of as relating to the gut.

These nerves are involved in immune responses, he explains, “and this process, called neurogenic inflammation, is a problem in many disabling diseases.” Signals from the enteric nervous system affect metabolism in the brain, liver, and elsewhere.  “The bigger picture here is enormous.”

Next: Bacteria in your gut, good and bad.

In addition to the book, I have written about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org.  The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  I firmly believe that knowledge is power.  Saving your life may start with you going to the doctor and knowing the right questions to ask.  I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease.  Many doctors don’t do this, so it’s up to you to ask for it.

©Janet Farrar Worthington

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