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Gastro Intestinal Health

Back Clinic Gastro Intestinal Health Functional Medicine Team. The gastrointestinal or (GI) tract does more than digest food. It contributes to various body systems and functions. Dr. Jimenez takes a look at procedures that have been created to help support the GI tract’s health and function, as well as promote microbial balance. Research shows that 1 in 4 people in the U.S. have stomach or intestinal problems that are so severe that it interferes with their daily activities and lifestyle.

Intestinal or digestion problems are referred to as Gastrointestinal (or GI) Disorders. The goal is to achieve digestive wellness. When an optimally working digestive system is on track, an individual is said to be in good health. The GI tract protects the body by detoxifying various toxins and participating in the immunological processes or when the body’s immune system interacts with antibodies and antigens. This combined with supporting the digestion and absorption of nutrients from an individual’s diet.


Exploring the Functions of Supportive Digestive Organs

Exploring the Functions of Supportive Digestive Organs

For individuals looking to improve their gut health, can learning about the supportive digestive organs help with how digestion works and how it can be affected by inflammatory bowel disease/IBD?

Exploring the Functions of Supportive Digestive Organs

Supportive Digestive Organs

Most people are familiar with food movement from the mouth through the esophagus, stomach, small intestine, and large intestine. However, digestion begins in the mouth with the formation of saliva, and the supportive digestive organs provide the necessary fluids to digest food and used by the body. The digestive tract runs from the mouth to the anus in one long, continuous tube. Several supportive digestive organs assist digestion but are not considered part of the digestive tract, including the salivary glands, pancreas, liver, and gallbladder.

Salivary Glands

The salivary glands produce saliva passed through ducts and into the mouth. Saliva is a clear liquid containing various substances important for digestion and the beginning of the food breakdown process (National Institute of Diabetes and Digestive and Kidney Diseases, 2017). Saliva is important to digestion because it aids chewing, contains antibodies, and helps keep the mouth clean. Infections, mumps, obstructions, Sjogren’s syndrome, and cancer are diseases and conditions that can affect the salivary glands.

Pancreas

Behind the stomach is the pancreas, which is important to digestion because it is where digestive enzymes and hormones are produced. Digestive enzymes help break down food (National Institute of Diabetes and Digestive and Kidney Diseases, 2017). The pancreas also creates Insulin, a hormone that helps balance blood sugar levels. Individuals with Type 1 diabetes are unable to make insulin and need insulin shots to balance sugar levels. Individuals with Type 2 diabetes also need insulin because their body is either resistant to insulin or their pancreas does not respond correctly. (American Diabetes Association, 2024) Glucagon is another hormone produced in the pancreas to raise blood sugar when the levels are very low. For individuals who have diabetes, glucagon can increase blood sugar levels too high. Insulin and glucagon work together to regulate blood sugar. (American Diabetes Association, 2024) Some diseases and conditions affecting the pancreas include pancreatitis, cancer, and cystic fibrosis.

Liver

The liver is one of the largest organs. Its functions include creating bile, storing nutrients and glycogen, converting toxins into harmless substances, and/or enabling their removal. Bile is passed through ducts that run from the liver to the duodenum of the small intestine. Blood circulates through the digestive tract and liver, where vitamins and nutrients are processed and stored (Johns Hopkins Medicine, 2024). The liver is also the body’s detox organ, helping remove byproducts produced by alcohol and medications. The liver also helps break down old or damaged blood cells and produces substances to help with blood clotting. (Johns Hopkins Medicine, 2024) Diseases and conditions of the liver include cirrhosis, hepatitis, hemochromatosis, and cancer.

Gallbladder

The gallbladder is a much smaller organ located just under the liver. This supportive digestive organ stores bile after it is made in the liver. After eating, the small intestine releases a special hormone called cholecystokinin, which prompts the gallbladder to send bile through ducts and into the small intestine. Once in the small intestine, the bile breaks down the fat from the food. Conditions that can affect the gallbladder include gallstones. Surgery to remove the gallbladder, known as a cholecystectomy, is common. Some individuals may initially need to make adjustments to their diet after surgery. (Johns Hopkins Medicine, 2024)

Injury Medical Chiropractic and Functional Medicine Clinic works with primary healthcare providers and specialists to develop highly effective treatment plans through an integrated approach for each patient and restore health and function to the body through nutrition and wellness, functional medicine, acupuncture, Electroacupuncture, and integrated medicine protocols. If the individual needs other treatment, they will be referred to a clinic or physician best suited for them. Dr. Jimenez has teamed up with top surgeons, clinical specialists, medical researchers, nutritionists, and health coaches to provide the most effective clinical treatments.


Healthy Diet and Chiropractic


References

National Institute of Diabetes and Digestive and Kidney Diseases. Dis (2017). Your digestive system & how it works. Retrieved from www.niddk.nih.gov/health-information/digestive-diseases/digestive-system-how-it-works

American Diabetes Association. (2024). About diabetes: common terms. diabetes.org/about-diabetes/common-terms

Johns Hopkins Medicine. (2024). Liver: anatomy and functions. www.hopkinsmedicine.org/health/conditions-and-diseases/liver-anatomy-and-functions

Johns Hopkins Medicine. (2024). Cholecystectomy. www.hopkinsmedicine.org/health/treatment-tests-and-therapies/cholecystectomy

Improve Constipation Symptoms with Brisk Walking

Improve Constipation Symptoms with Brisk Walking

For individuals who are dealing with constant constipation due to medications, stress, or lack of fiber, can walking exercise help encourage regular bowel movements?

Improve Constipation Symptoms with Brisk Walking

Walking For Constipation Assistance

Constipation is a common condition. Too much sitting, medications, stress, or not getting enough fiber can result in infrequent bowel movements. Lifestyle adjustments can regulate most cases. One of the most effective ways is to incorporate regular moderate-vigorous exercise, encouraging the bowel muscles to contract naturally (Huang, R., et al., 2014). This includes jogging, yoga, water aerobics, and power or brisk walking for constipation alleviation.

The Research

A study analyzed middle-aged obese women who had chronic constipation over a 12-week period. (Tantawy, S. A., et al., 2017)

  • The first group walked on a treadmill 3 times a week for 60 minutes.
  • The second group did not engage in any physical activity.
  • The first group had greater improvement in their constipation symptoms and quality of life assessments.

A gut bacteria imbalance is also linked to constipation issues. Another study focused on the effect of brisk walking versus exercises that strengthened core muscles like planks on intestinal microbiota composition. (Morita, E., et al., 2019) The results showed that aerobic exercises like power/brisk walking can help increase intestinal Bacteroides, an essential part of healthy gut bacteria. Studies have shown a positive effect when individuals engage in at least 20 minutes of brisk walking daily. (Morita, E., et al., 2019)

Exercise Can Help Decrease Colon Cancer Risks

Physical activity can be a significant protective factor in decreasing colon cancer. (National Cancer Institute. 2023) Some estimate the risk reduction to be 50%, and exercise can even help prevent recurrence after a colon cancer diagnosis, also 50% in some studies for patients with stage II or stage III colon cancer. (Schoenberg M. H. 2016)

  • The best effects were obtained through moderate-intensity exercise, such as power/brisk walking, about six hours per week.
  • Mortality was reduced by 23% in individuals who were physically active for at least 20 minutes several times a week.
  • Inactive colon cancer patients who began exercising after their diagnosis had significantly improved outcomes than individuals who remained sedentary, showing that it is never too late to start exercising.(Schoenberg M. H. 2016)
  • The most active patients had the best outcomes.

Exercise-Related Diarrhea Prevention

Some runners and walkers experience an overly active colon, resulting in exercise-related diarrhea or loose stools, known as runner’s trots. Up to 50% of endurance athletes experience gastrointestinal problems during intense physical activity. (de Oliveira, E. P. et al., 2014) Prevention steps that can be taken include.

  • Not eating within two hours of exercising.
  • Avoid caffeine and warm fluids before exercising.
  • If sensitive to lactose, avoid milk products or use Lactase.
  • Ensure the body is well-hydrated before exercise.
  • Hydrating during exercise.

If exercising in the morning:

  • Drink about 2.5 cups of fluids or a sports drink before bed.
  • Drink about 2.5 cups of fluids after waking up.
  • Drink another 1.5 – 2.5 cups of fluids 20-30 minutes before exercising.
  • Drink 12-16 fluid ounces every 5-15 minutes during exercise.

If exercising for over 90 minutes:

  • Drink a 12 – 16 fluid-ounce solution containing 30-60 grams of carbohydrates, sodium, potassium, and magnesium every 5-15 minutes.

Professional Help

Periodic constipation may resolve with lifestyle adjustments like increased fiber intake, physical activity, and fluids. Individuals who are experiencing bloody stools or hematochezia, have recently lost 10 pounds or more, have iron deficiency anemia, have positive fecal occult/hidden blood tests, or have a family history of colon cancer need to see a healthcare provider or specialist to perform specific diagnostic tests to ensure there aren’t any underlying issues or serious conditions. (Jamshed, N. et al., 2011) Before engaging in walking for constipation assistance, individuals should consult their healthcare provider to see if it is safe for them.

At Injury Medical Chiropractic and Functional Medicine Clinic, our areas of practice include Wellness & Nutrition, Chronic Pain, Personal Injury, Auto Accident Care, Work Injuries, Back Injury, Low Back Pain, Neck Pain, Migraine Headaches, Sports Injuries, Severe Sciatica, Scoliosis, Complex Herniated Discs, Fibromyalgia, Chronic Pain, Complex Injuries, Stress Management, Functional Medicine Treatments, and in-scope care protocols. We focus on what works for you to achieve improvement goals and create an improved body through research methods and total wellness programs. If other treatment is needed, individuals will be referred to a clinic or physician best suited to their injury, condition, and/or ailment.


Poop Testing: What? Why? and How?


References

Huang, R., Ho, S. Y., Lo, W. S., & Lam, T. H. (2014). Physical activity and constipation in Hong Kong adolescents. PloS one, 9(2), e90193. doi.org/10.1371/journal.pone.0090193

Tantawy, S. A., Kamel, D. M., Abdelbasset, W. K., & Elgohary, H. M. (2017). Effects of a proposed physical activity and diet control to manage constipation in middle-aged obese women. Diabetes, metabolic syndrome and obesity : targets and therapy, 10, 513–519. doi.org/10.2147/DMSO.S140250

Morita, E., Yokoyama, H., Imai, D., Takeda, R., Ota, A., Kawai, E., Hisada, T., Emoto, M., Suzuki, Y., & Okazaki, K. (2019). Aerobic Exercise Training with Brisk Walking Increases Intestinal Bacteroides in Healthy Elderly Women. Nutrients, 11(4), 868. doi.org/10.3390/nu11040868

National Cancer Institute. (2023). Colorectal Cancer Prevention (PDQ(R)): Patient Version. In PDQ Cancer Information Summaries. www.cancer.gov/types/colorectal/patient/colorectal-prevention-pdq
www.ncbi.nlm.nih.gov/pubmed/26389376

Schoenberg M. H. (2016). Physical Activity and Nutrition in Primary and Tertiary Prevention of Colorectal Cancer. Visceral medicine, 32(3), 199–204. doi.org/10.1159/000446492

de Oliveira, E. P., Burini, R. C., & Jeukendrup, A. (2014). Gastrointestinal complaints during exercise: prevalence, etiology, and nutritional recommendations. Sports medicine (Auckland, N.Z.), 44 Suppl 1(Suppl 1), S79–S85. doi.org/10.1007/s40279-014-0153-2

Jamshed, N., Lee, Z. E., & Olden, K. W. (2011). Diagnostic approach to chronic constipation in adults. American family physician, 84(3), 299–306.

Functional Gastrointestinal Disorders: What You Need to Know

Functional Gastrointestinal Disorders: What You Need to Know

Individuals with digestive problems that cannot be diagnosed could be experiencing functional gastrointestinal disorders. Could understanding the types help in developing effective treatment plans?

Functional Gastrointestinal Disorders: What You Need to Know

Functional Gastrointestinal Disorders

Functional gastrointestinal disorders, or FGDs, are disorders of the digestive system in which the presence of structural or tissue abnormality cannot explain symptoms. Functional gastrointestinal disorders lack identifiable biomarkers and are diagnosed based on symptoms. (Christopher J. Black, et al., 2020)

Rome Criteria

FGDs used diagnoses of exclusion, meaning that they could only be diagnosed after organic/identifiable disease was ruled out. However, in 1988, a group of researchers and healthcare providers met to devise strict criteria for the diagnosis of the various types of FGDs. The criteria is known as the Rome Criteria. (Max J. Schmulson, Douglas A. Drossman. 2017)

FGDs

A comprehensive list as described by the Rome III criteria (Ami D. Sperber et al., 2021)

Functional Esophageal Disorders

  • Functional heartburn
  • Functional chest pain believed to be of esophageal origin
  • Functional dysphagia
  • Globus

Functional Gastroduodenal Disorders

  • Unspecified excessive belching
  • Functional dyspepsia – includes postprandial distress syndrome and epigastric pain syndrome.
  • Chronic idiopathic nausea
  • Aerophagia
  • Functional vomiting
  • Cyclic vomiting syndrome
  • Rumination syndrome in adults

Functional Bowel Disorders

  • Irritable bowel syndrome – IBS
  • Functional constipation
  • Functional diarrhea
  • Unspecified functional bowel disorder

Functional Abdominal Pain Syndrome

  • Functional abdominal pain – FAP

Functional Gallbladder and Sphincter of Oddi Disorders

  • Functional gallbladder disorder
  • Functional biliary Sphincter of Oddi disorder
  • Functional pancreatic Sphincter of Oddi disorder

Functional Anorectal Disorders

  • Functional fecal incontinence
  • Functional Anorectal Pain – includes chronic proctalgia, Levator ani syndrome, unspecified functional anorectal pain, and proctalgia fugax.
  • Functional Defecation Disorders – include dyssynergic defecation and inadequate defecatory propulsion.

Childhood Functional GI Disorders

Infant/Toddler (Jeffrey S. Hyams et al., 2016)

  • Infant colic
  • Functional constipation
  • Functional diarrhea
  • Cyclic vomiting syndrome
  • Infant regurgitation
  • Infant rumination syndrome
  • Infant dyschezia

Childhood Functional GI Disorders:

Child/Adolescent

  • Vomiting and Aerophagia – cyclic vomiting syndrome, adolescent rumination syndrome, and aerophagia
  • Abdominal Pain-Related Functional GI Disorders include:
  1. functional dyspepsia
  2. IBS
  3. Abdominal migraine
  4. Childhood functional abdominal pain
  5. Childhood functional abdominal pain syndrome
  • Constipation – functional constipation
  • Incontinence – nonretentive fecal incontinence

Diagnosis

Although the Rome criteria allow the diagnosis of FGDs to be symptom-based, a healthcare provider may still run standard diagnostic tests to rule out other diseases or look for structural problems resulting in symptoms.

Treatment

Although no visible signs of disease or structural problems may be identified as causing the symptoms, it does not mean that they are not treatable and manageable. For individuals who suspect they may have or have been diagnosed with a functional gastrointestinal disorder, it will be essential to work with a healthcare provider on a working treatment plan. Treatment options can include: (Asma Fikree, Peter Byrne. 2021)

  • Physical therapy
  • Nutritional and dietary adjustments
  • Stress management
  • Psychotherapy
  • Medication
  • Biofeedback

Eating Right To Feel Better


References

Black, C. J., Drossman, D. A., Talley, N. J., Ruddy, J., & Ford, A. C. (2020). Functional gastrointestinal disorders: advances in understanding and management. Lancet (London, England), 396(10263), 1664–1674. doi.org/10.1016/S0140-6736(20)32115-2

Schmulson, M. J., & Drossman, D. A. (2017). What Is New in Rome IV. Journal of neurogastroenterology and motility, 23(2), 151–163. doi.org/10.5056/jnm16214

Sperber, A. D., Bangdiwala, S. I., Drossman, D. A., Ghoshal, U. C., Simren, M., Tack, J., Whitehead, W. E., Dumitrascu, D. L., Fang, X., Fukudo, S., Kellow, J., Okeke, E., Quigley, E. M. M., Schmulson, M., Whorwell, P., Archampong, T., Adibi, P., Andresen, V., Benninga, M. A., Bonaz, B., … Palsson, O. S. (2021). Worldwide Prevalence and Burden of Functional Gastrointestinal Disorders, Results of Rome Foundation Global Study. Gastroenterology, 160(1), 99–114.e3. doi.org/10.1053/j.gastro.2020.04.014

Hyams, J. S., Di Lorenzo, C., Saps, M., Shulman, R. J., Staiano, A., & van Tilburg, M. (2016). Functional Disorders: Children and Adolescents. Gastroenterology, S0016-5085(16)00181-5. Advance online publication. doi.org/10.1053/j.gastro.2016.02.015

Fikree, A., & Byrne, P. (2021). Management of functional gastrointestinal disorders. Clinical medicine (London, England), 21(1), 44–52. doi.org/10.7861/clinmed.2020-0980

Recommended Nutrition For Constipation

Recommended Nutrition For Constipation

The digestive system breaks down the foods eaten so the body can absorb the nutrients. During digestion, the unnecessary parts of these foods are turned into waste/stool, which is evacuated during a bowel movement. When the digestive system stops functioning properly due to factors such as diet change, eating unhealthy foods, lack of physical activity/exercise, medications, and certain health conditions, can cause constipation. Constipation occurs when the body cannot have a regular bowel movement. The distention, gas, bloating and not being able to have a bowel movement cause irritability and stress, which can worsen constipation. Incorporating recommended nutrition can help restore regular bowel movements and gut function.

Recommended Nutrition For Constipation

Recommended Nutrition For Constipation

Symptoms like abdominal pain, bloating, and difficult bowel movements are common. Diet and proper hydration have a significant role in digestive health, especially in relieving and preventing constipation. High-fiber foods, prebiotics, and adequate hydration from foods and beverages are essential for healthy bowel movements.

  • Fiber is found in whole grains, starches, fruits, and vegetables.
  • Soluble and insoluble fiber are important for digestive health.
  • Focusing on incorporating high-fiber fruits, vegetables, and whole grains.
  • Foods rich in prebiotics like fermented foods are recommended when constipated.

The recommended nutrition for constipation, according to a dietitian includes.

Avocados

  • Avocados can be paired with just about anything and are full of nutrients and fiber.
  • One avocado contains around 13.5 grams of fiber.
  • One avocado will provide almost half daily fiber needs.
  • Other high-fiber fruits: pomegranates, guava, raspberries, blackberries, and passionfruit.

Figs

  • Figs can be eaten fresh and dried.
  • Figs are considered a laxative and have been shown to treat and reduce constipation.
  • They contain antioxidants, polyphenols, polyunsaturated fatty acids, and vitamins.
  • Other fruits similar to a fig: dried apricots, prunes, and plums.

Plums

  • Plums, prunes dried plums are packed with fiber and prebiotics that have a natural laxative effect.
  • Sorbitol – a sugar found in plums and prunes, acts as an osmotic laxative that retains water.
  • The added H2O makes the stools softer and easier to pass.
  • Natural fruit juices, like pear, apple, or prune are often prescribed for constipation.
  • Other fruits that aid in bowel movements: peaches, pears, and apples.

Kefir

  • Fermented foods like kefir are rich in beneficial bacteria that work to maintain digestive system health.
  • It can be consumed on its own or used in smoothies, cooking, and baking recipes.
  • Other fermented foods: kombucha, yogurt, sauerkraut, kimchi, miso, and tempeh.

Oat Bran

  • Oat bran is oatmeal that has not had the bran removed.
  • The bran contains beneficial nutrients including fiber, antioxidants, vitamins, and minerals.
  • Oat bran contains soluble and insoluble fiber, as well as beta-glucan/non-starchy polysaccharides.
  • All improve the composition of gut bacteria and promote healthy bowel movements.
  • Other beneficial grains: oatmeal, wheat bran, rye, and barley.

Incorporating Gut-Beneficial Foods

How to incorporate recommended nutrition gut-beneficial foods into a regular menu:

Smoothie

  • Use kefir or yogurt as a base then balance it out with fiber-rich fruits like mango, blueberries, and kiwi.

Snacks

  • Diversify snacks with a plate of fiber and prebiotics.
  • Nuts, cheese, crackers, fruit, and a yogurt or avocado dip.

Oatmeal

  • Try oat bran to increase fiber.
  • Sprinkle a serving of flaxseeds, chia seeds, or hemp seeds for added fiber and healthy fats.

Parfait

  • Yogurt parfaits can maximize nutrients, flavor, and textures in a bowl.
  • Layer up on a favorite yogurt with granola, nuts, fruit, and seeds.

Grain Bowl

  • Fiber found in whole grains and seeds like barley, farro, and quinoa, helps promote healthy digestion.
  • Make a bowl with a grain base, then top with a protein, fresh or grilled veggies, avocado, and dressing.

Talk with a registered nutritionist or other healthcare provider to discuss recommended nutrition plan options.


Balancing Body and Metabolism


References

Arce, Daisy A et al. “Evaluation of constipation.” American family physician vol. 65,11 (2002): 2283-90.

Bharucha, Adil E. “Constipation.” Best practice & research. Clinical gastroenterology vol. 21,4 (2007): 709-31. doi:10.1016/j.bpg.2007.07.001

Gray, James R. “What is chronic constipation? Definition and diagnosis.” Canadian Journal of Gastroenterology = Journal Canadien de Gastroenterology vol. 25 Suppl B, Suppl B (2011): 7B-10B.

Jani, Bhairvi, and Elizabeth Marsicano. “Constipation: Evaluation and Management.” Missouri medicine vol. 115,3 (2018): 236-240.

Naseer, Maliha, et al. “Therapeutic Effects of Prebiotics on Constipation: A Schematic Review.” Current clinical pharmacology vol. 15,3 (2020): 207-215. doi:10.2174/1574884715666200212125035

National Institute of Diabetes and Digestive and Kidney Diseases. Symptoms and Causes of Constipation.

National Institute of Diabetes and Digestive and Kidney Disease. Your Digestive System and How It Works.

Sinclair, Marybetts. “The use of abdominal massage to treat chronic constipation.” Journal of bodywork and movement therapies vol. 15,4 (2011): 436-45. doi:10.1016/j.jbmt.2010.07.007

Understanding The Metabolic Connection & Chronic Diseases (Part 2)

Understanding The Metabolic Connection & Chronic Diseases (Part 2)


Introduction

Dr. Jimenez, D.C., presents how chronic metabolic connections like inflammation and insulin resistance are causing a chain reaction in the body in this 2-part series. Many factors often play a role in our health and wellness. In today’s presentation, we will continue on how these chronic metabolic diseases affect the vital organs and organ systems. It can lead to overlapping risk factors associated with pain-like symptoms in the muscles, joints, and vital organs. Part 1 examined how overlapping risk profiles like insulin resistance and inflammation affect the body and cause muscle and joints pain-like symptoms. We mention our patients to certified medical providers that provide available therapy treatments for individuals suffering from chronic conditions associated with metabolic connections. We encourage each patient when it is appropriate by referring them to associated medical providers based on their diagnosis or needs. We understand and accept that education is a marvelous way when asking our providers’ crucial questions at the patient’s request and acknowledgment. Dr. Alex Jimenez, D.C., uses this information as an educational service. Disclaimer

 

How The Liver Associated With Metabolic Diseases

So we can look to the liver to find earlier cues of cardiovascular risk. How can we do that? Well, let’s understand some liver biochemistry. So in a healthy liver cell hepatocyte, when you have increased insulin being secreted because there was a meal that required glucose to be absorbed, what you expect if the insulin receptor works is that the glucose would go in. Then the glucose would get oxidized and turned into energy. But here’s the problem. When the hepatocyte has insulin receptors that don’t work, you’ve got that insulin on the outside, and the glucose never made it in. But what also happens on the inside of the hepatocyte is it was assumed that the glucose was going to get in. So what it does is it turns off fatty acid oxidation, thinking, “Guys, we don’t need to burn our fatty acids. We’ve got some glucose coming in.”

 

So when the glucose is not there, and you’re not burning off fatty acids, very common for people to feel fatigued because nothing is burning for energy. But here is the secondary sequela; where are all those fatty acids going, right? Well, the liver may try to repackage them as triglycerides. Sometimes, they stay in the hepatocyte or get shifted out of the liver into the bloodstream as VLDL or very low-density lipoprotein. You might see it as a high triglyceride shift in a standard lipid panel. So, when all of us are talking about getting a triglyceride level to around 70 as your 8+ goal, when I start seeing triglycerides rising, we wait until they’re 150, even though that’s the cutoff for our labs. When we see it at 150, we know they are shunting triglycerides out of the liver.

 

So that will happen many times before we find impaired fasting glucose. So look at your triglycerides, fasting triglycerides, as an emerging or early biomarker of insulin dysfunction. So this is another diagram that says that if the triglycerides are being created because the fatty acids are being oxidized, they can stay in the liver. Then that makes steatosis or the fatty liver, or they can be pushed out, and they turn into lipoproteins. We’re going to talk about that in just a second. The body is like, “What are we going to do with these fatty acids?” We can’t try to shove them into places because nobody wants them. To that point, the liver is like, “I don’t want them, but I will keep some with me.” Or the liver would have these fatty acids transported and stuck to the blood vessel walls.

 

And then the blood vessels and arteries are like, “Well, I don’t want them; I’ll put them underneath my endothelium.” And so that’s how you get atherogenesis. The muscles are like, “I don’t want them, but I’ll take some.” That’s how you get the fatty streaks in your muscles. So when the liver is getting bogged down with steatosis, inflammation occurs in the body and produces this feed-forward cycle inside the hepatocyte, damaging the liver. You’re getting cellular death; you’re getting fibrosis, which is just an extension of what happens when we don’t address the core issues for fatty liver: inflammation and insulin resistance. So, we look for subtle rises in AST, ALT, and GGT; remember that it is a liver-based enzyme.

 

Hormone Enzymes & Inflammation

GGT enzymes in the liver are smoke detectors and tell us how much oxidative stress is going on. Will we look at HSCRP and APOB to see the output of this liver? Is it starting to dump excess fatty acids through VLDL, APOB, or triglycerides? And how it picks that is just genetics, honestly. So I look for liver markers to tell me what’s going on in the liver as a sign of what’s happening everywhere. Because that might be the genetic weak spot of the person, some people are genetically vulnerable just in terms of their lipid profiles. To that point, we can look for something called metabolic dyslipidemia. You know this as high triglycerides and low HDL. You can specifically look for a ratio; an optimal balance is three and lower. It starts going from three to five and then five to eight, like eight is almost pathognomonic of insulin resistance. You’re just reaching becoming more and more insulin resistant.

 

As the number increases for that trig over HDL ratio, that is a simple, easy way to screen for insulin resistance. Now some people look 3.0 on this but still have insulin resistance. So there are other tests you do. This is a way to find those who show insulin resistance through lipids. And remember, everybody is different. Women with PCOS could have amazing lipids but could express an increase or decrease of hormones associated with insulin, estrogen, and inflammation. So look for something other than one test or ratio to indicate whether they’ve got it. You’re looking to see what could be the place where we will find the clue.

 

So let’s use the word healthy. A healthy person has VLDL that looks to be a healthy normal size in their bodies, and they have normal LDL and HDL. But now look at what happens when you get insulin resistance. These VLDL ls start to pump up with triglycerides. That’s why they’re fattening up. It’s lipotoxicity. So if you start looking at the VLDL three numbers in a lipoprotein profile, you’ll see that that number is creeping up, and there are more of them, and their size is bigger. Now with LDL, what happens is that the cholesterol amount within the top and the bottom is the same. If I pop all these water balloons, it’s the same amount of LDL cholesterol. However, that amount of LDL cholesterol in insulin resistance is repackaged in small dense LDL.

 

How Does Functional Medicine Play Its Part?

Now we understand that there may be some of you who cannot or do not have access to this testing, or your patients cannot afford it, and that’s why we answered the questions and looked for other clues of insulin resistance and treat the root cause that is affecting the body. Look for signs of inflammation and other overlapping profiles of insulin resistance. The particle number is higher when they’re insulin resistance. So cholesterol is the same, whereas the particle number is more elevated, and small dense LDL is more atherogenic. Treat it because whether or not you have access to knowing the LDL particle, there should be something in your head that says, “Man, even though this person’s LDL cholesterol looks good, they have tons of inflammation and insulin resistance; I can’t be sure that they don’t have higher particle number.” You might assume that they do this just to be safe.

 

The other thing that happens in insulin resistance is that the HDL or the healthy cholesterol tends to become small. So that’s not very good because the efflux capacity of HDL is lessened when it’s smaller. So we like the larger HDL, if you will. Access to these tests would give you a solid indication of what’s going on with your patient from a cardiometabolic perspective.

 

When it comes to these tests, it is important to utilize them to determine the patient’s timeline when they have inflammation or insulin resistance in their bodies, affecting their quality of life. However, many people would often express that these tests are expensive and would go with the gold standard of testing for affordability and be able to decide if it is worth it to better their health and wellness.

 

Look For Cardiometabolic Risk Patterns

So when it comes to cardiometabolic risk factor patterns, we look at the insulin aspect and how it correlates with mitochondrial dysfunction associated with insulin resistance and inflammation. A research article mentions how two mitochondrial dysfunctions can affect the body. Okay, let’s talk about the first issue, which is the quantity issue. One could be endotoxins that we encounter in our environment, or two; it can be genetically passed along from generation to generation. So the two types could indicate that you don’t have enough mitochondria. So that’s a quantity issue. The other problem is it’s a quality issue. You got plenty of them; they don’t work well, so they don’t have high output or at least normal results. Now how does this play out in the body? So out in the periphery, your muscles, adipocytes, and liver, you have mitochondria in those cells, and it’s their job to energize that lock and jiggle. So if your mitochondria are in the right number, you’ve got plenty to energize the insulin cascade lock and jiggle.

 

Interesting, right? So here it is in summary, if you don’t have enough mitochondria, which is the problem in the periphery, you get insulin resistance because the lock and jiggle aren’t working well. But if you do not have the mitochondria working well in the pancreas, especially in the beta cell, you don’t secrete insulin. So you still get hyperglycemia; you don’t have high insulin state. When this happens, we know your brain should be hurting, but hopefully, it will come together slowly.

 

Another article mentions that it connects mitochondrial dysfunction with type two diabetes, and poor maternal nutrition can prime it. This one talks about how fatty liver is associated with lipotoxicity, right? That’s that increased fatty acid, and oxidative stress, which, remember, is the byproduct of inflammation. ATP depletion and mitochondrial dysfunction. When this happens, it can affect the liver, which then turns into the fatty liver, and can also be associated with gut dysfunction, which leads to chronic inflammation, elevated insulin resistance, mitochondrial dysfunction, and many more. These chronic metabolic diseases are connected, and there are ways to reduce these symptoms from affecting the body.

 

Conclusion

When having a conversation with their doctors, many patients know that the same drivers affect a whole host of other phenotypes, all commonly rooted in inflammation, insulin, and toxicity. So when many people realize these factors are the root cause, doctors will work with many associated medical providers to develop personalized functional treatment plans. So remember, you always have to use the timeline and the matrix to kind of help you know where do you start with this patient, and for some people, it might be you’re just going to tweak a little bit of lifestyle because all they’re working on is changing their body count. So it’s one of the blessings of functional medicine that we were able to turn off the inflammation in the gut, which helps reduce the toxic impact burdening the liver. It also allows the individual to find out what works or doesn’t work with their bodies and take these small steps to improve their health.

 

We hope you have fresh eyes about inflammation, insulin, and toxicity and how it is at the root of so many conditions that your patients are facing. And how through very simple and effective lifestyle and nutraceutical interventions, you can change that signaling and change the course of their symptoms today and the risks they have tomorrow.

 

Disclaimer

Understanding The Metabolic Connection & Chronic Diseases (Part 2)

The Metabolic Connections Between Chronic Diseases (Part 1)


Introduction

Dr. Alex Jimenez, D.C., presents how metabolic connections are causing a chain reaction to major chronic diseases in this 2-part series. Many factors often play a role in our health and wellness. It can lead to overlapping risk factors associated with pain-like symptoms in the muscles, joints, and vital organs. Part 2 will continue the presentation on metabolic connections with major chronic diseases. We mention our patients to certified medical providers that provide available therapy treatments for individuals suffering from chronic conditions associated with metabolic connections. We encourage each patient when it is appropriate by referring them to associated medical providers based on their diagnosis or needs. We understand and accept that education is a marvelous way when asking our providers’ crucial questions at the patient’s request and acknowledgment. Dr. Jimenez, D.C., makes use of this information as an educational service. Disclaimer

 

How Inflammation Affects The Body

Dr. Alex Jimenez, D.C., presents: So here you have a lean set of adipocytes on the left, and then as they start to plump up with more cellular weight, you can see those macrophages, the green boogies come around looking, saying, “Hey, what’s going on here? It doesn’t look right.” So they are investigating, and this causes local cell death; it’s just a part of the inflammatory cascade. So there is also another mechanism happening here. Those adipocytes are not just getting plumper by accident; it’s often related to a calorie surfette. So this nutrient overload damages the endoplasmic reticulum, leading to more inflammation. What these cells and the adipocytes are trying to do is protect themselves from glucose and lipo toxicity.

 

And the whole cell, the adipocyte cell, is creating these caps that are trying to say, “Please stop, we can’t take any more glucose, we can’t take any more lipids.” It’s a protection mechanism known as insulin resistance. It’s not just some random thing happening. It is the body’s way of trying to prevent glucose and lipotoxicity. Now that the inflammation alarm is occurring more than just in the adipocytes, it’s getting systemic. Other tissues and organs are starting to feel the same burden of the calorie surfette, causing inflammation and cell death. So glucose and lipotoxicity look like fatty liver when dealing with the liver. And you can also have it just like fatty liver progresses to cirrhosis with hepatocyte death. The same mechanism that’s happening in muscle cells. So our skeletal muscle cells specifically see cell death after inflammation and see fatty deposition.

 

The best way to think about it is, for example, the cows raised for food consumption and how they have marbled. So that’s the fatty deposition. And in humans, you can think about how people become sarcopenic as they become more and more insulin resistant. It’s the same phenomenon when body tissue tries to protect itself from glucolipotoxicity, causing a local inflammatory response. It becomes an endocrine response when it starts targeting other tissues in the periphery, whether the liver, muscle, bone, or brain; it’s just whatever is happening; they’re in the visceral adipocytes that can occur in other tissues. So that’s your paracrine effect. And then it can go viral, if you will.

 

Inflammation Associated With Insulin Resistance

Dr. Alex Jimenez, D.C., presents: You’re getting this local and systemic pro-inflammatory response coupled with insulin resistance, returning to this protection mechanism against glucose and lipotoxicity. Here you see how the blood vessels in our arteries get caught in the loop of fatty deposition and cell death. So you’ll see leaky blood vessels and fatty deposits, and you’ll see damage and pro-atherogenesis. Now, this is something we explained in AFMCP for the cardiometabolic module. And that is the physiology behind the insulin receptor. This is known as the lock and jiggle technique. So you have to have insulin lock into the insulin receptor up at the top., which is known as the lock.

 

And then there’s a phosphorylation cascade called the jiggle that then creates this cascade that ultimately causes the glucose-4 channels to open up the glucose-4 receptors to go into the cell so that it can be then the glucose, which is then utilized for energy production by the mitochondria. Of course, insulin resistance is where that receptor isn’t sticky or as responsive. And so not only do you fail to get glucose into the cell for energy production, but you are also rendering a hyper insulin state in the periphery. So you get hyperinsulinemia as well as hyperglycemia in this mechanism. So what can we do about that? Well, many nutrients have been shown to improve the lock and jiggle things that can improve the glucose-4 transporters coming up towards the periphery.

 

Anti-Inflammatory Supplements Reduce Inflammation

Dr. Alex Jimenez, D.C., presents: You see these listed here: vanadium, chromium, cinnamon alpha lipoic acid, biotin, and another relatively new player, berberine. Berberine is a botanical that can dampen all primary pro-inflammatory signals. So what precedes these comorbidities often and it’s insulin dysfunction. Well, what precedes insulin dysfunction many times? Inflammation or toxicity. So if berberine is helping the primary inflammation issue, it will address the downstream insulin resistance and all the comorbidities that can happen. So consider berberine as your option. So again, this shows you that if you can reduce inflammation up here at the top, you can minimize many cascade effects downstream. Berberine specifically seems to act in the microbiome layer. It modulates the gut microbiota. It may create some immune tolerance, therefore not rendering as much inflammation.

 

So consider berberine as one of the tools you can use to support insulin dysfunction and insulin resistance-related comorbidities. Berberine seems to increase insulin receptor expression, so the lock and jiggle work more effectively and improve the cascade with the glucose-4 transporters. That’s one mechanism by which you can start to find the root cause of many of the conditions we discussed when you see paracrine and endocrine glucose toxicity, lipotoxicity organ damage. Now another mechanism for you to consider is leveraging NF kappa B. So the goal is to keep NF kappa B grounded because as long as they don’t translocate, a host of inflammation signals do not get triggered.

 

So our goal is to keep NF kappa B grounded. How can we do that? Well, we can use NF kappa B inhibitors. So in this presentation of treatment options for any comorbidities related to insulin dysfunction, there are many ways to reduce these overlapping conditions affecting our bodies. So you can directly affect insulin resistance through anti-inflammatory supplements or indirectly help insulin resistance or insulin dysfunction by leveraging things against inflammation. Cause if you remember, insulin dysfunction is what then causes all those comorbidities. But what causes insulin dysfunction is generally inflammation or toxins. So our goal is to address pro-inflammatory things. Because if we can address pro-inflammatory things and nip the insulin dysfunction in the bud, we can prevent all the downstream organ damage or organ dysfunction.

 

Reducing Inflammation In The Body

Dr. Alex Jimenez, D.C., presents: Let’s move on to the next section that you can leverage or reduce the inflammation and insulin soup damage if you will, that the genes bathe in the body. This is the one you’ll often hear in our presentation, and that’s because, actually, in functional medicine, we help fix the gut. That’s usually where you need to go. And this is the pathophysiology for why we do that in cardiometabolic medicine. So if you have that poor or sad diet, that modern western diet with bad fats, it will directly damage your microbiome. That change in the microbiome can render increased intestinal permeability. And now lipopolysaccharides can translocate or leak into the bloodstream. To that point, the immune system says, “Oh no way, buddy. You’re not supposed to be in here.” You’ve got these endotoxins in there, and now there is a local and systemic inflammatory response that inflammation will drive the insulin dysfunction, which will cause the metabolic disorders that come after that.

 

Whatever the person’s genetically prone to, it gets clicked on epigenetically. So remember, if you can quell the inflammation in the microbiome, meaning create this tolerant and strong microbiome, you can reduce the inflammatory tone of the entire body. And when you reduce that, it’s been shown that it sets the insulin sensitivity. So the lower the inflammation, the higher the insulin sensitivity related to the microbiome. So surprise, it’s been shown that probiotics are associated with improved insulin sensitivity. So the right probiotics will create immune tolerance. Microbiome strength and modulation occur with probiotics. And so insulin sensitivity is preserved or regained based on where you are. So please consider that as another indirect mechanism or treatment option for leveraging cardiometabolic health for patients.

 

Probiotics

Dr. Alex Jimenez, D.C., presents: So when it comes to probiotics, we will use them in someone who might also concurrently have irritable bowel syndrome or food allergies. We might pick probiotics over NF kappa B inhibitors if they also have insulin resistance issues. But if they have many neurocognitive problems, we might start with the NF kappa B. So, that’s the way you can decide which ones to pick. Now, remember, when talking with patients, it is important to discuss how their eating habits are causing inflammation in their bodies. It is also important to note that it’s not just a quality conversation; it’s a quantity conversation and an immune conversation.

 

This reminds you that when you fix the gut by feeding it well and reducing its inflammatory tone, you get a host of other preventative benefits; you stop or at least reduce the strength of the dysfunction. And you can see that, ultimately can reduce the overlapping risk of obesity, diabetes, and metabolic syndrome. We are trying to drive home that metabolic endotoxemia, or just managing the microbiome, is a powerful tool to help your insulin-resistant or cardiometabolic patients. So much data tells us that we cannot just make the conversation about eating right and exercising.

 

It’s so much beyond that. So the more we can improve the gut microbiota, we can change inflammation signals through proper diet, exercise, stress management, sleep, all the other things we’ve been talking about, and fixing the gums and the teeth. The less the inflammation, the less the insulin dysfunction and, therefore, the less all those downstream disease effects. So what we want to make sure you know is to go to the gut and make sure that the gut microbiome is happy and tolerant. It’s one of the most potent ways to influence a healthy cardiometabolic phenotype. And aside, although it was a bigger thing a decade ago, non-caloric artificial sweeteners do as they might be non-caloric. And so people may be tricked into thinking it’s zero sugar.

 

But here’s the problem. These artificial sweeteners can interfere with healthy microbiome compositions and induce more type two phenotypes. So, even though you think you’re getting the benefit with no calories, you’re going to increase your risk for diabetes more through its effect on the gut microbiome. All right, We’ve made it through objective one. Hopefully, you’ve learned that insulin, inflammation, adipokines, and all the other things that happen in the endocrine response affect many organs. So let’s now start to look at emerging risk markers. Okay, we’ve talked a bit about TMAO. Again, that’s still a relevant concept here with gut and insulin resistance. So we want to make sure that you look at TMAO not as the end all be all but as another emerging biomarker that could give you a clue about microbiome health in general.

 

Looking For The Inflammatory Markers

Dr. Alex Jimenez, D.C., presents: We look at elevated TMAO to help the patient recognize that they have changed their eating habits. Most of the time, we help patients reduce unhealthy animal proteins and increase their plant-based nutrients. It’s generally how many doctors use it in standard medical practice. Alright, now another emerging biomarker, okay, and it sounds funny to call it emerging because it seems so obvious, and that is insulin. Our standard of care is centralized around glucose, fasting glucose, to our postprandial glucose A1C as a measure of glucose. We are glucose so centric and need insulin as an emerging biomarker if we try to be preventative and proactive.

 

And as you remember, we talked yesterday that fasting insulin in the bottom of the first quartile of your reference range for fasting insulin might be where you want to go. And for us in the US, that tends to be between five and seven as a unit. So notice that this is the pathophysiology of type two diabetes. So type two diabetes can happen from insulin resistance; it can also occur from mitochondrial problems. So pathophysiology of type two diabetes could be because your pancreas is not secreting enough insulin. So again, this is that little 20% that we talk about the majority of the people who are getting type two diabetes; it’s from insulin resistance, as we would suspect, from a hyper insulin problem. But there is this group of people who have damaged mitochondria, and they are not outputting insulin.

 

So their blood sugar rises, and they get type two diabetes. Okay, then the question is, if there is a problem with pancreatic beta cells, why is there a problem? Is the glucose going up because the muscles have insulin resistance, so they cannot capture and bring in glucose? So is it the liver that’s hepatic insulin resistant that cannot take in glucose for energy? Why is this glucose running around in the bloodstream? That’s what this is paraphrasing. So contributing role, you have to look at the adipocytes; you have to look for visceral adiposity. You must see if this person is just a big belly fat inflammatory-like catalyst. What can we do to reduce that? Is the inflammation coming from the microbiome?

 

Conclusion

Dr. Alex Jimenez, D.C., presents: Even the kidney can play a role in this, right? Like perhaps the kidney has increased glucose reabsorption. Why? Could it be because of an oxidative stress hit to the kidney, or could it be in the HPA axis, the hypothalamus pituitary adrenal axis where you’re getting this cortisol response and this sympathetic nervous system response that’s generating inflammation and driving the blood insulin and blood sugar disturbances? In Part 2, we will talk here about the liver. It’s a common player for many people, even if they don’t have fulminant fatty liver disease; it’s generally a subtle and common player for people with cardiometabolic dysfunction. So remember, we’ve got the visceral adiposity causing inflammation and insulin resistance with atherogenesis, and the liver is like this innocent bystander caught up in the drama. It’s happening before sometimes the atherogenesis starts.

 

Disclaimer

The Digestive Process: Functional Medicine Back Clinic

The Digestive Process: Functional Medicine Back Clinic

The body needs food for fuel, energy, growth, and repair. The digestive process breaks down food into a form the body can absorb and use for fuel. The broken-down food gets absorbed into the bloodstream from the small intestine, and the nutrients are carried to the cells throughout the body. Understanding how the organs work together to digest food can help with health goals and overall health.The Digestive Process: Chiropractic Functional Medicine Clinic

The Digestive Process

The organs of the digestive system are the following:

  • Mouth
  • Esophagus
  • Stomach
  • Pancreas
  • Liver
  • Gallbladder
  • Small intestine
  • Large intestine
  • Anus

The digestive process starts with the anticipation of eating, stimulating the glands in the mouth to produce saliva. The digestive system’s primary functions include:

  • Mixing food
  • Moving food through the digestive tract – peristalsis
  • The chemical breakdown of food into smaller absorbable components.

The digestive system converts food into its simplest forms, which include:

  • Glucose – sugars
  • Amino acids – protein
  • Fatty acids – fats

Proper digestion extracts nutrients from food and liquids to maintain health and function properly. Nutrients include:

  • Carbohydrates
  • Proteins
  • Fats
  • Vitamins
  • Minerals
  • Water

Mouth and Esophagus

  • The food is ground up by the teeth and moistened with saliva to swallow easily.
  • Saliva also has a special chemical enzyme that starts breaking down carbohydrates into sugars.
  • Muscular contractions of the esophagus massage the food into the stomach.

Stomach

  • The food passes through a small muscle ring into the stomach.
  • It gets mixed with gastric chemicals.
  • The stomach churns the food to break it down further.
  • The food is then squeezed into the first part of the small intestine, the duodenum.

Small Intestine

  • Once in the duodenum, the food mixes with more digestive enzymes from the pancreas and bile from the liver.
  • The food passes into the lower parts of the small intestine, called the jejunum and the ileum.
  • Nutrients are absorbed from the ileum, lined with millions of villi or thread-like fingers that facilitate the absorption.
  • Each villus is connected to a mesh of capillaries, which is how nutrients get absorbed into the bloodstream.

Pancreas

  • The pancreas is one of the largest glands.
  • It secretes digestive juices and a hormone called insulin.
  • Insulin helps regulate the amount of sugar in the blood.
  • Problems with insulin production can lead to conditions like diabetes.

Liver

The liver has several different roles that include:

  • Breaks down fats using bile stored in the gallbladder.
  • Processes proteins and carbohydrates.
  • Filters and processes impurities, medications, and toxins.
  • Generates glucose for short-term energy from compounds like lactate and amino acids.

Large Intestine

  • A large reservoir of microbes and healthy bacteria live in the large intestine and play an important role in healthy digestion.
  • Once the nutrients have been absorbed, the waste is passed into the large intestine or bowel.
  • Water is removed, and the waste gets stored in the rectum.
  • It is then passed out of the body through the anus.

Digestive System Health

Ways to keep the digestive system and the digestive process healthy include:

Drink More Water

  • Water helps the food flow more easily through the digestive system.
  • Low amounts of water/dehydration are common causes of constipation.

Add More Fiber

  • Fiber is beneficial to digestion and helps with regular bowel movements.
  • Incorporate both soluble and insoluble fiber.
  • Soluble fiber dissolves in water.
  • As soluble fiber dissolves, it creates a gel that can improve digestion.
  • Soluble fiber may reduce blood cholesterol and sugar.
  • It helps your body improve blood glucose control, which can aid in reducing your risk for diabetes.
  • Insoluble fiber does not dissolve in water.
  • Insoluble fiber attracts water into the stool, making it softer and easier to pass with less strain on the bowels.
  • Insoluble fiber can help promote bowel health and regularity and supports insulin sensitivity which can help reduce the risk of diabetes.

Balanced Nutrition

  • Eat fruit and vegetables daily.
  • Choose whole grains over processed grains.
  • Avoid processed foods in general.
  • Choose poultry and fish more than red meat and limit processed meats.
  • Cut down on sugar.

Eat Foods with Probiotics or Use Probiotic Supplements

  • Probiotics are healthy bacteria that help combat unhealthy bacteria in the gut.
  • They also generate healthy substances that nourish the gut.
  • Consume probiotics after taking antibiotics that often kill all the bacteria in the gut.

Eat Mindfully and Chew Food Slowly

  • Chewing food thoroughly helps to ensure the body has enough saliva for digestion.
  • Chewing food thoroughly also makes it easier for nutritional absorption.
  • Eating slowly gives the body time to digest thoroughly.
  • It also allows the body to send cues that it is full.

How The Digestive System Works


References

GREENGARD, H. “Digestive system.” Annual review of physiology vol. 9 (1947): 191-224. doi:10.1146/annurev.ph.09.030147.001203

Hoyle, T. “The digestive system: linking theory and practice.” British journal of nursing (Mark Allen Publishing) vol. 6,22 (1997): 1285-91. doi:10.12968/bjon.1997.6.22.1285

www.merckmanuals.com/home/digestive-disorders/biology-of-the-digestive-system/overview-of-the-digestive-system

www.niddk.nih.gov/health-information/digestive-diseases/digestive-system-how-it-works

Martinsen, Tom C et al. “The Phylogeny and Biological Function of Gastric Juice-Microbiological Consequences of Removing Gastric Acid.” International journal of molecular sciences vol. 20,23 6031. 29 Nov. 2019, doi:10.3390/ijms20236031

Ramsay, Philip T, and Aaron Carr. “Gastric acid and digestive physiology.” The Surgical clinics of North America vol. 91,5 (2011): 977-82. doi:10.1016/j.suc.2011.06.010