Gut Health: 10 Things You Should Know to Survive Your 60s

Transcript:

Narrator: 0:01

Welcome to MedEvidence podcast, this episode is a rebroadcast from a live MedEvidence presentation.

Dr. Michael Koren: 0:18

So Dr. Misra and I are friends, we work together all the time, we have fun together, we have meetings together and we also do some pretty high level research together, and Bharat has been kind enough to put together his thoughts on things that are important to you folks your demographic in terms of your GI health and we're going to have a conversation. We call it Two Docs Talk, and you're going to glean what you find to be true from our conversation, knowing that we have nothing to hide except just having a good conversation, having fun and telling you what we do. So, with that in mind, the topic here is 10 things you should know about your gut to survive your 60s and I'm sure Dr. Misra will start by saying the best way to survive your 60s and beyond we're not just getting to the 60s is to have a plan before you hit 60. But if you don't have a plan and you're in your 60s, we still can help you.

Dr. Michael Koren: 1:16

So with that introduction, these are our lovely faces and let's go ahead, Dr. Misra, why don't you jump through your this is almost like a David Letterman top 10 type sequence and you're going to walk through it and you're going to explain to people what the 10 things are that they should know to survive their 60s and beyond from a GI standpoint. And I may interject here and there, especially if it gets a little jargony or you have to break down something for the audience. So go ahead. The floor is yours, Bharat.

Dr. Bharat Misra: 1:47

Thank you, Mike, it's a pleasure being here this afternoon and I wanted to thank everybody. This is quite an attendance. I was here about a year and a half ago. It's almost double.

Dr. Bharat Misra: 1:58

And I was telling Mike, the gut finally gets its due. You know, the cardiologists, the neurologists of the world have been ruling roast. Everybody only talks to them. So it's nice to see that the gut is finally getting some respect. So when we give a talk, we can go deep or we can go wide. This is a wide talk and that's what I think makes it very useful. You know, one of the definitions of being a specialist is we know more and more about less and less. I have to read four journals every week, go through a lot of CME, but everything limited to one specialty. So the goal of this talk was I got to come out of my specialist well and communicate to non-specialists. And the genesis of this talk is when we go to cocktail parties and people find out you're a gastroenterologist, they always ask you okay, so what should I do for my gut health? T hat's the question I get the most. So today we're going to talk about the top 10 things.

Dr. Michael Koren: 3:01

So this is a cocktail party talk. Do you need a few drinks before we start?

Dr. Bharat Misra: 3:05

Unfortunately I have clinic after this, so I'll have to decline.

Dr. Bharat Misra: 3:10

We can start with the first thing you have to know about your gut. The first thing you have to know is that colon cancer is very prevalent. About 150,000 people get colon cancer in the United States every year and 50,000 approximately die from it every year. It is a very common cancer. Depending on how you look at it, it's the fourth most common cancer and third most common cause of cancer death. And here's the main message it is preventable.

Dr. Bharat Misra: 3:45

People make a big deal about breast cancer. I see pink ribbons everywhere I go in medicine. Breast cancer cannot be prevented. You can only find it early. Prostate cancer you can't prevent prostate cancer. You can only find it early. In fact, out of the top 10 cancers, the only two cancers you can prevent is cancer of the uterine cervix and colon cancer. That's why the most important message today is this is a preventable cancer. If you are above the age of 45, get a test to find the precancerous lesions early. There are multiple tests you can do, but only three that we commonly use. The first one is a colonoscopy. I'm sure many of you sitting here have had one and it is probably the best test, but not everybody wants to be subjected to a colonoscopy, of course, if you're sitting, you probably didn't have one yesterday.

Dr. Bharat Misra: 4:54

So it is the gold standard test and it finds the precancerous lesions, prevents cancer. The downside is it is expensive, it is somewhat invasive, you got to take a lot of time off and there is a small amount of risk associated with it. As a gastroenterologist, my partners will hate me for saying this, but there are other tests. The two other tests that I want you to know about is the first one is Cologuard. Cologuard is a stool test for colon cancer. It's actually a very good test to find early cancer. It's a pretty good test to find large polyps and it's an okay test for small polyps. But it is a perfectly acceptable alternative to colon cancer. The Cologuard is done every three years. Colonoscopy is every 10 years and if the Cologuard test is positive then they refer you for a colonoscopy. The third test, which is not used much in the US, actually has the most evidence. It's a simple 10 to $20 stool test for occult blood which should be done every year or every other. Occult means blood. You cannot see. Any of these three tests are good all over the world. The least expensive test is preferred.

Dr. Bharat Misra: 6:14

In the US, colonoscopies become the de facto standard, but it doesn't matter which test you have. Any test finds colon cancer early and prevents significant what we call morbidity, which is suffering and death. And remember that the most important factor associated with cancer is getting older. Whatever, your risk of cancer is at 50. It's much higher at 60 and it's even more higher at 70. So this is particularly pertinent to this audience, and I learned in preparing for this talk that I'm a baby boomer too, I'm 1963. So all of us, as we get older, have to remember that age is the main risk factor for colon cancer.

Dr. Michael Koren: 7:05

So interesting. So, I loved your comparison of colon cancer versus other cancers like breast cancer. So for breast cancer, you know, we have taught people to hang pink ribbons to raise awareness. What should we be hanging for colon cancer?

Dr. Bharat Misra: 7:22

Actually, our societies have come up with the color blue, so March is actually colon cancer awareness month, and everywhere you go you wear blue. So I don't think it's as good as pink.

Dr. Michael Koren: 7:41

Okay and should the ribbon be scented at all? Okay, so let's, let's move on to the next thing. So that was a great little summary and we're gonna hit these things fast, cuz we have ten things. So let's talk about the epidemic of fatty liver.

Dr. Bharat Misra: 7:49

Okay. So the second most important thing, which we see very frequently but lay people are not aware. Everybody should know their body mass index, everybody in the room. Mine is 22.4, as you know, as a country, our body mass index is rising. In other words, we're becoming heavier.

Dr. Bharat Misra: 8:14

Once your body mass index exceeds 25, the fat gets deposited in different organs. When it gets deposited in the liver, it is especially harmful because it creates inflammation and then scarring, and that's scarring can lead to cirrhosis of the liver. And the numbers are startling 100 million people in the United States have fatty liver and a quarter of them, which is 25 million, have a severe form of inflammation with scarring, which is called NASH. How do you find out if you have fatty liver? A simple ultrasound test or a newer test which we offer at ENCORE Research Group called a Fibro scan. It's a 10-minute test. It will tell you if you have fatty liver or scarring, but first you have to suspect it. Patients have no symptoms until it's very late.

Dr. Bharat Misra: 9:12

So if your BMI is above 25, you should ask your doctor, do I have fatty liver? Am I the one in three people who have fat in the liver and then, if you have fat in the liver, you might be referred to a specialist like myself to find out. Do you have a severe form of fat in the liver called NASH? As of now, there is no treatment for this condition, but we have exciting clinical trials that we can offer. I take that back. There is a treatment you have to lose weight and weight loss is harder, as those of us who tried know. It's very hard to lose weight, but that is the definitive treatment, and so that's the second thing you need to be aware of. Be aware that fat in the liver is very prevalent and very damaging.

Dr. Michael Koren: 10:03

So there's a name alert change. So I want you to let everybody know about some of these acronyms that we use, because we throw them around NASH being non-alcoholic steatohepatitis or just fatty liver, but correct so the initial term was non-alcoholic.

Dr. Bharat Misra: 10:16

In other words, if you drink a lot, you get fat in the liver too. This is fat in the liver without drinking. It's as if your liver is drinking. So that used to be the name, but just a couple of months ago the wise heads in our specialties got together and changed the name. From now on it will be called MASLD, which is Metabolic Dysfunction Associated Steatotic Liver Disease. And I hate that name. I hate acronyms, but when specialists get together it flows off their tongue very easily, but for lay people, unfortunately, it's quite a bit of a tongue twister.

Dr. Michael Koren: 10:58

That's a new one on me. I wasn't aware of this. So this is hot off the presses. Hot off the press. Now, c an we call it maslid or MASLD? Masld? Okay, we'll call it MASLD. How does that sound? Messed up? Yeah, okay, so that's interesting, and you mentioned that there's really not a good treatment, but there's some really interesting treatments in clinical trials, including trials that we've been involved with.

Dr. Bharat Misra: 11:24

Correct, so we are currently doing about five or six trials which involve very interesting methods of treating the liver. In addition to losing weight, these reduce liver inflammation, and they are in different phases. Some are in early phase, some are right, ready to get approved by the FDA. The only way to access these new treatments is to ask to be part of that trial, and if you need more information, our staff is in the back and they'll give you some good information about our trials.

Dr. Michael Koren: 11:58

Yeah, another little tidbit from a cardiology standpoint is we do a lot of cross referrals. And the number one reason that I would do a cross referral to Dr. Misra because I put somebody on a statin drug to treat their cholesterol and the next thing I know their liver function tests change a little bit and a lot of those people that have changes in their liver function tests when they are exposed to statins actually have MASLD. So that's a sign of fatty liver disease. Is that your liver is telling us when we give you a statin which, by the way, helps get fat out of the liver it's causing a little bit of inflammation that shows up in the tests. That is correct, all right. Number three avoid probiotics.

Dr. Bharat Misra: 12:39

Okay, so probiotics. What are probiotics? Probiotics are basically bacteria that are frozen and encapsulated. They come from different sources and they have been around for a little while. A lot of my patients are taking probiotics. In fact, when I made the slide about two years ago, the global market was 34 billion. I had to update it. It's now $55 billion worth of probiotics sold.

Dr. Bharat Misra: 13:12

Now here's the problem with it there is no evidence that probiotics work. Every single clinical trial that we have done on probiotic shows they are of no use. They don't help almost any condition, partly because the probiotics that we're using are very primitive technology and for many reasons, they don't have any effect on your microbiome. Remember, for every single human cell, there are 10 bacterial cells in your body. We are basically a spaceship that carries bacteria and most of those bacteria live in the gut. We know they play a critical role in disease, in body weight, in depression, in mood, but we haven't figured out how to change them yet and probiotics is not the way to go, except for a couple of instances.

Dr. Bharat Misra: 14:09

You went to Mexico. You had diarrhea. They shortened illness by maybe a day. If you're taking antibiotics, you get diarrhea. Some help with few exceptions. There is almost no role for probiotics for the general public. It is a triumph of marketing over science. So don't use probiotics. They're expensive. There are some reports that they may be harmful. In a small number of people they cause confusion, pancreatitis that is pretty rare. What is better is to take prebiotics. What are prebiotics? Prebiotics are compounds that promote a healthy bacteria in your gut. So prebiotics are helpful, probiotics probably not much.

Dr. Michael Koren: 14:56

Okay so there was a little bit of a groan in the audience when they first saw avoid probiotics. So you're not against the microbiome, no, the bacteria in the gut are extremely important, but you're skeptical about whether the marketed products really help the bacteria in your gut.

Dr. Bharat Misra: 15:16

That is correct. In fact, the microbiome is my area of research interest. What I'm trying to communicate to you is, if you look at the probiotics like we do all drugs, we do studies on them. We double blind them. That means you don't know what you're getting. And we follow them. It turns out they're not beneficial. So by the highest bar that we have, which is a good clinical trial, probiotics are not helpful. They don't make any difference in your microbiome.

Dr. Michael Koren: 15:48

So the key thing is to look at dietary fiber and other things that help your microbiome, your own bacteria, become healthy and should be doing it in the first place. That is correct. Not necessarily bring in some outside bacteria. That is unproven.

Dr. Bharat Misra: 16:03

That is correct, and that brings me to the next slide. So how do you promote a healthy microbiome? Well, this is where fiber comes in. Fiber has not gotten any respect. Most people think of fiber for regularity. I take fiber so I can go every day. Well, in the last few decades, what we have found is that what we call fiber may be the most important nutrient that you consume, more important than protein, fat, carbohydrates and even vitamins. Fiber is the part of your diet that is not completely digested, and this is what the microbiome use to grow and multiply. So fiber leads to a better microbiome and the microbiome leads to a better health in many different ways.

Dr. Bharat Misra: 17:02

So where does fiber come from? Well, fiber mainly comes from plants. It comes from fruits, vegetables, nuts and seeds. There are two types, which I think is not as important to know. What is important to know is you got to eat more of those fiber sources. The recommendation for women is 30 grams of fiber. For men is 40 grams of fiber. What is the average fiber intake in the American diet? It's, I think, about 11 grams. So all of us could do better. We have the diet of a prosperous, wealthy country, so what has happened is we have taken out everything that doesn't taste good out of our diet and it turns out some of the things will have to be put back in.

Dr. Bharat Misra: 17:46

As I have mentioned, dietary fiber helps regulate gut function, better microbiome. There's lower incidence of cancer, especially colon, but many other cancers, h eart disease, stroke, dementia, obesity. So fiber has multiple effects on the body and it should be considered a critical nutrient. That's why I like to use the word phytonutrient rather than fiber. So, for example, broccoli. Broccoli has 155 known cancer fighting compounds. That little vegetable, it's fiber. That's where all these benefits come from. So that's the key message about the microbiome Don't use probiotics, eat broccoli.

Dr. Michael Koren: 18:35

Okay and thank you, that was great. So I got a call on my cell phone yesterday saying that fiber is coming to my neighborhood and I told them that well, it's already here. I'm eating oatmeal as we speak. So if you get those calls, it should be a reminder to get to the 30 or 40 grams of fiber per day. Got it Okay? There we go. All right, next, liver injury from herbal and dietary supplements. So educate us about that, please.

Dr. Bharat Misra: 19:07

So again, this is a thing that, as I said, marketing over science. There are 80,000 commercially available herbal and dietary supplements. Almost half of us today are on a supplement. This is very important to know. Supplements are food products, so they're not regulated by any agency. Their claims are unfounded. More than half the supplements do not contain what they say they contain and their claims are unlike medicines. Their claims are completely unfounded. Now again, as I told you, specialists live in a well and I had to come out of the well and tell you this.

Dr. Bharat Misra: 19:56

The number one cause of liver failure in emergency room visits today is toxins and supplements which are damaging the liver. 20% and these people quite often need a new liver. That's how much damage there is. For example, there are reports of anabolic steroids, green tea extract, hydrocut. Each of these has been associated with permanent liver injury. So again, I tell people don't take a turmeric supplement. Put turmeric in your food. That's how it was used for centuries. Don't take a magnesium supplement. Eat some nuts, mushrooms and other foods that have a lot of magnesium. All these products, when they are taken out the way they were supposed to be consumed and put in a capsule, they suddenly go from beneficial to either not being beneficial and potentially harmful.

Dr. Michael Koren: 20:57

So that's an important message, yeah, yeah. So on the supplements one of the signs of a good and focused physician is somebody that asks you if you're on supplements. So often you go to your primary care doctor's office or another physician's office, ask you what drugs you're on and you give them a list. But people often forget to list their supplements and Bharat and I both share this is that we take that extra step and ask our patients what supplements you're taking, and inevitably it's in addition to what's on the list that we see, and very often there can be some harmful ingredients amongst those supplements.

Dr. Michael Koren: 21:37

So we give you a couple of examples from a heart standpoint that have really changed my thinking over the years. So when I first started practice, I would recommend that people took vitamin E, based on epidemiological data suggesting that people that had more vitamin E consumption had fewer heart attacks and lived longer. But when we actually did clinical trials of giving people vitamin E supplements, we found that two or three times they had a worse prognosis. That's correct. So remember, supplements are chemicals and they're not necessarily benign.

Dr. Bharat Misra: 22:11

Correct, and I think I want to make another point. A gain we do clinical trials, so we read clinical trials. So if you take folic acid, folic acid is a vitamin and green leafy vegetables. When you take folic acid and put it into a capsule and give it to people, it's no longer beneficial. In the largest trial they took lung cancer patients but half of them on folic acid, the other didn't. The people who were on folic acid actually had more cancer, more mortality. That's true for vitamin E. It's true for almost every supplement that is studied in a capsule form in a clinical trial. It turns out it's more harmful. The only exception may be vitamin D. That is an exception, vitamin D as a supplement. In other words, in Florida we should be getting our vitamin D by going out in the sunlight for 15 to 30 minutes. But if you don't want to do that, then vitamin D supplementation has some benefits. With that exception, almost all the supplements that are studied in clinical trials turn out to be harmful.

Dr. Michael Koren: 23:18

So again, and I'll make one caveat to that, that's for healthy people. So vitamin D, to your point, is probably the only supplement that's been shown to have independent benefit. But there are reasons to use supplements. You mentioned magnesium. So my patients are on diuretics for their high blood pressure. They're on diuretics for congestive heart failure that causes your kidneys to get rid of magnesium and potassium. So I, in many, many of my patients, will use magnesium and potassium supplements, but that's to offset an effect of something else. We know diuretics lower blood pressure, they keep people out of trouble to have congestive heart failure, but they have this offsetting effect that needs to be treated with a supplement. So again, the point that Dr. Misra made is for healthy people. Now, if you have a disease process and your doctor is using it specifically to treat that, there could be some reason for it.

Dr. Bharat Misra: 24:09

Correct and there are individual cases. This is why you've got to discuss it with your doctor.

Dr. Michael Koren: 24:12

And there are other situations where supplements have similar properties to proven drugs. A great example of that is red yeast rice, which is a statin, but it's sold as a supplement, and there are many, many other examples of that. Some antidepressant agents that are sold as supplements that have been proven in clinical trials to have some effects. Correct, yeah, so St. John's wort is an example of something that has been used to treat depression. There are verified clinical trials showing that it works. The problem with it, by the way, is it has so many drug-drug interactions and it's not regulated, as you mentioned. So if you're on St. John's wort, you really need to tell your physicians about it, because it'll interact with other drugs that we use.

Dr. Bharat Misra: 24:56

So there are narrow exceptions. Again, I want to clarify this is a broad talk about broad messages. It does not apply to each individual physician. So there are exceptions to the rules, so to speak.

Dr. Michael Koren: 25:09

But please tell your physicians about what supplements you're on, because you should think about them as chemicals. You should think about them as drugs, because they are. Okay next, all right.

Dr. Bharat Misra: 25:20

This is a minor point but it may be have bearing to some of you. I routinely get counsels for people who had an ultrasound or a CAT scan and they have gallstones and they have bloating or gas and they say, go and see a gastroenterologist. And they come to see me. They have no symptoms. We reassure them. So gallstones that are not bothering you should be ignored. The risk of turning into trouble some gallstones is very rare. As you can see, almost 10% of women have gallstones. So that's about 20 people in the room today. In the absence of symptoms, which is severe pain, nausea, vomiting and fevers, gallstones do not cause gas, bloating, even heartburn, and they should be ignored. So this is just a minor message, but I find that it makes a difference in how patients look at their gallstones.

Dr. Michael Koren: 26:16

So when I was in my intramedicine training, we talked about the 4Fs for gallstones. Is that still something that people talk about? Yeah, I think that's not considered true anymore. Okay, I want to explain to people what the old 4Fs were.

Dr. Bharat Misra: 26:30

It's very politically incorrect, but I have to say it since Mike say it. It's fat, fertile female of 40. That is the traditional group that was supposed to have gallstones, but I think gallstones are pretty much universal occurrence. As you can see they're occurring in 6% of men too.

Dr. Michael Koren: 26:49

Absolutely. Okay, so that's helpful. And what about surgery and silent gallstones?

Dr. Bharat Misra: 26:55

If you don't have symptoms, don't go to surgery. I do see patients who take medications to dissolve the gallstones. So, unlike kidney stones that can be dissolved and don't come back, there is no dissolution therapy for gallstones yet. You dissolve them. As soon as you stop they come right back. So you can't dissolve gallstones. So if you want to pay your surgeon's mortgage, then you go to him and he'll take it out. But in the absence of symptoms don't do that.

Dr. Michael Koren: 27:26

So if somebody suggests you have to do something to get a gallstone out, that's not bothering you. Maybe find another doctor, get a second opinion, yeah, okay.

Dr. Bharat Misra: 27:35

All right. Next. Now this actually is my most controversial point. As I said, in gastroenterology, heart burn is very common, by the way, it's where acid from the stomach goes into the esophagus. Some people think it's the most common GI disease in the world 17% of the population has heartburn. So I threw this in there for a reason. So in gastroenterology, all the conferences, when we go for our lunches and have our experts, one guy who says top down is better, the other guy says bottom up is better. I'm here to tell you that the bottom-up approach is better.

Dr. Bharat Misra: 28:14

The reason for this is many of you go to doctors for different symptoms. You can admitted to the hospital and the doctors prescribe a very strong medicine to block the acid. That's the most common one is Prilosec or Omeprazole, and then patients just stay on it for years and we're learning that some of these patients did not need it in the first place. And there are some unusual side effects that are being reported in patients. Very rare but still being reported. They have a higher incidence of dementia, heart disease, infections, etc. So many of these patients remain on the most potent class of medication for decades. I have patients who come to see me. I stop it and they have no problem. But they've been taking it for 10 years.

Dr. Bharat Misra: 29:00

So look at your medicine cabinet and see if you have a PPI. So there are three classes of drugs Antacids, Tums. The other is H2 receptors, which are Tagamet and Zantac, and Pepcid. And the third is the class is PPI. Most of us, if we have heartburn, should reach for Tums first. If that fails, go for Pepcid. If that fails, then go for Prilosec. This is very important because heartburn is very common. You have spicy Indian food or you have a glass of red wine, you will have heartburn. Reach for Tums. So you want to do the weakest first and then progress to the most strongest medication. The two exceptions to this are people who actually have damage to their esophagus. There's a condition called Barrett's esophagus which is pre-cancerous condition and severe inflammation. So if you do not have damage to the esophagus, which is the vast majority of people, go with the weaker medicine first, over the stronger medicine.

Dr. Michael Koren: 29:59

Okay, and all those in terms of your bottom-up approach. All those products are available over the counter now. S o it's actually a very important consumer choice, and your recommendation would be to start with Tums or Gaviscon or something that's just neutralizing the acid in a physical form. O kay, that's great advice. The other thing I'll point out is that the drugs that you take that get into your bloodstream and work through a chemical mechanism are, I should say, biochemical mechanism, are more likely to have an interaction with another drug and that's a consideration.

Dr. Bharat Misra: 30:31

Some of them have a drug interaction. That's another reason not to take the most potent form, unless you need it. There are people who have severe heartburn. Tums is not going to do it for them, Then it's okay to take it.

Dr. Michael Koren: 30:43

Right. But the flip side of that point, of course, is that if you take an antacid, it's possible that can affect the absorption of certain drugs, of some drugs too, correct? So there, like anything, there's a basic, simple concept that anybody can access, and then there's a more advanced concept. So if you have a very complicated medical regimen, that's one thing to maybe run by your doctor, correct? Do you feel like I should be using an antacid or a PPI for heartburn when that comes up? Yeah, based on the medicines on your list. All right, moving on.

Dr. Bharat Misra: 31:17

All right, so hepatitis C is a viral infection that infects the liver and it's very common. About 3 to 3.5 million Americans have it and 84% of them are baby boomers. Now, this is the important point it causes no symptoms. It doesn't show up in any routine blood tests, even with the liver function test. Most liver function tests are normal. So if you are a baby boomer, ask your doctor that you should be tested. This is official FDA guidelines. Ask the doctor that you should be tested for hepatitis C. It's a simple blood test and if you do that, some number between 2% to 5% will have a positive blood test. And then you go to see a gastroenterologist.

Dr. Bharat Misra: 32:04

Why is this important? Well, when I was training about 35 years ago, we had no treatment for hepatitis C. Then we got a treatment that is 5% effective, then 10%, then 20%. As of now, there is an 8 or 12-week treatment which is 95% plus effective. This is now curable. So because we have a very easy-to-use treatment that can cure this, we can wipe out hepatitis C as a disease in the United States. It is the number two cause for liver transplantation in the United States. So that would be a huge public health victory. And it starts with testing.

Dr. Michael Koren: 32:49

Beautiful. All right, celiac disease. Let's jump into this, okay.

Dr. Bharat Misra: 32:54

Okay, so again we are giving you a lot of information, but hopefully a couple of take-home points. So celiac disease is caused by an allergy to a protein in wheat called gluten. About 3% to 5% of the population, 3% roughly has the genes for celiac disease. 1% get the disease. So today, 2 of you have celiac disease and do not know it. It's a very prevalent disease. It's usually silent, but in the later phases it causes terrible symptoms, makes you weak, anemic, you can't absorb any nutrients, you lose weight, but then it's pretty advanced. We have a simple test, a simple blood test which has a 95% sensitivity and almost 97% specificity, to rule out. Again, if you go to your physician, ask to be tested. It's a fairly common disease. Those of you who've had a 23andMe test, there is a Celiac test in there so you can look at that 23andMe test.

Dr. Michael Koren: 34:01

Is it called just the Celiac test or is there something more specific?

Dr. Bharat Misra: 34:05

It can go by different names, but the most common is a Celiac test. There are two genes. If you have the genes, then your risk is higher. So this is a very common condition that we see and it has a very easy treatment. You stay away from wheat, you go into remission. It's hard to treat but that's the treatment. So this is. I wanted to raise a little bit of awareness about Celiac disease.

Dr. Michael Koren: 34:29

And sometimes it's very hard to completely avoid gluten because if you go to restaurants and other things, there may be some gluten. And I know that you've done some research in this area, pretty high-level research. I don't know if you want to comment on that briefly.

Dr. Bharat Misra: 34:41

Well, thank you. Yeah, I think we have a phase one unit. Phase one means first in humans and we actually have an ongoing clinical trial, first in human trial, where if you have Celiac disease, they give you a medicine that can prevent the reaction to gluten and it's ongoing. So if you have anybody you know who has Celiac, refer to them. It's a very prestigious phase one research, considered to be the most prestigious and we have, Mike will agree, one of the best phase one units, probably in the United States. Very well run, very efficient.

Dr. Michael Koren: 35:15

And access to things that you wouldn't ordinarily have access to very cutting edge therapies, all right. So, speaking of clinical trials, why don't you give us your spin on how you got involved and why we do what we do every day, correct?

Dr. Bharat Misra: 35:31

And you know, here I have to give credit to Mike. Mike has been doing clinical trial for almost three decades and I happened to attend one of his lectures almost 15 years ago and he got me very excited and since then I have been interested and you know, together we've done some very good clinical trials. But the question is for you why should you participate in a clinical trial? But the first reason is you have to, of course, have a disease that you're not happy with their treatment of. That's the basic condition. So if you have something that you're not happy with, the next miracle drug is in clinical trial somewhere. We talked about hepatitis C. We have been curing hepatitis C for 20 years, 10 years before the drug came out on the market. Our patients participated in the trial were cured. So this is the most important reason. The next best drug is there.

Dr. Bharat Misra: 36:24

Safety, especially patient safety, is the pillar of clinical trials. I know the word is used. I don't want to be a guinea pig. Well, if you're a guinea pig in this situation, you are the most precious, most monitored, most important pampered guinea pig in the world. So we really focus on your safety. That is the main thing I learned and I actually want to participate in some of the lipid trials, but as an investigator I'm not allowed to participate.

Dr. Michael Koren: 36:55

He asked me to do this all the time and say, Bharat, I'm sorry.

Dr. Bharat Misra: 36:58

Yeah, I did too. So the third reason is you get very good medical care. You get free imaging, blood work, GI studies, you get a colonoscopy, you get evaluated by a physician, the kind of care that does not exist in private practice anymore. So if you're interested, go to clinicaltrials. gov or to ENCOREdocs. com and you'll see some exciting trials. The last time I checked this I think it's a little old there were about 300 active clinical trials. This is the secret to the success of American medicine. We get the best drugs because we do the best clinical trials, and each of you can be a beneficiary of that process.

Dr. Michael Koren: 37:39

Yeah, I was very impressed by your precision on the 30 2,485 listed trials. I just got a text, so now that's 486. 486. But great stuff. The other thing I'd point out is that, psychologically, being in a clinical trial helps people and that's been shown over and over again. There's something called the Hawthorne effect and that was based on some observation that was done in the industrial psychology 100 years ago. That shows that when people are observed, they tend to perform better. They tend to do better whether it's better compliance with their medicines or they're better at sticking with their diet and exercise programs or there's something from your brain that helps you knowing that you're being observed. We don't know, but we see it over and over and over again is that people who are involved in clinical research live longer and have fewer complications than we even expect. That's interesting. So it's a very important part of human psychology and participating in something where you're observed.

Dr. Bharat Misra: 38:41

And I wanted to point out we do our own internal surveys. Nine out of 10 patients would come back and do a clinical trial.

Dr. Michael Koren: 38:48

It's actually 99 out of 100. Thank you for bringing up that statistic. If you ask people who have never been exposed to clinical trials before, are you interested in a clinical trial? In a general sense, about four out of 10 say yes. But when you ask a person that has been in a clinical trial, would you do another one? The survey showed between 97 and 99% say yes. So there's something about the process that's very nurturing and that encourages repeat customers, which is why we call ourselves ENCORE.