Colon Health, Microbiome, Endurance exercise concerns
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Fall 2015 Health News


Michelle Crowder, ND - Licensed Naturopathic Physician


Hello! I am back with some updates and articles for you all. I continue to enjoy the challenges, learning, and people I have the honor to work with at Dr Kennedy's family practice in Rochester Hills and Beaumont Integrative Medicine in Grosse Pointe. Both locations are accepting new patients; see my website for relevant contact information.  

Outside of clinic, here are some other things I have been up to since last time...
  • I led a 21-day detox group at Dr Kennedy's in September. These programs are intended to provide a way to explore positive lifestyle and dietary changes in a group setting, under a doctor's guidance. I try to offer them twice per year and hope to hold one in Grosse Pointe with Beaumont next spring. Stay tuned to my Facebook page or website for updates.   
  • Also in September, I appeared as a guest speaker representing integrative medicine on the TV show, Ask Dr Nandi. It was a great experience! I really enjoyed working with Dr Nandi and his staff, and getting to know the other guest speakers. See article below for more details, and tips on promoting colon health.
  • Last month, I ran my first marathon! See article below for a bit more info, as well as special health considerations for endurance athletes. 
  • Next month, I will be traveling to rural Ecuador with Paramos de Esperanza, a group of physicians who have been providing free medical care to the local people for over 30 years. In the past, I have worked with organizations in rural areas of Nicaragua and Guatemala. This work is one of my greatest passions and a primary reason I chose to pursue medicine, so I am very excited and grateful for the opportunity. Updates to follow!

Please note that I will be out of the office from December 14 to 25; please plan follow up visits accordingly. I wish you all a wonderful holiday season! 

Previous newsletter from Summer 2015.
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En salud,

Dr. Colleen Kennedy Family Practice
75 Barclay Circle, Suite 225
Rochester Hills MI 48307

Beaumont Integrative Medicine
Beaumont Vein Center, First Floor
87 Kercheval, Grosse Pointe Farms MI 48236 

Colon Health

I recently appeared as a guest speaker on the TV Show, Ask Dr Nandi. The episode will be airing in the next several months; stay tuned to my Facebook page for updates. The topic of the show was colon health and colorectal cancer. I spoke on behalf of the integrative medicine world about various approaches to these health concerns.

Colon health in general is a huge topic, and I have written on it before (see here and here; as well as article on Microbiome below). Colorectal cancer is a smaller, but very important topic. First, a few important points on the topic of cancer and naturopathic medicine: Naturopathic doctors are NOT trained to treat cancer; instead, we are trained in complementary support for conventional treatment like surgery, radiation, and chemotherapy. There are various natural substances and lifestyle habits that have been shown to improve efficacy of conventional treatments, improve survivorship, and/or help mitigate common side effects and nutrient depletions of conventional therapies. Some naturopathic doctors have completed additional training in this area, and are designated FABNO (Fellow of the American Board of Naturopathic Oncology). This is currently the only board certified speciality in naturopathic medicine.

Colorectal cancer is the third most common cancer and the second leading cause of cancer death among men and women in the US. Screening via colonoscopy can identify and remove precancerous polyps, reducing incidence of disease. Risk factors may include age, African American race, history of polyps, inflammatory bowel disease, certain genetic syndromes, family history of colon cancer, sedentary lifestyle, obesity, diabetes, smoking, heavy alcohol consumption, and low-fiber diet.  

Here are a few important points to consider regarding integrative approaches to colorectal cancer prevention while waiting for the episode to be released: 

Dietary considerations (and the recent uproar about "red meat causes cancer"): A low-fiber, high-sugar, high-animal fat diet is considered to be a risk factor for colorectal cancer, while a diet high in colorful vegetables and fruits is considered to be protective. (Although studies on this topic are mixed - 1, 2, 3.) Certain food compounds, such as polysaccharides found in mushroom and apple, seem to have particular preventive qualities. The World Health Organization (WHO) recently released a report developed by the International Agency of Cancer Research (IACR) classifying red and processed meats as group 1 human carcinogens - in the same category as tobacco and asbestos. This caused quite a stir in the media and among the public. While the evidence for the carcinogenic impact of these subjects is considered to be strong, the report did NOT state anything about the degree of carcinogenicity or assess the level of risk. If we look at the impact of these substances on overall mortality, we see that red and processed meats actually contribute a relatively small amount to overall risk compared to other factors. As stated in an article by UK Cancer Research: "According to the most recent estimates by the Global Burden of Disease Project, an independent academic research organization, about 34,000 cancer deaths per year worldwide are attributable to diets high in processed meat; red meat could be responsible for 50,000 cancer deaths per year worldwide. In contrast, about 1 million cancer deaths per year globally are due to tobacco smoking, 600,000 per year are due to alcohol consumption, and more than 200,000 per year are due to air pollution."
Here are additional articles that explain this concept of how different risk factors contribute to cancer mortality - 
UK Cancer Research

Physical activity. Regular physical activity is important for so many health concerns, and seems to be particularly important in colorectal cancer prevention. Studies have shown that regular physical activity reduces relative risk of colon cancer by approximately 25-50% (1, 2, 3). Approximately 16% of colon cancers diagnosed globally are thought to be due to physical inactivity.

Vitamin D status. A large body of clinical and epidemiological evidence supports the importance of Vitamin D status on colorectal cancer prevention. Studies have shown that intake and circulating levels of Vitamin D are inversely correlated with risk (1, 2, 3). However, there is no consensus on what an optimal level of Vitamin D should be. The Institute of Medicine recommends a minimum level of 20 ng/ml, while a meta-analysis suggested that 35 - 44 ng/ml seems to be most protective. It is also unclear whether supplementing with Vitamin D reduces risk, or whether Vitamin D status is more of a marker for risk (1). Optimal Vitamin D level is an active area of research and an important discussion to have with your healthcare provider.

Botanical medicines. Although lifestyle will be a much more important factor in colon cancer prevention than any individual compound for most people, there are a few botanicals that deserve mention. 
  • Turmeric. This bright yellow culinary spice, common in cuisine of India and other parts of Asia, contains the active compound curcumin. Curcumin is proving to be quite an amazing compound in terms of human health; it possesses anti-inflammatory and other properties, and is used for a variety of health conditions. See here for a past article on turmeric. In terms of colon cancer, curcumin has been shown to stop growth of colon cancer cells by inhibiting expression of certain receptors in colon cancer cell lines. It also has been shown to inhibit NFk-B (a powerful inflammatory signal associated with many cancers) by both directly affecting the protein and by interrupting its genetic expression. Curcumin (in combination with the flavonoid quercetin) has been shown to reduce the number and size of ileal and rectal adenomas in patients with Familial Adenomatous Polyposis, in a small but compelling study
  • Green Tea is rich in the flavonoids catechin and epicatechin. Epigallocatechin-3-gallate (EGCG) is the most abundant catechin in green tea. Green tea seems to protect against cancer by reducing tumor growth and promoting apoptosis (programmed cell death) of cancerous cells (1, 2). Studies have shown that green tea may reduce incidence of precancerous adenomas and of colon and rectal cancer in humans. 

The Microbiome

Microbiome is a very hot topic these days. It is an exciting area of research and discovery. The microbes (bacteria, viruses, protozoans, fungi, etc.) that exist in and on our bodies are proving to have profound influences on our overall health, with clear effects on our immune, gastrointestinal, and nervous systems. Although the ratio is often disputed, it has been estimated that microbial cells outnumber our own human cells by 10 to 1. The term given to the collection of these microbes is "microbiome."  

Here are some key points regarding the microbiome and human health:
  • Diversity is important. We know from ecology that communities that are less diverse are also less robust to changes in the environment and more susceptible to insults. Think about agricultural monocropping - if an entire field is planted with the same species of corn and a pathogenic fungus invades, the entire field could be wiped out; whereas if a variety of species - or even different varieties of corn - had been planted, some would likely be resistant to the fungus and survive. Diversity allows for more potential solutions to environmental challenges and promotes a more sustainable system. This concept also applies to our own microbial communities. In addition, it is thought that greater diversity allows for increased information exchange between our microbes and our immune system. I listened to a great talk by integrative pediatrician Maya Shetreat-Klein MD, who described a "meet and greet" philosophy on the topic of healthy microbiome. The body's interaction with microbes seems to help the immune system develop "social skills" and understand who belongs in the body and who does not. Allergies and autoimmune diseases can be thought of as a confusion on the part of the immune system as it attacks benign stimuli (e.g., pollen allergy), or its own tissues (autoimmunity). We see in the literature that diverse microbiomes seem to protect against atopic disease like allergies and asthma (1, 2), as well as other chronic diseases like type 2 diabetes. It may be surprising that certain parasites like helminths (hookworms and the like) are showing to be quite beneficial in treating certain autoimmune disorders, and even promoting overall microbial diversity. Perhaps this is part of the reason that atopic and autoimmune conditions are present at such lower frequency in areas of the world where parasitic infection is greater.
  • What we eat influences our microbiome. While microbiomes exist throughout our body (skin, lungs, even placenta), it is the microbiome of the gut that seems to receive the most attention. A very neat study showed that the microbial community of the gut seems to have the capacity to change quickly in response to changes in its environment; i.e., certain organisms predominated when fed an animal-based diet, while others flourished when a vegan diet was consumed. These changes occurred sometimes within 1 day of dietary modification. The microbiome can adapt very quickly! However, while these short-term changes were happening, it also seems that certain characteristics of the microbiome are retained long-term, like fingerprints. These microbial fingerprints may be unique enough to identify an individual with a fairly high degree of accuracy.  
  • The microbiome of the gut nourishes our own cells. In ecology, a mutualism refers to a relationship that benefits all individuals involved. The human-microbiome relationship includes many examples of mutualism. An important one to understand is the following: Food compounds that we cannot digest, such as fiber and certain starches, provide food to beneficial microbes in the gut. The microbes consume the fiber and as a by-product create compounds called short-chain fatty acids (SCFAs) including butyrate, that then nourish and feed the cells lining the intestine, keeping the gut healthy. This is why fibers are so important to maintaining a healthy gut barrier. See below for more info on which foods to emphasize.
  • The microbiome affects our immune system. It is estimated that 70-80% of the immune tissue in our body exists in the area surrounding the intestines. Thus, due in part simply to proximity, the gut microbiome can greatly influence immune response. For example, certain microbes seem to be protective: Bacteroides fragilis seems to protect against development of colitis and central nervous system demyelinating disease (multiple sclerosis is an example of the latter). Other microbes seem to promote immune-mediated disease: Bilophila organisms, when present at high frequency, were associated with increased incidence of colitis.  
  • The microbiome affects our nervous system and mood. Gut microbes secrete neurotransmitters such as serotonin, dopamine, and GABA. At least half of the serotonin, and a majority of the dopamine produced in the body is made in the gut. These chemicals help to regulate appetite, feelings of fullness, and digestion. Microbes produce other neuro-active compounds; for example, butyrate (the SCFA produced by microbes when we eat fiber, described above) is linked to reduced age-related memory decline in rats. It appears that at least some of the communication between the gut and the brain occurs via the vagus nerve. Studies in mice have shown that certain pathogenic bacteria were associated with more anxious behavior; certain microbes seem to be important for neuronal development of motor control and regulation of anxiety behavior; the microbe B. fragilis can correct intestinal permeability and autism-like behavior; and Lactobacillus rhamnosus reduced anxiety and depression. Studies in humans have shown that probiotics are effective for treating symptoms of chronic fatigue syndrome and psychological distress (1, 2); L. acidophilus and B. longum protected against stress-induced intestinal discomfort; people who consumed probiotic yogurt seemed to react more calmly to emotional stressors; people who consumed prebiotic compounds had lower levels of the stress hormone cortisol and an overall more positive outlook. This is such an interesting area of research. See this recent NYT article for more. 
  • Associations exist among certain microbes and certain health parameters, but in most cases we are still unsure if the relationship is causative or merely associative. For example, certain bacteria are more likely to be found in depressed patients; these same bacteria are associated with stress, inflammation, IBS, obesity, chronic fatigue, and low fiber diet. Certain microbes are closely associated with colorectal tumors. Certain microbes are more predominant in obese versus thin subjects.

So how you do you promote a healthy microbiome? 
  • Eat whole foods. Processed foods and refined sugars are not only nutrient-poor and generally inflammatory, but they also negatively impact the microbiome. Certain organisms like Firmicutes bacteria, when out of balance, are associated with increased obesity and other health problems; Firmicutes feed on sugar and thrive under conditions of low-fiber diet.  
    • Certain foods seem to have particular benefit. Foods containing "prebiotic" compounds like inulin and other polysaccharides are not digested well by our own enzymes. Consequently, they remain in the gut and are consumed by the microbes present. These fibers and starches feed the microbes, allowing them to thrive and do their good work. Asparagus, garlic, onion, leek, jerusalem artichoke, dandelion greens, beans and lentils, unripe banana are some of the foods containing prebiotics. It is important to mention that people with certain health needs (such as inflammatory bowel diseases like crohn's and ulcerative colitis, or SIBO - small intestine bacterial overgrowth) may not be able to tolerate prebiotic foods; for many, but not all of these people, prebiotics can worsen disease, so I recommend working with a knowledgable practitioner when possible. 
  • Probiotics. It is unclear to what extent common probiotics like Lactobacillus and Bifidobacterium, when taken in supplement form, actually take up residence and establish themselves in the gut. However, that does not mean they are useless. Many studies have shown that taking probiotic supplements can improve symptoms and disease progression for conditions such as IBS (irritable bowel syndrome), IBD like Crohn's and Ulcerative colitis, and Autism Spectrum Disorders. It seems that these organisms may be a type of "keystone" species in the gut, meaning that they are important and influential to health even at very low concentrations. For example, they may pass on DNA or other substances to bacteria that already reside in the gut, or impact physiology as they transit through the digestive tract. 
  • Manage stress. Stress suppresses the immune system, including the immune proteins that line the gut, called secretory IgA. Without these proteins, we are more susceptible to overgrowth by undesirable organisms like certain bacteria, yeast, and parasites. Stress also promotes increased intestinal permeability, or "leaky gut," which carries with it a host of problems, including increased inflammation, allergy, and autoimmunity
  • Avoid unnecessary antibiotics, acid-suppressing medications, and NSAIDs like ibuprofen. Antibiotics reduce diversity of the microbiome. Because proper stomach acid is required to promote proper microbial balance, acid suppressing-medications can make people more susceptible to overgrowth and infection (1, 2). Acid-suppressing meds and NSAIDs are both associated with increased intestinal permeability ('leaky gut") (1, 2), discussed above. These medications are necessary in certain situations, and we are lucky to have them at our disposal. However, many people take them to control symptoms that could be addressed in another manner, such as lifestyle modification, nutrition, botanical medicine, acupuncture, etc. that is targeted at addressing the root cause(s) for the symptoms. Antibiotics are often taken for viral illness or for infection that could resolve with supportive or integrative therapies. This is not only detrimental to the individual microbiome, but also contributes to the growing public health crisis of antibiotic resistance.
  • Avoid exposure to toxins like tobacco, pesticides. Chemical toxins in the environment unfortunately cannot be avoided in many cases, so it is important to reduce exposure to those that you can control. Tobacco smoke is  associated with pro-inflammatory changes in the  microbiome. Pesticides can be active against our own microbes and reduce diversity. For a list of most important produce to purchase as organic, see Environmental Working Group

Health Considerations Related to Endurance Exercise

As mentioned above, I ran my first marathon last month. This was a goal of mine since becoming a regular runner ~2.5 years ago. It was an interesting process, working up from barely being able to run 1 mile, to 26.2. I took care of myself and gave ample time for my body to rest and recover during the training process. It ended up being a positive experience for me. That said, I believe it is important to make clear that marathon and other endurance exercise is not necessarily the best approach to general health for most people. Endurance exercise is stressful to the body in various ways. So if you decide to embark on an intense exercise program to work towards a goal or for other reasons, there are special health considerations to keep in mind. 

Here are a few issues that may be more common in people who engage in endurance exercise:
  • Increased intestinal permeability ("leaky gut"): For more detail on leaky gut, see this article from a past newsletter. Leaky gut can occur from a variety of stressors on the body, including physical exercise. Our autonomic (involuntary) nervous system has two branches - the parasympathetic ("rest and digest"), and the sympathetic ("fight or flight"). We need a balance of each, without either one being too dominant. Exercise, especially strenuous, activates the fight or flight response, shunting blood and energy to our muscles and cardiovascular system, and away  from our digestive tract. While this is a functional response to physical activity, if it is not balanced with a proper amount of "rest and digest", for example because of a high amount of emotional stress in your life, lack of sleep, etc., leaky gut can result. Leaky gut can trigger or worsen inflammation, nutritional imbalance, allergies, autoimmune disease, and other problems. Studies have looked into use of probiotics and bovine colostrum to help reduce the intestinal permeability brought on by exercise.     
  • Adrenal imbalance: The "fight or flight" response described above is orchestrated in part by adrenal hormones such as cortisol, epinephrine, and norepinephrine. Again, we need this stress response in order to be able to adapt to changes in the environment, but it must be balanced and not persist for too long. Endurance exercise can cause prolonged elevations in the stress hormone cortisol, which can lead to health problems such as elevated blood sugar and diabetes, weight gain especially in the abdomen, reproductive hormone imbalances, and increased inflammation that can trigger or exacerbate many illnesses including autoimmune conditions and cardiovascular disease.
  • Immune suppression: Building from the previous point -- although we need a cortisol spike in the morning to promote proper immune response, if cortisol remains elevated or is otherwise out of balance throughout the day, our immune system suffers. We become more susceptible to infection. Techniques that balance cortisol response, such as yoga and meditation, have been shown to positively impact the immune system, benefitting conditions such as HIV and cancer.    
  • Nutrient deficiencies: Common nutrient deficiencies in endurance athletes include B vitamins, Iron (1, 2), Zinc; other important considerations include Vitamin DMagnesium, possibly antioxidants such as Vitamin C; and Glutamine (an amino acid important in the health of the intestinal membrane, and often used to treat leaky gut) (1, 2, 3, 4). (Vitamin C, Vitamin B5, and Zinc are all very important for adrenal function, by the way.) Deficiencies in any of these could be a cause of consequence of any of the previous points discussed above. There is evidence that supplementing with these nutrients can be beneficial. For example, a Cochrane Review found that Vitamin C was not very effective for common cold prophylaxis in the general population, but it was more effective in a subgroup analysis that included marathon runners and other endurance athletes. However, supplementation may not be the best approach in every case. There is evidence that supplementing with antioxidants like Vitamin C and Vitamin E can actually reduce benefits of training, possibly due to changes in mitochondrial adaptation (1, 2). Very little, if anything, is certain in medicine, and so much depends on factors unique to the individual. 

On the other hand, too little exercise is associated with adverse physiology like imbalances in blood sugar, neurotransmitters, and hormones; and increased risk for illnesses such as diabetes, heart disease, depression, osteoporosis, and some cancers like colon and breast cancer. So, like most things in life, moderation is probably the key -
  • Lead an active lifestyle (go for walks or park farther from your destination, take the stairs, do housework, play, go for a bike ride).
  • Engage in regular moderate exercise to tolerance (~30 minutes of cycling, running, swimming, workouts, yoga)
  • Possibly add intermittent strenuous exercise if tolerated by your individual physiology (high intensity interval training, longer workouts).
Furthermore, each individual will vary in his or her tolerance to the stress of physical activity. If you are otherwise healthy, eat well, receive adequate sleep and rest, and manage your stress, your tolerance for physical stress is likely higher and you may receive more benefit from it. (As an aside, challenging the body with physical, nutritional, and other stressors seems to be important for activating our innate repair and antioxidant pathways.) On the other hand, if your lifestyle is out of balance, or you have an inflammatory condition, endocrine imbalance, or other chronic illness, gentle or moderate physical activity may be best for you. I aim to work with my patients to develop a plan that works best for their individual physiology and lifestyle.  

What is Naturopathic Medicine?

In short, Naturopathic Medicine combines the best of conventional and alternative medicine into an individualized, whole-person approach to primary health care. NDs are trained as primary care providers with an emphasis on natural and common sense approaches including clinical nutrition, lifestyle counseling, and botanical medicine.

What to Expect from Your Visit

I work with my clients to identify the root causes of disease, taking into account the various factors that influence health, including lifestyle, genetics, physiology, and mental-emotional state. First visits are 90 minutes and include a thorough health history, followed by discussion of my preliminary assessment and recommendations. I may order conventional or specialty lab work to aid in my understanding of your condition. We work together to devise a plan that will meet your health goals.

Follow-up visits generally last 30-45 minutes and are important so that I can better get to know your unique physiology, track your progress, and refine my recommendations. I can consult with your other health providers and make referrals as necessary.

Integrative Medicine

I am fortunate to work in an integrative primary care practice, alongside a D.O. (Doctor of Osteopathy), N.P. (Nurse Practitioner), and P.A. (Physician's Assistant).  We share patients and regularly consult with each other to coordinate care. 

I believe this approach benefits patients by offering them the best of both worlds - conventional and natural.  These two worlds are not mutually exclusive; in fact, many health concerns are best addressed by a multifaceted approach.  The power of Integrative Medicine is backed by research, especially for chronic conditions such as heart disease.
Gift Certificates are available at both Dr. Kennedy's office and Beaumont Integrative Medicine. Please call the relevant office to inquire.

FYI: Licensing and Regulation of Naturopathic Medicine

Licensed Naturopathic Physicians attend a 4-year post-graduate medical school accredited by the Council on Naturopathic Medical Education and recognized by the U.S. Department of Education. They must pass basic science and clinical licensing exams administered by the North American Board of Naturopathic Examiners. Currently, 16 states license Naturopathic doctors as primary care providers. National and state legislative efforts are organized by the American Association of Naturopathic Physicians.  Because NDs are not currently licensed in Michigan, they function as complementary providers.

For more information about the active legislative efforts to license Naturopathic Medicine in Michigan, visit the Michigan Association of Naturopathic Physicians.


About Michelle Crowder, ND

Michelle Crowder, ND is a licensed Naturopathic Physician with a focus in holistic and preventative primary care.  She works with people of all ages to identify and treat the root causes of disease, empowering her clients with the tools they need to understand and take control of their own health. Areas of special interest include digestive health, hormone imbalance, and immune dysfunction, including thyroid disease.

National College of Natural Medicine, Doctorate of Naturopathic Medicine, High honors
University of Vermont, Master of Science in Botany, Summa Cum Laude
University of Michigan, Bachelor of Science in Biology, Summa Cum Laude
Copyright © 2015 Michelle C Davila, ND, All rights reserved.
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