Diets high in fat, sugar may reduce cognitive functioning by altering gut bacteria

A Diet high in fat or sugar may do more than expand our waistlines. A new study by researchers from Oregon State University finds such diets may lead to reduced cognitive functioning, with a high-sugar diet named as the biggest culprit.

The team found diets high in sugar or fat triggered alterations to the gut microbiome linked to reduced cognitive functioning.

Published in the journal Neuroscience, the study reveals that high-fat and high-sugar diets trigger changes in gut bacteria that are largely associated with loss of "cognitive flexibility" - the ability to adapt to changing situations.

In addition, the high-sugar diet was associated with poorer short- and long-term memory.

Principal investigator Prof. Kathy Magnusson, of the College of Veterinary Medicine and the Linus Pauling Institute at Oregon State, notes there is an increasing amount of evidence emerging that gut bacteria can communicate with the brain.

"Bacteria can release compounds that act as neurotransmitters, stimulate sensory nerves or the immune system, and affect a wide range of biological functions," Prof. Magnusson explains. "We're not sure just what messages are being sent, but we are tracking down the pathways and the effects."

One example of how gut bacteria may interact with the brain was revealed in a study published in the journal Cell in April, in which researchers from the California Institute of Technology (Caltech) found that gut bacteria influence the production of serotonin - a neurotransmitter responsible for maintaining mood balance.

Reduced cognitive flexibility with high-fat, high-sugar diets

Prof. Magnusson and colleagues reached their findings using 2-month-old male mice, which were randomized to be fed either a high-fat diet (42% fat, 43% carbohydrate), a high-sugar diet (12% fat, 70% carbohydrate - mainly from sugars) or normal chow.

Prior to dietary intervention and 2 weeks after, the researchers analyzed the feces of the mice in order to establish the composition of their gut bacteria.

The short- and long-term memory and cognitive flexibility of the mice were assessed before and after dietary intervention via water maze testing and novel object and location tasks.

Compared with mice fed normal chow, mice fed the high-fat or high-sugar diets experienced a significant reduction in cognitive functioning - particularly in cognitive flexibility.

Explaining what cognitive flexibility is, Prof. Magnusson asks us to imagine driving home using a route that is very familiar. One day, the road is closed, meaning we need to find a different route.

An individual with a high level of cognitive flexibility would adapt to the situation straight away, immediately seeking out an alternative route. But a person with impaired cognitive flexibility may find the unexpected change in situation very stressful, causing them to become flustered and take longer getting home.

Reduction in cognitive flexibility was strongest for mice fed the high-sugar diet, according to the researchers, and this diet was also found to reduce short- and long-term memory.

Diets altered gut microbiome of mice

The team believes the reduction in cognitive functioning following diets high in fat or sugar was driven by alterations to the composition of gut bacteria, or the gut microbiome.

Both diets were linked to an increase in bacteria called Clostridiales and a reduction in bacteria known asBacteroidales, with such changes associated with reduced cognitive flexibility.

Mice fed the high-sugar diet experienced the highest increases in Clostridiales and the biggest reductions in Bacteroidales, consistent with the largest reductions in cognitive flexibility.

The team says their findings are consistent with some previous studies suggesting that a Western diet - typically high in fat and sugar - may negatively impact cognitive functioning. Past research has associated a Western diet with greater risk of Alzheimer's disease, for example. Their study indicates that such a diet may affect cognitive functioning via alteration of the gut microbiome.

Prof. Magnusson says:

"We've known for a while that too much fat and sugar are not good for you. This work suggests that fat and sugar are altering your healthy bacterial systems, and that's one of the reasons those foods aren't good for you. It's not just the food that could be influencing your brain, but an interaction between the food and microbial changes."

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Gut microbes important for serotonin production

Serotonin is probably best known as a brain chemical that affects emotions and behavior, an imbalance of which is thought to contribute to depression. Less well-known is that scientists estimate 90% of serotonin is made in the gut, and imbalances in this peripheral serotonin have been linked to diseases ranging from irritable bowel syndrome and cardiovascular disease, to osteoporosis.

90% of serotonin is made in the gut.
Image credit: E. Hsiao/Caltech

Now, researchers from the California Institute of Technology (Caltech) in Pasadena report a study in the journal Cell that shows certain bacteria in the gut play an important role in the production of peripheral serotonin.

Senior author Elaine Hsiao, research assistant professor of biology and biological engineering at Caltech, says studies of mice and other lab animals are increasingly showing that changes in gut microbes affect behavior.

She explains that she and her colleagues were interested in finding out more about how gut microbes and the nervous system talk to each other, and:

"To start, we explored the idea that normal gut microbes could influence levels of neurotransmitters in their hosts."

In the gut, there are three types of cell we know of that produce serotonin: immune cells, nerve cells or neurons, and enterochromaffin (EC) cells.

Gut microbes appear to influence serotonin production by EC cells

For their study, Prof. Hsiao and colleagues wanted to find out which cells the gut microbes might be influencing to have an effect on serotonin levels.

In the first part of the study, they compared peripheral serotonin levels produced from these cells in two groups of mice: one with normal gut microbes and another group of germ-free mice without gut bacteria.

The team found that in the germ-free mice, their EC cells produced around 60% less serotonin than the mice with normal gut bacteria.

And when they restored bacteria colonies in the gut of the germ-free mice, their EC cells began producing normal levels of serotonin - showing the effect on the EC cells can be reversed.

In the next part of the study the team set out to find which bacteria in particular were interacting with the EC cells to make serotonin.

They introduced single species and groups of gut microbes one by one into the germ-free mice, and found that serotonin levels went up when there was a certain mix of about 20 species of spore-forming bacteria.

Introducing this particular bacterial mix into the germ-free mice increased the movement of food through their digestive tract. It also changed activity in their blood platelets, which use serotonin to boost clotting.

Bacteria control gut microbiota metabolites to influence serotonin production

Further exploration in cell cultures revealed some of the molecular mechanisms underpinning the findings. The team found several metabolic byproducts of gut bacteria are controlled by the mix of spore-forming bacteria and act on EC cells to alter serotonin production.

When the researchers increased these metabolic byproducts in germ-free mice, it increased their levels of peripheral serotonin.

Other investigations have shown bacteria can make serotonin on their own. The researchers say their study suggests a lot of the serotonin in the body relies on the interaction between bacteria and host cells.

Prof. Hsiao says a lot more research needs to be done before findings like theirs are ready for clinical use, and offers a word of caution:

"We identified a group of bacteria that, aside from increasing serotonin, likely has other effects yet to be explored. Also, there are conditions where an excess of peripheral serotonin appears to be detrimental."

She and her team now plan to find out how their findings may apply to the human brain.

Researchers are also discovering other surprising things about serotonin in the body. For example, Medical News Today recently learned how a previously unknown source of serotonin could affect antidepressant activity.

One of the main drawbacks of SSRIs (selective serotonin reuptake inhibitors - a class of antidepressants that prevent reuptake of serotonin by increasing levels of it outside cells) is that they take a while to kick in. A study led by the University of Florence found that the source of this extracellular serotonin is not what experts have assumed, and finding out more about it should help improve drugs that target serotonin.

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CDC: drug-resistant intestinal bug spreading in US

A group of bacteria called Shigella is responsible for 500,000 cases of diarrhea in the US every year. Now a new report says a multi-drug resistant strain of the bug is entering the country in infected travelers and causing a series of outbreaks.

The CDC recommend people wash their hands often with soap and water to prevent spread of the diarrhea illness shigellosis.

Shigella causes shigellosis - an intestinal illness that is accompanied by watery or bloody diarrhea, abdominal pain, fever and malaise.

The Centers for Disease Control and Prevention (CDC) say a strain of Shigella sonnei - the most common species of Shigella in the US - that is resistant to the antibiotic ciprofloxacin (Cipro) infected 243 people in 32 states and Puerto Rico between May 2014 and February 2015.

Shigella is one of the types of bacteria that cause intestinal illness in travelers going from developed countries to under-developed countries. This "traveler's diarrhea," is variously referred to as "Montezuma's revenge," or "Delhi belly," or the "Turkey trots."

The bacteria are found in water used for drinking, to wash food or to irrigate crops, that has been contaminated by human or animal stools.

Cipro is a first choice drug for treating shigellosis among adults in the US. Until recently, Cipro resistance was only found in around 2% of Shigella infections tested in the US.

In the new report - which describes investigations into recent clusters of Shigella infection in Massachusetts, California and Pennsylvania - the CDC say Cipro resistance was found in 90% of the samples tested.

Some people infected with Shigella only have mild symptoms, but this does not stop the bug from spreading. The report says that in these outbreaks, the bacteria spread easily in childcare facilities and among homeless people and gay and bisexual men.

Investigators found unique strain of Cipro-resistant Shigella

CDC Director Dr. Tom Frieden says the outbreaks they investigated are a troubling trend:

"Drug-resistant infections are harder to treat and because Shigella spreads so easily between people, the potential for more - and larger - outbreaks is a real concern."

Dr. Frieden states the US is moving quickly to put in place a national plan to curb antibiotic resistance, because "we can't take for granted that we'll always have the drugs we need to fight common infections."

In the US, most strains of Shigella are already resistant to the antibiotics ampicillin and trimethoprim/sulfamethoxazole. Around the world, Shigella is becoming more resistant to Cipro, which is often prescribed to people traveling out of the US in case they develop diarrhea while abroad.

The report describes how through the CDC's PulseNet lab network, it was possible to identify an increase in shigellosis cases caused by a unique strain of Cipro-resistant Shigella. About half of the cases were people known to have returned from the Dominican Republic, India and other places outside the US.

The CDC recommend good hygiene habits to prevent the spread of Shigella, including:

• Wash hands frequently with soap and water
• Always wash hands with soap and water after using the toilet, and before preparing food and eating
• If your child is sick with diarrhea, keep them home and away from childcare and group activities
• Don't prepare food for others if you have diarrhea
• Avoid swimming pools and other public water places for a few weeks as you recover from a diarrhea illness.

Dr. Anna Bowen, a medical officer in CDC's Waterborne Diseases Prevention Branch, and lead author of the report, says:

"Washing your hands with soap and water is important for everyone. Also, international travelers can protect themselves by choosing hot foods and drinking only from sealed containers."

Scientists are starting to discover that antibiotic use - and overuse especially - is linked to a range of problems that affect, among other things, the immune system, glucose metabolism, food digestion, gut health and behavior.

For instance, in February 2015, Medical News Today reported another study that showed antibiotic use has more more unwanted side effects on the gut than previously thought. In that study, led by the College of Pharmacy at Oregon State University, Corville, researchers tested the effect of four antibiotics commonly given to lab animals.

Previously, it was thought the drugs only killed bacteria and blocked some immune functions in the gut. However, the study found they also destroy cells in the lining of the gut.

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Father inspired after child's autism improved by course of antibiotic

A parent has been prompted to investigate the connections between gut bacteria and autism following surprising improvements in his son's autism while taking an antibiotic for strep throat.

Amoxicillin is a form of penicillin and is frequently used to treat bacterial infections such as bronchitis, pneumonia and tonsillitis.

John Rodakis' son was prescribed a 10-day course of amoxicillin, one of the most frequently used antibiotics in the US, and within just 4 days of commencing the treatment, changes were observed in his autism symptoms.

"[He] began making eye contact, which he had previously avoided; his speech, which was severely delayed, began to improve markedly; he became less 'rigid' in his insistence for sameness and routine; and he also displayed an uncharacteristic level of energy, which he had historically lacked," explains Rodakis.

In an article published in Microbial Ecology in Health and Disease, Rodakis describes this unexpected turn of events and the journey of discovery he has since embarked upon, as he attempts to understand what caused his son's symptoms to change.

It became apparent to him early in his investigation that many other parents had experienced similar changes following courses of antibiotics, with some even routinely giving their autistic children antibiotics in order to improve their symptoms.

As well as these positive experiences, Rodakis also notes that some parents found their children's symptoms worsened under the influence of the medicine. "In my view, these stories are not contradictory but rather reinforce the notion that an antibiotic can create an effect in autism," writes Rodakis.

Rodakis' investigation brought him into contact with Dr. Richard Frye, head of the Autism Research Program at Arkansas Children's Hospital Research Institute. Together, in collaboration with other researchers from across the world, they decided a research trial was required, and a scientific conference was warranted.

Could research into the 'gut-brain' connection reveal the core biology of autism?

"Careful parental observations can be crucial," Dr. Frye explains. "In science we take these observations, put them through the scientific method, and see what we find. This is what can lead to ground-breaking scientific discoveries and breakthroughs in the field."

The First International Symposium on the Microbiome in Health and Disease with a Special Focus on Autism was held in June and it has led to a special edition of Microbial Ecology in Health and Disease being published, focusing on autism and the microbiome.

In recent years, evidence associating the microbiome - the collection of micro-organisms living on and in the human body - with autism has grown sharply.

Ellen Bolte, another parent of a child with autism spectrum disorder, had a hypothesis in 1999 that some cases of autism were affected by gut bacteria. From this hypothesis, a small clinical trial was conducted and since then, a significant body of research has been compiled.

One of the speakers at the conference, Dr. Rosa Krajmalnik-Brown, led a team of researchers at Arizona State University for a study in which children with autism were found to have less diversity in their gut bacteria than typically developing children. This link between the microbiome and autism is referred to as the "gut brain" connection.

Rodakis believes that antibiotics may be useful as a research tool and could lead to the development of future treatment methods for his son. "I was determined to better understand this phenomenon because I believed that if we could understand the biological basis of his improvements, we might gain insight into how autism works and be able to help him," he explains, adding:

"Current research is demonstrating that gut bacteria play previously undiscovered roles in health and disease throughout medicine. The evidence is very strong that they also play a role in autism. It's my hope that by studying these antibiotic-responding children, we can learn more about the core biology of autism."

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Long-term antacid use linked to vitamin B12 deficiency

Antacids are commonly used to neutralize the acid in the stomach, helping many individuals who have acid reflux. But a new study suggests that using this medication consistently for 2 years or more is linked to a deficiency of vitamin B12, which can have adverse effects for the nervous system.
The research, published in JAMA, is among the first to show associations between long-term exposure to antacids and vitamin B12 deficiency in a large population-based study.
The investigators say that antacids, including proton pump inhibitors (PPIs) and histamine 2 receptor antagonists (H2RAs), are some of the most commonly used pharmaceuticals in the US.
However, because they suppress the creation of gastric acid, the team says antacids may lead to malabsorption of vitamin B12. This vitamin helps to keep the nervous system - consisting of the brain, nerves and spinal cord - healthy.
"Vitamin B12 deficiency is relatively common," say the researchers, "especially among older adults; it has potentially serious medical complications if undiagnosed."
They continue:

"Left untreated, vitamin B12 deficiency can lead to dementia, neurologic damage, anemia and other complications, which may be irreversible."

To conduct their study, the researchers, led by Jameson R. Lam of Kaiser Permanente in California, looked at the link between using antacids and vitamin B12 deficiency within the Northern California population of Kaiser Permanente patients.

Stronger association in women and younger age groups

The study found a link between 2 years' use of antacids or more and a deficiency of vitamin B12.

With a study population consisting of 25,956 vitamin B12-deficient patients and 184,199 control patients without the deficiency, the researchers compared their use of acid inhibitors by using electronic pharmacy, laboratory and diagnostic databases.
They found that among the patients who were newly diagnosed with a vitamin B12 deficiency, 12% were given a 2-year or more supply of PPIs, compared with 7.2% of patients who were exposed to PPIs in the control group.
Similarly, 4.2% of the vitamin-deficient patients had a 2-year or more supply of H2RAs, versus 3.2% in the control group.
The researchers say that receiving a 2 or more years' supply of either of these medications was associated with a greater risk for becoming vitamin B12 deficient. They add that doses over 1.5 PPI pills per day were more strongly linked to the deficiency than doses under 0.75 pills per day.
Though they say cannot completely rule out confounding factors as they relate to their findings, they do note that using antacids "identifies a population at higher risk of B12 deficiency."
The magnitude of the association was stronger in women and younger age groups, they add, noting that the association decreased after patients stopped using the antacids.
The authors conclude:

"These findings do not recommend against acid suppression for persons with clear indications for treatment, but clinicians should exercise appropriate vigilance when prescribing these medications and use the lowest possible effective dose."

Vitamins have been a hot topic of late. A recent study cast doubts over vitamin D supplementation, while another suggested that low vitamin B9 in males' diets could cause birth defects in offspring.

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Breath Test Reveals Gut Bacteria Linked To Obesity

A growing body of evidence is increasingly showing us that the microbes in our gut influence our metabolism in surprising ways. Now a new study from the US suggests that a breath test of the gases they give out may indicate how susceptible a person is to developing obesity.

In The Endocrine Society's Journal of Clinical Endocrinology & Metabolism 26 March online issue, researchers from the Cedars-Sinai Medical Center in Los Angeles report how people with high levels of both hydrogen and methane in their breath are more likely to have a higher body mass index (BMI) and a higher proportion of body fat.

They suggest the presence of certain bacteria in the gut causes it to extract more calories from food, adding to weight gain.

Lead author Ruchi Mathur, director of the Diabetes Outpatient Treatment and Education Center in the Division of Endocrinology at Cedars-Sinai, says in a statement:

"This is the first large-scale human study to show an association between gas production and body weight," adding that "this could prove to be another important factor in understanding one of the many causes of obesity."

Mathur and her colleagues tested the exhaled breath of 792 people and found four patterns: normal breath, or breath containing higher levels of methane, higher levels of hydrogen, or higher levels of both gases.

And the participants' whose breath had higher levels of both methane and hydrogen were the ones significantly more likely to have a higher BMI and higher proportions of body fat.

A gut bacterium called Methanobrevibacter smithii is responsible for most of the methane produced in the human gut.

Mathur says that usually bacteria like M. smithii are beneficial because they help extract energy and nutrients from food.

But if there is too much M. smithii, it alters the energy balance so as to make the person more likely to put on weight.

It does not do this directly, but by the effect it has on neighbouring bacteria, the researchers suggest.

M. smithii produces methane by scavenging hydrogen from other microrganisms. The researchers propose that this gives hydrogen- producing bacteria a boost, making them more efficient so as to extract more nutrients and calories from food. It is this, which eventually leads to weight gain, says Mathur.

Mathur is also working on another study that seeks to confirm the link between M. smithii, obesity and pre-diabetes. On that study the participants are given a dose of antibiotics to wipe out the bacterium so that researchers can compare how efficiently they digest food when they have the bacterium in their gut to when they do not.

Mathur says we are only "beginning to understand the incredibly complex communities that live inside of us".

"If we can understand how they affect our metabolism, we may be able to work with these microscopic communities to positively impact our health," she adds.

Several examples of the surprising ways gut bacteria influence the human body have emerged in recent years.

For instance, an animal study published in the Journal of Proteome Research in February 2012, suggests that gut bacteria may play a role in obesity by slowing down the activity of energy-burning brown fat.

And in a study published in February 2013, US scientists describe how gut bacteria form part of a complex system that maintains the body's blood pressure.

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IPhone Microscope Helps Diagnose Intestinal Worms

Scientists have developed the camera on an iPhone into a microscope that can detect intestinal worm infections.
Photo Credit: Isaac Bogoch

Smart phones are transforming the way that people communicate throughout the world. Now scientists are using them in an innovative way to help diagnose intestinal worm infections in school children living in rural Tanzania.

The scientists have developed an inexpensive microscope using a glass lens costing $8 USD, a strip of double-sided tape, and a cheap flashlight - altering an iPhone 4s into a device that can detect intestinal worm infections; parasites that infect two billion people and result in malnutrition.

Isaac Bogoch, MD, an infectious disease specialist at Toronto General Hospital and the study's lead author explained:

"There's been a lot of tinkering in the lab with mobile phone microscopes, but this is the first time the technology has been used in the field to diagnose intestinal parasites."

The scientists' findings were published in the American Journal of Tropical Medicine and Hygiene, and evaluated 199 stool samples of children using their unique device.

Along with a standard light microscope the researchers examined the samples with the cell phone microscopes and a regular laboratory slide. The kids participating in the trial on Pemba Island, Tanzania, were undergoing different treatments for eliminating intestinal worms.

Scientists first covered the slide in cellophane, then used the double-sided tape to attach it to the camera, lit it from underneath with the flashlight and finally took a picture.

The iPhone microscope was found to be not as sensitive as a light microscope, however, the scientists believe that with some changes it will come close. Bogoch commented, "We think cell phone microscopes could soon become a valuable diagnostic tool in poor, remote regions where intestinal worms are a serious health problem, particularly in children."

Intestinal Worms - A Global Issue

The cell phone microscope sensitivity was dependent on the type of worm and the strength of the infection.

For example, the cellphone found 81 percent of infections of giant roundworm (A. lumbricoides) and 54 percent of roundworm infections (T. trichiura ). But, it only detected 14 percent of all hookworm infections; the researchers say that this is due to the much smaller number of eggs present than with the other parasites.

"It was quite successful at detecting moderate to heavy infections, but not very good at detecting mild infections where there might be only a few eggs in the sample," Bogoch said.

Worms that infect the intestines, such as roundworms and hookworms - or soil-transmitted helminths - harm nearly two billion people worldwide. In isolated, poor regions of developing nations rates of this disease are particularly high and can result in chronic malnutrition and anemia in kids.

Bogoch and his team aimed to find an alternative tool by taping a 3 millimeter ball lens to the camera of Bogoch's Apple iPhone 4S - one he already owned. However, the researchers noted that any phone that has a camera with a zoom option could work effectively. Ball lenses are normally used in the telecommunications field in couplings for optical fiber cable. They are inexpensive - generally $8 to $10 USD.

Instead of an electric light, they used a small flashlight that just needs a single battery for many hours of operation. The entire set-up can be developed for $15 USD, in addition to the cost of the phone, and can be assembled in five minutes.

Cell Phone Microscope - Several Implications

The authors believe that the "mobile phone microscope would likely be of clinical use when it is sensitive enough to detect 80 percent of infections," and note that even now there are new developments underway to improve the current cell phone microscopes.

Bogoch said, "I'm confident that in the near future we will see cell phone microscopes widely used in low-resource settings. They're easy to make, portable, and today, you can find mobile phones with cameras even in some of the most remote regions in the world."

The cell microscope can be used for treating and diagnosing people with worm infections as well as observing the prevalence of disease amongst the broader population.

One example could be when administering drug treatment to large populations. Cell phone microscopes could serve as cheap and effective tools to calculate the effectiveness of these mass drug administration campaigns.

David H. Walker, MD, president of the American Society of Tropical Medicine and Hygiene said:

"I have nothing but praise for the ingenuity of scientists using all available tools to solve pressing health problems in some of the poorest parts of the world. This study is an illustration of how a modest investment in tropical disease research can help reap enormous health benefits for children."

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HIV Patients May Benefit From Probiotics

Antiretroviral (ARV) drugs are the first line therapy for patients with HIV; however, ARV-treated, HIV-infected individuals still have a higher mortality rate than uninfected individuals. During the course of infection, HIV patients develop inflammation that damages the walls of the intestines, known as the gut mucosa, allowing intestinal microbes to escape and enter the blood stream to cause a life-threatening systemic infection. The health of the gut mucosa is significantly influenced by the complement of bacteria in the gut and there is mounting evidence that probiotic supplements benefit patients intestinal disorders, such as irritable bowel syndrome, C. difficile infection, and inflammatory bowel disease.

In this issue of the Journal of Clinical Investigation, researchers led by Jason Brenchley at the National Institute of Allergy and Infectious Disease, demonstrated that probiotic supplementation may also be beneficial for ARV-treated HIV patients. Brenchley and colleagues treated SIV-infected macaques (a model of human HIV-infection) with either ARV alone or ARV in combination with a mixture of probiotics. Macaques treated with probiotics had enhanced gastrointestinal immune function and decreased inflammation compared to macaques treated with ARV alone. In a companion article, Judith Aberg and colleagues at New York University School of Medicine discuss how these findings could benefit HIV patients.

TITLE: Probiotic/prebiotic supplementation of antiretrovirals improves gastrointestinal immunity in SIV-infected macaques

View this article at: http://www.jci.org/articles/view/66227?key=1cff041937d9040dfed7

ACCOMPANYING THE ATTENDING PHYSICIAN TITLE: Clash of the microbes: let's bring back the good guys

View this article at: http://www.jci.org/articles/view/66736?key=64b158b04e2a168811a3

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Chewing Gum Health Scare

"A sweetener used in sugar-free chewing gum, some toothpastes and thousands of other products could be a severe health risk," the Daily Mail reported. It says that the sweetener, Sorbitol, can trigger severe weight loss, abdominal pain and diarrhoea.
This newspaper and several others are covering a recent report in a medical journal which highlights the cases of two patients who had chronic diarrhoea and suffered severe weight loss (up to a fifth of their body weight), the cause of which was traced back to excessive intake of sorbitol through their use of chewing gum.

While the authors of the report do say that consumers may fail to recognise a link between sorbitol and gastrointestinal problems as warnings are "usually found only within the small print", the severity of the warning by the Daily Mail could be construed as excessive. As the authors explain, only a minority of people who chew gum develop diarrhoea and that the two patients in this study replaced their gum sticks frequently, which accounted for the high doses of sorbitol ingested.

These two cases highlight a need for clearer packaging information on chewing gum about ingredients and effects.

Such extreme reactions are rare. However, users of sugar-free gum should bear in mind the known link between high levels of sorbitol and potential abdominal problems and limit their intake. High doses of sorbitol are known to have a laxative effect. As the authors mention, "sorbitol consumption is also associated with irritable bowel syndrome", and IBS sufferers may want to take this into account.

This report should not prompt people to attempt to lose weight through increasing their intake of sorbitol, one of several similar chemicals used in laxative products. The misuse of laxatives is associated with health problems and anyone tempted to try this should bear in mind that the two people in this report were admitted to hospital.

Where did the story come from?

Dr Juergen Bauditz, Kristina Norman and colleagues from the Department of Gastroenterology, Hepatology, and Endocrinology at the Charité Universitätsmedizin in Berlin wrote the report. The report was published in the peer-reviewed British Medical Journal.

What kind of scientific study was this?

This was a report on two separate cases of chronic diarrhoea and substantial weight loss in a man and woman at a hospital in Germany. The cause of their illness was unknown when they were initially admitted or referred to the department. Their diarrhoea and weight loss was then linked to their habitual use of large amounts of sugar free chewing gum, which contains sorbitol, a sweetener that also has laxative properties.


In the report, the doctors described the patient's histories, their illness at the time of diagnosis and the diagnosis and treatment of the cause of the problems.

What were the results of the study?

The report includes details about a 46-year-old man admitted to hospital with unexplained diarrhoea, who visited the toilet 10 times a day, and who had lost 3.5 stone (22 kg) in the previous year.

On admission to hospital he weighed 12stone 8lb (79.9kg), with a BMI of 25.8. Tests on his blood and stool and other examinations of his bowel and stomach showed no abnormalities. Apart from slight tenderness, his abdominal examination was normal. When doctors asked in detail about his diet, suspecting he may have sorbitol-induced diarrhoea, they discovered that he ate about 20 sticks of sugar-free gum per day and 200g of sweets. They estimated that this was about 30g of sorbitol per day. Further examinations confirmed that his diarrhoea was probably linked to the intake of sorbitol, and when he started a sorbitol-free diet, his problems resolved themselves.

In a similar case, a 21 year old woman had abdominal pain and diarrhoea, and visited the toilet 12 times a day for eight months. By the time she was admitted for further testing, she had lost 1.7 stone (11kg) and her weight was down to 6 stone (40.8kg), with a BMI of 16.6. Physical examinations were largely negative, but further examination of her stools suggested her diarrhoea was linked to high sorbitol intake. When asked, she told the doctors that she chewed large amounts of sugar-free gum, which accounted for about 18 to 20g of sorbitol per day (about 16 sticks of gum). When the woman started a sorbitol-free diet in the hospital, her diarrhoea subsided and after one year, bowel movements and weight balance had returned to normal.

What interpretations did the researchers draw from these results?

The authors highlight these two cases as examples of a known problem - that high sorbitol-intake can cause abdominal problems in some people.

They recommend that when investigating unexplained weight loss and diarrhoea, doctors should consider taking a detailed dietary history to establish whether there is a link with foods and other substances containing sorbitol.

What does the NHS Knowledge Service make of this study?

Case reports are a useful way of generating theories about the causes of illness and publishing previously undocumented associations between exposures and outcomes. Previous studies, referenced in the paper, have shown that 20g (16 sticks) of sorbitol produces diarrhoea in half of normal people.

These two case reports serve as examples of the known fact that high sorbitol-intake causes abdominal problems in some people. An interesting feature is the associated weight loss, though this is not unexpected in cases where diarrhoea has persisted for up to a year.

- As the doctors say, warnings on chewing gum packaging that "excessive consumption may produce laxative effects" are in small print and "consumers may be unaware of its laxative effects and fail to recognise a link with their gastrointestinal problems". Manufacturers of sugar-free chewing gum could increase the prominence of their labelling about possible side effects.

- The article is also of relevance to doctors who, based on its findings, are advised to consider the possibility of sorbitol-induced problems in cases of diarrhoea of uncertain origin. The authors also highlight the fact that analysing stool composition is a cheap and reliable way to clarify the type of diarrhoea and this could be used in investigations. Diarrhoea caused by sorbitol is of a particular type - osmotic diarrhoea - that can be identified by determining how much sodium and potassium there is in stool.

This article should not prompt people who are trying to lose weight to increase their intake of sorbitol for this purpose. The misuse of laxatives is associated with health problems, which can be severe and include dehydration and potassium imbalance (which can lead to heart problems).

Similarly, people who use sugar-free chewing gum should not be overly alarmed by this report as such extreme reactions are rare. However, they should bear in mind the known link between high levels of sorbitol and potential abdominal problems and limit their intake. The use of sweeteners in foods is controlled by the Food Standards Agency, which aims to ensure that including them in foodstuffs does not lead to serious health concerns.

On a different note, sorbitol is not the only chemical used in "sugar-free" products. Another - aspartame - should be avoided by people with phenylketonuria (a rare genetic disorder in which the body cannot used phenylalanine - a component of aspartame).

This news comes from the National Health Service (NHS) of the UK.

Links to the science:

Pirlich M, Bauditz J, Norman K, et al. Severe weight loss caused by chewing gum.BMJ 2008; 336: 96-97

http://www.nhs.uk/News/Pages/NewsIndex.aspx

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Gestational Diabetes Linked To ADHD Risk In Offspring

According to a report Online First by Archives of Pediatrics & Adolescent Medicine, babies who are born to mothers with diabetes during their pregnancy and/or living in low income households, have a higher risk of subsequently developing ADHD during childhood.

The authors stated:

"Gestational diabetes mellitus (GDM) typically develops in the second and third trimesters and is defined as glucose intolerance with onset or first recognition during pregnancy. The prevalence of GDM has been rising for over 20 years, particularly among ethnic minorities and individuals with low socioeconomic status (SES), as have lifestyle changes that heighten risk including greater consumption of saturated fats, sugar, and processed foods, and sedentary working environments."

Yoko Nomura, M.D., Ph.D, of Queens College, and team set out to determine whether there might be a connection between gestational diabetes mellitus (GDM) and low income environments, with attention deficit hyperactivity disorder (ADHD). They compared babies born to mothers with and without GDM and of all social classes.

According to an online communiqué issued by the journal:

"The researchers distributed the ADHD Rating Scale-IV to parents of 3- and 4-year-old children in preschools surrounding Queens College, and recruited 212 participant at a 2:1 ratio of "at risk" to "typically developing" children. At-risk children had at least six inattention or six hyperactive and impulsive symptoms as rate by parents, teachers, or both. "Typically developing" children had fewer than three symptoms in each domain. "

The overall score for children born to mothers with GDM was notably higher than for the other kids. However, the hyperactivity scores between the two groups of children were fairly similar. Children in low income families in comparison with high income ones had displayed signs of more inattention and hyperactivity. At the beginning of the study, findings showed no difference. However, by the time those who had been born to mothers with GDM were six years old, their chances of developing ADHD were double that of the other children.

The authors reported that children whose mothers had GDM and came from low income families..:

• Tended to have lower IQs
• Had more communication problems
• Had more emotional difficulties
• Had more behavioral problems

These children - born to GDM mothers, plus from poorer households - were14 times as likely to receive an ADHD diagnosis than any of the other children, including those with just one factor, such as either having GDM mothers, or being from a poorer household.

The researchers concluded:

"This study demonstrates that children of mothers with GDM raised in lower SES households are at far greater risk for developing ADHD and showing signs of suboptimal neurocognitive and behavioral development. Since ADHD is a disorder with high heritability, efforts to prevent exposure to environmental risks through patient education may help to reduce the nongenetic modifiable risk for ADHD and other developmental problems."

Accompanying Editorial

Joel Nigg, Ph.D., of Oregon Health and Science University, Portland, said:

"In the current issue of the Archives we see additional evidence, in a retrospective design, that early developmental events are related to subsequent attention-deficit/hyperactivity disorder (ADHD) in children.

Most of the relevant environmental risks are presumed to occur very early in development," continues Dr. Nigg. "If causal, and if able to be understood pathophysiologically, such environmental effects on ADHD are of 'game-changing' importance because they open the door to eventually preventing that portion of cases of ADHD caused by early insult to the nervous system.

If a specific environmental causal influence can be demonstrated, even if effective in a subset of children, and its biological mechanisms elucidated, then a powerful model will be created for how ADHD can develop," Dr. Nigg concludes. "That discovery will be a crucial stepping-stone toward parsing multiple causal routes to what may be a final common pathway of the ADHD phenotype."

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What Is Anal Cancer? What Causes Anal Cancer?

Anal cancer occurs in the anus, the end of the gastrointestinal tract. Anal cancer is very different from colorectal cancer, which is much more common. Anal cancer's causes, risk factors, clinical progression, staging and treatment are all very different from colorectal cancer. Anal cancer is a lump which is created by the abnormal and uncontrolled growth of cells in the anus.

Anal cancer is very rare. In the UK approximately 800 patients are diagnosed annually, out of a total population of 61 million (2009). According to the American Cancer Society, approximately 5,070 new cases of anal cancers were diagnosed in the USA in 2008, of which about 60% were women. Most anal cancer patients are diagnosed in their early 60s. Approximately 680 people died from anal cancer in the USA in 2008. The USA has a population of 300 million (2009). Reports indicate that the incidence of this type of cancer is rising. The number of anal cancer cases is increasing in both sexes, particularly among American men, and changing trends in sexual behavior - combined with current tobacco use and infection by a specific strain of the human papillomavirus - may help explain the increase.


Anal cancer is more common among women, men who receive anal intercourse, and people with weakened immune systems. Experts say that anal cancer is closely associated with some HPV (human papilloma virus) strains.

The anus, the anal canal and squamous cell carcinomas

The anus is right at the end of the gastrointestinal tract - the area right at the end. While the anal canal is the tube that connects the rectum to the outside of the body. The anal canal is surrounded by the sphincter - a muscle. The sphincter controls bowel movements by contracting and relaxing. In short, the anus is the outside area while the anal canal is the tube.

The anal canal is lined with squamous cells - flat cells that look like fish scales under the microscope. The majority of anal cancers develop from these squamous cells. Such cancers are known as squamous cell carcinomas.

The point at which the anal canal meets the rectum is called the transitional zone. The transitional zone has squamous cells and glandular cells - these produce mucus which helps the stool (feces) pass through the anus smoothly. Adenocarcinoma (type of cancer) of the anus can develop from these glandular cells. However, squamous cell carcinomas make up the vast majority of anal cancers.

What are the symptoms of anal cancer?

• Rectal bleeding - the patient may notice blood on feces or toilet paper.
• Pain in the anal area.
• Lumps around the anus. These are frequently mistaken for piles (hemorrhoids).
• Mucus discharge from the anus.
• Jelly-like discharge from the anus.
• Anal itching.
• Change in bowel movements. This may include diarrhea, constipation, or thinning of stools.
• Fecal incontinence (problems controlling bowel movements).
• Bloating.
• Women may experience lower back pain as the tumor exerts pressure on the vagina.
• Women may experience vaginal dryness.

What causes anal cancer?

Experts are not sure what causes anal cancer. However, the following are considered as possible risk factors:

• HPV (human papilloma virus) - some types of HPV are closely linked to anal cancer. Approximately 80% of patients with anal cancer are infected in the anal area with a HPV.


• Sexual partner numbers - this is also linked to HPV. The more sexual partners somebody has (or has had) the higher are the chances of being infected with HPV, which is closely linked to anal cancer risk.


• Receptive anal intercourse - both men and women who receive anal intercourse have a higher risk of developing anal cancer. HIV-positive men who have sex with men are up to 90 times more likely than the general population to develop anal cancer, this study revealed.


• Other cancers - women who have had vaginal or cervical cancer, and men who have had penile cancer are at higher risk of developing anal cancer. This is also linked to HPV infection.


• Age - the older somebody is the higher is his/her risk of developing anal cancer. In fact, this is the case with most cancers.


• A weak immune system - people with a weakened immune system have a higher risk of developing anal cancer. This may include people with HIV/AIDS, patients who have had transplants and are taking immunosuppressant medications.


• Smoking - smokers are significantly more likely to develop anal cancer compared to non-smokers. In fact, smoking raises the risk of developing several cancers.


• Benign anal lesions - IBD (irritable bowel disease), hemorrhoids, fistulae or cicatrices. Inflammation resulting from benign anal lesions may increase a person's risk of developing anal cancer.

How is anal cancer diagnosed?

The first person to see will probably be a GP (general practitioner, primary care physician). The GP will ask the patient about his/her symptoms and carry out an examination. The doctor will also need to know about the patient's medical history. Then the patient will be referred to a colorectal surgeon - this is a doctor who specializes in bowel conditions. Colorectal surgeons are sometimes called proctologists. The specialist may carry out the following tests:

• A rectal examination - this may be a bit uncomfortable, but is not painful. A proctoscope or sigmoidoscope may be used - an instrument that allows the doctor to examine the area in more detail. In some countries this device is called an anoscope, and the procedure 'anoscopy'. The examination will determine whether the patient needs a biopsy.


• A biopsy - a small sample of tissue is taken from the anal area and sent to the lab for testing. Tissue will be examined under a microscope.

If cancerous tissue is detected after the biopsy the patient will need further tests to find out how advanced (big) the cancer is and whether or not it has spread. The following tests may be done:

• CT (computerized tomography) scan - X-rays are used to create a 3-dimensional picture of the target area.


• MRI (magnetic resonance imaging) scan - magnets and radio waves produce 2-dimensional and 3-dimensional pictures of the target area.


• Ultrasound scan - sound waves are used to create an image of the target area. This could be done internally with a rectal ultrasound - the instrument is inserted into the anus before the scanning begins.

What is the treatment for anal cancer?

Treatment for anal cancer will depend on various factors, including how big the tumor is, whether or not it has spread, where it is, and the general health of the patient. If the tumor is small it can be removed surgically, and that's it.

• Surgery

The type of surgery a patient will require depends on the size and position of the tumor.


• Resection - this removes a small tumor and some surrounding tissue. This type of surgery can only be carried out if the anal sphincter is not sacrificed. Patients who undergo a resection do not have their ability to pass a bowel movement affected.


• Abdominoperineal resection - the anus, rectum and a section of the bowel are surgically removed. The patient will need a colostomy - the end of the bowel is brought out onto the skin on the surface of the abdomen. A bag is placed over the stoma - the opening of the bowel - and collects the stools (feces) outside the patient's body. Although this sounds shocking, people with colostomies can lead normal lives, play sports and have active sex lives.

In most cases, the patient will probably have to undergo chemotherapy and/or radiotherapy.


• Chemotherapy and radiotherapy
  
  Radiotherapy combined with chemotherapy treatments (chemoradiation) are commonly used to destroy the anal cancer cells. Treatments are either given simultaneously or consecutively. This combined therapy approach has led to a much higher percentage of patients with an intact anal sphincter - survival and cure rates are good.
  
  Chemotherapy uses cytotoxic drugs (antineoplastics) - cytotoxic drugs prevent the cancer cells from dividing. They are administered either by injection or orally.
  
  Radiotherapy uses high-energy rays that destroy the cancer cells. This can be given by an external beam or internally (brachytherapy).
  
  Radiotherapy has side effects, as does chemotherapy. When the treatment is combined the side effects may be more acute. Side effects may include:


• Diarrhea
• Constipation
• Soreness and blistering around the target area (anus)
• A higher susceptibility to infections during treatment
• Low white blood cell count (which raises infection risk)
• Fatigue
• Loss of appetite
• Nausea or vomiting
• Mouth ulcers
• Sore mouth
• Loss of hair
• Narrowing and dryness of the vagina
• Anemia (low red blood cell count)
• Low platelet count which raises risk of bruising or bleeding
• Dry skin
• Rashes
• Muscle and nerve problems
• Excessive coughing, sometimes breathing difficulties
• Fertility problems

Prevention

• Reduce your chances of being infected with HPV
• Use condoms when having sex
• Limit the numbers of sexual partners
• Abstain from anal intercourse
• Quit smoking

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What Is Cystitis? What Causes Cystitis?

Cystitis refers to inflammation of the lining of the bladder. It usually occurs when the normally sterile urethra and bladder (lower urinary tract) are infected by bacteria and become irritated and inflamed. Cystitis is fairly common and can affect both men and women and people of all ages. However, it is more common in women.

What causes cystitis?

• When women insert a tampon there is a slight risk of bacteria entering via the urethra.


• When a urinary catheter is changed there may be damage to the area.


• There is a higher incidence of cystitis among women who use the diaphragm for contraception, compared to sexually active women who don't.


• The patient does not empty his/her bladder completely, creating an environment for bacteria to multiply in the bladder. This is fairly common among pregnant women, and also men whose prostates are enlarged.


• Sexually active women have a higher risk of bacteria entering via the urethra.


• Part of the urinary system may be blocked.


• Other bladder or kidney problems.


• Frequent and/or vigorous sex increases the chances of physical damage or bruising, which in turn makes the likelihood of cystitis developing higher.


• During the menopause women produce less mucus in the vaginal area. This mucus stops the bacteria from multiplying. Women on HRT (hormone replacement therapy) have a lower risk of developing cystitis compared to menopausal women not on HRT.


• During the menopause the lining of a woman's urethra gets thinner as her levels of estrogen drop. The thinner the lining becomes, the higher the chances are of infection and damage.


• A woman's urethra opening is much nearer the anus than a man's. Consequently, there is a higher risk of bacteria entering the urethra from the anus.

Experts say that the majority of women will have at least one incidence of cystitis during their lives. A sizeable number have more than one incidence. Doctors say a woman should see her GP (general practitioner, primary care physician) when she gets cystitis for the first time, as should any woman who has cystitis three or more times within a twelve-month period.

All men and children should see their doctor if they have cystitis.

When men get cystitis it tends to be potentially more serious than when women get it. Male cystitis is more likely to be caused by some other serious underlying condition, such as a prostate infection, cancer, an obstruction, or an enlarged prostate. In most cases of male cystitis early treatment is effective and the problem is solved. However, untreated male bladder infection can lead to kidney or prostate infections and/or damage. Men who have sex with men are more likely to have cystitis than other men.

What are the symptoms of cystitis?

• Urine may have traces of blood
• Urine is dark and/or cloudy
• Urine has a strong smell
• Pain just above the pubic bone
• Pain in the lower back
• Pain in the abdomen
• Only small amount of urine is passed each time
• Frequent need to urinate
• Burning sensation when urinating
• Older women may feel weak and feverish but have none of the other symptoms mentioned above
• When children have cystitis they may have any of the symptoms listed above, plus vomiting and general weakness.

Other illnesses or conditions may have the same symptoms as cystitis. They include:

• Urethritis (inflammation of the urethra)
• Urethral syndrome
• Some bacterial infections
• Prostatitis (inflammation of the male prostate gland)
• Gonorrhea
• Chlamydia
• Candida (thrush)

How is cystitis diagnosed?

A doctor will ask the patient some questions, carry out an examination, and do a urine test. The urine test will either be sent to a laboratory, or the GP may use a dipstick. A "clean catch" (urine culture) or catheterized urine specimen may be performed to determine the type of bacteria in the urine. After finding out which specific bacterium is causing the infection the patient will be prescribed an oral antibiotic.

Most GPs in the UK will also offer to find out whether the patient might have a Sexually Transmitted Infection (STI). STIs often have similar symptoms to cystitis.

Patients who get cystitis regularly may need further tests. This could include an ultrasound scan, an X-ray, or a cytoscopy (a fiber optic camera examination) of the bladder.

What is the treatment for cystitis?

In the vast majority of cases, mild cystitis will resolve itself within a few days. Any cystitis that lasts more than about four days should be consulted with your GP.

Sometimes a short 3-day course of antibiotics is given. Most patients will experience the beneficial effects of an antibiotic within the first day of treatment. If symptoms do not improve after taking the antibiotics the patient should return to her/his doctor. The following antibiotics are commonly used for cystitis: Nitrofurantoin, Trimethoprim-sulfamethoxazole, Amoxicillin, Cephalosporins, Ciprofloxacin or levofloxacin, and Doxycycline.

Elderly people, and those with possible weakened immune systems, such as people with diabetes, have a higher risk of the infection spreading to the kidney, as well as other complications. Vulnerable people should be treated promptly.

The following home remedies and measures may help:

• Painkillers, such as paracetamol (Tylenol) or ibuprofen may help with the discomfort. If you are pregnant discuss this with either your doctor or a well-qualified pharmacist.


• Drink plenty of fluids. This will help flush the bacteria from the system.


• Do not consume alcohol.


• Sodium citrate or potassium citrate in sachets or solutions sometimes ease symptoms.


• Cranberry juice has been shown to be good for the urinary tract. Drinking some cranberry juice each day may prevent recurrences - some people have even experienced relief of symptoms. Cranberry juice also has condensed tannins, Manoose - D and proanthocyanidins which have been found to inhibit the activity of E. coli by preventing the bacteria from sticking to mucosal surfaces lining the bladder and gut, helping to clear bacteria from the urinary tract.


• Refrain from sex while you are infected.

Cystitis prevention

Many cases of cystitis are not preventable. However, the following measures may help:

• Practice good hygiene after sex, especially women. Try using neutral soaps around the genitals, not perfumed ones.


• When you urinate try to make sure you have emptied your bladder completely.


• If you feel you need to urinate go straight away - do not postpone it.


• Avoid tight underwear, and tight pants (trousers).


• Wear cotton underwear.


• Wipe from front to back.


• When having sex make sure sexual organ is lubricated, if necessary use a lubricant.


• Empty bladder as soon as possible after sex.


• If you wear a catheter ask your doctor or nurse how to avoid damage when you have to change it.

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What Are Gallstones? What Causes Gallstones?

Gallstones are lumps or stones that develop in the gallbladder or bile duct. Some of the chemicals which exist in the gallbladder, such as cholesterol, calcium bilirubinate, and calcium carbonate, harden into either one large stone or many small ones. According to Medilexicon's medical dictionary, a gallstone is "A concretion in the gallbladder or a bile duct, composed chiefly of a mixture of cholesterol, calcium bilirubinate, and calcium carbonate, occasionally as a pure stone composed of just one of these substances". An article describes a gallbladder in the bile duct similar to trying to squeeze a golf ball through a straw.

It is estimated that about 20 million Americans have gallstones. A study revealed that the prevalence of gallstones in adults of industrialized countries is approximately 10% and is showing a tendency to rise.

In order to better understand what gallstones are, we need some information about the gallbladder and the bile ducts.

What is the gallbladder?

The gallbladder is a small sac located on the right-hand side of the body, on the underside of the liver. Gall (bile) is a greenish-brown liquid which the liver produces. Gall is stored and concentrated in the gallbladder. Gall goes into the small intestine via the bile ducts to facilitate the digestion, mainly of fats. Every time we eat some gall is released into the intestines. The bile duct is a narrow tube.

What are gallstones?

When the chemicals in the gallbladder, cholesterol, calcium bilirubinate, and calcium carbonate are out of balance gallstones may form. There are two main types of gallstones:

• Cholesterol gallstones - these may form if there is too much cholesterol in the bile? They are the main type of gallstones in the UK and the USA.


• Pigment gallstones - these form when the bile has too much bilirubin. They are more common among patients who have liver disease, infected bile tubes or blood disorders, such as sickle-cell anemia.

What are the symptoms of gallstones?

The majority of people with gallstones have no symptoms at all. This is because the stones generally stay in the gallbladder and cause no problems. Sometimes, however, gallstones may lead to cholecystitis (inflamed gallbladder). Symptoms of gallbladder inflammation include:

• Pain on the right-hand side of the body, just below the ribs
• Back pain
• Pain in the right shoulder
• Nausea
• Vomiting
• Sweating
• Restlessness

Biliary colic - Sometimes the gallstones may pass down through the bile duct into the duodenum. When this happens the patient may experience biliary colic - a painful condition. The pain is felt in the upper part of the abdomen, but can also exist in the center of the abdomen, or a little to the right of it. Pain is more common about an hour after eating, especially if the patient has had a high-fat meal. The pain will be constant and will last a few hours, and then subside. Some patients will have non-stop pain for 24 hours, while others may experiences waves of pain.

Infection - If the gallstones have caused a gallbladder infection the patient may have a fever and experience shivering. In the majority of gallstone infection cases the patient will be hospitalized and have the gallstone surgically removed.

Jaundice - If the gallstone leaves the gallbladder and gets stuck in the bile duct it may block the passage of bile into the intestine. The bile will then seep into the bloodstream and the patient will show signs of jaundice - the skin and the whites of the eyes will be yellow. In most cases this complication will require the surgical removal of the gallstone. Some patients are lucky and the gallstone eventually passes into the intestine.

Pancreatitis - If a small gallstone passes through the bile duct and blocks the pancreatic duct, or causes a reflux of liquids and bile into the duct, the patient may develop pancreatitis.

What causes gallstones?

Experts are not completely sure why some people develop a chemical imbalance in their gallbladder which causes gallstones, while others do not. However, we do know that gallstones are more common among:

• Overweight/obese people, especially women. A study revealed that a bulging midriff almost doubles a woman's chances of developing gallstones and the need for surgery to remove them. Women who have been pregnant


• People who have recently lost lots of weight.


• Intentionally losing weight and then regaining it may increase men's risk for gallstones later in life.


• Women taking oral contraceptives.


• Women undergoing high-dose estrogen therapy


• People with a close relative who has had gallstones.


• A study revealed that a gene variant significantly increases the risk of developing gallstones.


• People whose intake of dietary fat is high.


• Twice as many women get gallstones than men.


• People over 60 years of age.


• Native American Indians.


• People who take statins (cholesterol-lowering drugs).


• People with diabetes.


• Hormone replacement therapy (HRT) for women during the menopause is linked to a higher risk of gallbladder problems. A study found that HRT administered by skin patches or gels poses a smaller risk than HRT given orally.

How are gallstones diagnosed?

In many cases gallstones are discovered by accident when the patient is being treated for something else. A doctor may suspect gallstones after a cholesterol test, an ultrasound scan, a blood test, an ultrasound scan, or even an X-ray. Blood tests may be used to look for signs of infection, obstruction, pancreatitis, or jaundice.

• Cholangiography
  
  A dye is either injected into the blood stream so that it concentrates into the bile ducts or gallbladder, or it is inserted straight into the bile ducts suing an endoscope (ERCP - endoscopic retrograde cholangiopancreatolography). The dye shows up on X-rays. ERCP is also used to locate and remove stones in the bile duct.
  
  The doctor will then be able to look at the X-rays and identify possible gallbladder or bile duct disorders, such as pancreatitis, cancer of the pancreas, or gallstones. The X-rays will indicate to the doctor whether the dye is going to where it should go - i.e. the liver, bile ducts, intestines and gallbladder. If the dye does is not present in one of these areas it generally means that the gallstone is causing a blockage. An expert will have a better idea of where the gallstone is located.


• CT scan (Computerized tomography scan)
  
  This is a non-invasive X-ray that produces cross-section pictures of the inside of the human body.


• Cholescintigraphy (HIDA scan)
  
  A small amount of harmless radioactive material is injected into the patient. This is absorbed by the gallbladder, which is then stimulated to contract. This test may diagnose abnormal contractions of the gallbladder or an obstruction of the bile duct.

What is the treatment for gallstones?

The gallstones are only treated if they have caused gallbladder inflammation, blockage of the bile ducts, or if they have moved from the bile ducts into the intestines. Patients who are treated are generally put on a low fat diet.

• Cholecystectomy
  
  Cholecystectomy means the surgical removal of the gallbladder. This is usually performed with keyhole surgery (minimally invasive surgery) - a small incision is made. However, sometimes keyhole surgery is not possible for about 10% of patients, who need open cholecystectomy. With open cholecystectomy a large cut is made in the patient's abdomen. Patients who undergo open surgery require a longer hospital stay and recovery time. If a patient's gallbladder is severely inflamed he/she will require open surgery.
  
  A study found that using a robotic assistant to remove a patient's gallbladder by key-hole surgery (laparoscopic cholecystectomy) is as safe as working with a human assistant.
  
  The gallbladder can be removed by entering through the vagina, this article explains.
  
  A study found that contrary to widespread belief, early cholecystectomy significantly reduces hospital stays in patients with mild to moderate gallstone pancreatitis with no increase in complications or mortality.
  
  As approximately 1 in 4 patients who undergo cholecystectomy have gallstone recurrence within a year, many patients are given urosdeoxycholic acid (the acid found in bile). Urosdeoxycholic acid lowers the cholesterol content of bile, making it less likely that stones will form.


• Ursodeoxycholic acid
  
  If the gallstone is made of cholesterol it can sometimes be slowly dissolved with ursodeoxycholic acid. This type of treatment, known as dissolution, may take up to 24 months to be effective. It is not as effective as surgery, but is sometimes the only choice for patients who cannot have a general anesthetic.


• ERCP (Endoscopic retrograde cholangiopancreatolography)
  
  In some rare cases, when a patient cannot have surgery or ursodeoxycholic acid, he/she may undergo ERCP, which requires a local anesthetic. A flexible fiber-optic camera (endoscope) goes down the patient's mouth, through his/her digestive system and into the gallbladder. An electrically heated wire widens the opening of the bile duct; the stones are removed or left to pass into the intestine.


• Lithotripsy
  
  Ultrasonic shock waves are aimed at the gallstones which break them up. If they become small enough they can then pass safely in the patients stools. This type of treatment is uncommon and is only ever used when there are few gallstones present.

Complications of gallstones

If the bile duct or duodenum are blocked by gallstones the flow of digestive juices to the pancreas may be blocked, this can cause jaundice and acute pancreatitis. Treatment usually involves the surgical removal of the gallbladders.

If is common for people who have had their gallbladder removed to experience feelings of bloating and indigestion, especially when they have a high fat meal. Some may pass stools more often than before.

How can you prevent gallstones?

Such factors that increase the risk of developing gallstones, such as age, sex and ethnic origin cannot be altered. However, it is possible that having a vegetarian diet may reduce the risk of developing gallstones. Vegetarians have a significantly lower risk of developing gallstones, compared to people who eat meat.

Many experts say that a diet low in fat and high in fruit and vegetables, including plenty of dietary fiber may help protect people from developing gallstones.

Controlling your bodyweight - not allowing yourself to become overweight/obese - may also help prevent the formation of gallstones. However, crash dieting and rapid weight loss are risk factors in the development of gallstones.

An animal study indicated that exercise can reduce the risk of developing gallstones.

Can we live without our gallbladder?

Fortunately, we can live without our gallbladder. The liver produces enough bile to digest a normal diet. If a person's gallbladder is removed the bile reaches the small intestine from the liver via the hepatic ducts, rather than being stored in the gallbladder. A small proportion of patients who have had their gallbladder removed will experience softer and more frequent stools for a while because their bile flows into the small intestine more often.

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