Nutrition Essentials | Gut Rehabilitation with Dr. Donald Kirby, MD

Podcast Transcript

John Horton:

Hello, and welcome to another episode of Nutrition Essentials, a side project of our popular Nutrition Essentials Podcast. I'm John Horton, your co-host with registered dietitian, Julia Zumpano.

Julia Zumpano:

Hey, John. Today's topic is very fascinating. We're going to talk about intestinal rehabilitation.

John Horton:

Julia, gut rehab is one of those treatments that just doesn't get a lot of attention. And that's probably because it's used to help just a small group of people who are dealing with intestinal failure. It's one of those things that's just not that common and not that well known, but we're about to learn a lot more about it.

Julia Zumpano:

And that's why we brought on our guest, Dr. Donald Kirby. He's the medical director of the Center for Human Nutrition at the Cleveland Clinic. He's going to tell us all about what he does.

John Horton:

Julia, it's worth noting that Cleveland Clinic is one of the largest and most comprehensive programs in the world when it comes to treating intestinal failure. So let's find out a little bit more about the life-changing work being done there, and how they're using nutrition to get that job done. Welcome to the podcast, Dr. Kirby. We have really been looking forward to you dropping in to chat.

Dr. Donald Kirby:

Well, thank you.

John Horton:

So I have to tell you, I know we've all watched medical shows where a close-to-death patient meets a charming doctor and gets put on a new treatment that brings just miraculous results, the sort of moment when a person in a wheelchair rises up and starts walking again. I watched an interview with you where you talked about that sort of Hollywood drama being a real-life reality in your office, thanks to gut rehabilitation. That is just some amazing stuff to have as just part of your workday.

Dr. Donald Kirby:

It is true. People come in extraordinarily weak, malnourished and hardly able to do anything during the course of a day. And once they go through intense and nutritional rehabilitation — and it takes a village to actually complete all that stuff — it really is very rewarding and very miraculous to see people. The human body is just amazing. And there's a lot of things that we can do to help people that have bad intestinal failure and short bowel syndrome, things that we're going to talk about in this wonderful segment.

Julia Zumpano:

Well, thank you so much for what you do, Dr. Kirby. And just for the audience, can you tell us in brief words what intestinal failure is?

Dr. Donald Kirby:

“Intestinal failure” is a term that, really, is not well appreciated in the United States. That's something that Europeans actually are far ahead of us in defining this and figuring out what it is. Most people understand what heart failure is or kidney failure and what dialysis is, but what's intestinal failure? So intestinal failure basically means that, for whatever reason — and we'll talk about causes — your gut does not have the wherewithal to do the two processes that it really needs to do.

You need to first digest food that you eat, but then the important part is absorbing it. And if you can't do that, then bad things happen. And we are now 50 years into being able to do intravenous nutrition. Formally, before the early 1970s, people would go for an operation, and the surgeon would say, "Hey, you did great." And then, they would not be able to survive from a nutritional standpoint because they had had so much gut resected that they couldn't really — either from a nutritional standpoint or fluids and electrolytes — maintain a normal balance. So intestinal failure is basically what it sounds like: Your gut doesn't do what it needs to do.

John Horton:

Dr. Kirby, it's one of those things … I don't think we appreciate what our gut is doing for us all the time. It's just one of those parts that just works for us. And you really brought home … we talk on here all the time about the importance of eating certain foods to get nutrients. And if you're not absorbing it correctly through your gut, it's wasted there, you're not getting what you need.

Dr. Donald Kirby:

So true.

Julia Zumpano:

Yeah, and it's amazing the advancements that we've made in that area. Just thinking that only 50 years ago, we started IV nutrition and how essential that is in the healing of the gut and meeting all our nutrient needs for these specific patients, but other patients as well, ideally, if it can be used on the short term.

Dr. Donald Kirby:

And you're very lucky if it's used in the short term. And that may be someone that goes in for an operation, they may have an ostomy placed, and the surgeon says, "Hey, you may need this for three to six months before I can go back in and hook you back up." Simple plumbing. Really? Not so simple, but once they get put back together, they don't need the IVs anymore. So that's really short-term intestinal failure with a really good ending.

John Horton:

Now, when we talk about the long term, the people with the really serious intestinal failure, this is a relatively small number of people that we're talking about, correct?

Dr. Donald Kirby:

Absolutely. So we, actually, in this country, don't know the absolute number of people that are on IV nutrition at any one time because that goes up and down. And the way we do healthcare isn't like many of the small countries in Europe, where the government pays for everything. So they know exactly how many people are on IV nutrition at any one time, or tube feeding for that matter. In this country, it's a mishmash of what we can get from some of the hospitals or the insurance companies, maybe Medicare. So we think that they're somewhere between 10 and 15,000 people that are on chronic IV nutrition. And yeah, that's a really small number compared to a lot of other things that we deal with in medical history here.

Julia Zumpano:

I know that there's many ways that folks can get intestinal failure. You mentioned surgery, surgical disasters. Can you tell us a little bit about how the various kinds of ways someone may develop intestinal failure?

Dr. Donald Kirby:

So there are lots of causes that people can get intestinal failure, or what's called “short bowel syndrome.” So what's the difference? Well, intestinal failure is really defined by the need for either IV hydration or IV nutrition. But the big thing here is you need intravenous help. And if you don't need intravenous help, but you've got a damaged gut, so to say — that might be what's termed “intestinal insufficiency” — but the different causes — you may have a tumor, there may be trauma, inflammatory bowel disease. We know that Crohn's disease or ulcerative colitis, patients that suffer from those disorders often end up having a surgery, and the surgeon goes in and has to take out a piece of bowel. Well, it may be more than just a piece. And that function may end up being that they've had so many surgeries or such a pervasive surgery that their bowel isn't enough to maintain them either for fluids and electrolytes or for nutrition in general.

People that go for bariatric surgeries, we think that that's great. People help the obesity epidemic by doing a surgery or doing medications these days. If you've had a surgery, you can have something go wrong with that surgery. While it's a minority of those patients, when it happens, it can be absolutely life-altering and terrible. There can be blood clots, blood clots to various places within the GI tract that cause death to portions of the bowel, and if they're not removed, the patient dies. So what's left is someone who does not digest or absorb well, and they can't maintain themselves.

So surgical issues are probably the most important. I'm at an inflammatory bowel hospital. We see so many patients with inflammatory bowel that have had so many different surgeries. We now have a lot of great drugs to help with inflammatory bowel disease, but we haven't always had those. In the last five to 10 years, we've seen a real wonderful explosion of medications as we understand the types of problems that these autoimmune diseases cause. And do you actually have to have bowel removed to have intestinal failure? And that answer is no. There are a couple of causes where we still have to support them with either IVs or IV nutrition. And that might be refractory celiac disease, people that are gluten-sensitive, that even when they follow an absolutely gluten-free diet, they don't get well. And that's a very small minority of those patients, but that does happen.

And then there's another thing that's called “chronic intestinal pseudo-obstruction.” And basically, think about your car. If your car doesn't have a motor, guess what? You're not moving. Likewise, if your motor of your GI tract doesn't work, you're not going to be able to be hydrated or be able to keep up with your nutrition. So patients like that end up needing help. And then, there's some pediatric causes that I've never seen because I'm an adult gastroenterologist, but what's called a “mucosal tufting disease,” where the lining of the small bowel is just unusable and does not really absorb. And those people either need to be on long-term intravenous nutrition — or the other thing that we do here at the Cleveland Clinic, we're one of the few centers in the United States that does intestinal transplant. An intestinal transplant is the least transplanted organ in the body. We do 300 to 500 livers a year, heart transplants, kidney transplants, lung transplants. But if we do 10 to 15 bowel transplants in a year, that's considered a lot.

John Horton:

That'll help people on their next trivia night. That's always good to have those bits of knowledge in there.

So Dr. Kirby, you obviously just laid out a bunch of different avenues that can lead people to this place you really don't want to go. Are there any prevention strategies, or is it just, these things happen in these unusual circumstances, and it just leads you toward intestinal failure?

Dr. Donald Kirby:

Great question. All I got to say is, people don't wish themselves to have intestinal failure or short bowel, it's something that happens to them, whether it's from a surgical aspect or the other nonsurgical diseases that I just mentioned. So it may happen over time. You may have a disease like Crohn's disease, where you've had several surgeries, where you've had little bits and pieces removed at a time, but over time, you can't add that up and survive on your own.

John Horton:

That all makes sense.

Julia Zumpano:

Yeah.

Dr. Donald Kirby:

When I was in Virginia — we used to call it “Whitland syndrome” — the surgeon would go in there and say, "I took a piece of bowel about that big. And gee, it came right back where I put it together. So I went back in and I took a big piece," and kept doing it and kept doing it, and then they had to send them to me to give them IV nutrition. So it's not something that we're really thrilled about seeing this type of patient, but it's important because we take nutrition for granted. How many times a day do people put things into their body? You enjoy your breakfast, your lunch, your dinner. Thanksgiving's coming, but many of those patients can't really enjoy those holidays as well because the gut just doesn't work as well.

Julia Zumpano:

I think we commonly overlook that when we, as healthy individuals, take for granted the things that work so well, just like if you break your leg or break your foot, and then you're really recognizing how much you utilize that. But when you think about the gut, it's not something we often think about if we have a healthy gut. And Dr. Kirby, you mentioned those with IBD, irritable bowel disease. I think it's also important to highlight the management of that, good management. And if you have IBD or know someone that does, a family member, friend, just making sure that they're getting the best treatment options there, too, to be able to extend their healthy gut situation as long as possible.

Dr. Donald Kirby:

Right. So there are resources. There are a number of intestinal rehabilitation centers scattered around the country. Unfortunately, they're not in every state, and they're often busy. But there are other resources, like the Oley Foundation, O-L-E-Y. And they help people that have either tube feeding or IV nutrition, and they're a great resource. So people feel very alone that they think that they're the only people in their neighborhood that's got a gut problem, and then these chat rooms or these other areas that they can find online are very helpful.

John Horton:

Well, I'm glad you mentioned treatment options because we've been talking about the problem so far, and let's take a turn to the optimistic side here and talk about what we can do or what can be done to help people get that gut functioning again. So when somebody comes in and they have intestinal failure, where do we see treatment start?

Dr. Donald Kirby:

Well, one of the first things I want to do is assess what's going on with the kidneys, because what's really disturbing to me is a lot of these people may have an operation and then they're not doing well from a fluid and electrolyte standpoint, and they go to the emergency room again and again and again. And their potassium's low, their magnesium's low or they're dehydrated, or now they've got an acute renal failure. So I want to make sure that those kidneys are happy and healthy because those kidneys are smarter than we are. So it's important to make sure those kidneys are happy and getting enough fluid. And then, we do what we do best. We start working as a team — and I work with a whole host of absolutely wonderful registered dietitians and nurses to work on what we do. And the first thing we do is we talk about diet because diet is really important.

And it's a major change for a lot of these people that we start decreasing the amount of fat that they eat. We may increase their carbohydrates. And it all depends on what the anatomy is, because if we know what the anatomy is, we can predict what problems they're going to get into. And that helps to fuel what we choose to tell them and counsel them on what the best diet is for them. So we work very hard on that. And one of the biggest things and hardest things for people to understand is that lowering the amount of free sugar — all those sweets or soda. And the second thing after diet that we really work on is fluids, because we want people to be able to absorb those fluids. And I liken water in many of these cases, too, like liquid plumber, it clears out those pipes.

If you've got an ostomy bag, suddenly your ostomy may be full or you're in the bathroom a lot because from the time you're 2 years old, your mom's telling you, "Drink water to make sure you don't get dehydrated." Well, great advice if your gut's normal, but if your gut isn't normal, then it's going to cause other problems. So we work on helping them, a little salt, little sugar gets absorbed very, very nicely. It's called “oral rehydration solutions.” These are predicated on what happened with the World Health Organization many years ago with cholera. Cholera's a disorder, a diarrheal disease often from bad water. And you don't die from cholera; you die from the dehydration. So they figured out that the small bowel works great, but the colon is secreting all this fluid. So they designed a fluid that the small bowel would drink up like a sponge, and decreased the mortality rate significantly. With that knowledge, this is what we really teach our patients, and it's very important for them.

Julia Zumpano:

It sounds like a dietitian plays a huge role here, and there's not one diet that fits all. It really depends on what's going on with each individual patient — what's left, what gut is intact. And then, I think really important to pinpoint the importance of hydration and reducing sugars, which is interesting because it's the theme of today's world, is thinking of low sugar this or avoiding sugars and sugars are inflammatory, but it's fascinating how important it is in this world as well, and how that can lead to increased symptoms and fluid losses. So fascinating here.

Dr. Donald Kirby:

And like you said, we love our dietitians. We need them because it is a team effort. And teaching the diet is absolutely key, and working on fluids. And then, we add medications. We call them “bowel stoppers,” things commonly known as Imodium®, or “loperamide” is the generic term, or another medication that we use is called Lomotil®, which is diphenoxylate atropine. That's a little bit of narcotic tied in with atropine molecule. And those work synergistically. Some people will say, "Well, gee, don't they do the same thing?" Well, you can say acetaminophen and ibuprofen do the same thing. Well, yes and no, but they work by different pathways. So these other two medications that slow the gut work by different pathways. So you get a synergistic one, two effects that really helps a lot of people slow down their gut so they have more time to digest, more time to absorb. The key element here is absorb.

Julia Zumpano:

You mentioned something about sugars. What about artificial sugars? Where do those play a role?

Dr. Donald Kirby:

Artificial sugars, we aren't keen on. It depends, if they're sugar alcohols and you still have a colon, those can actually cause more diarrhea, things like sorbitol, mannitol, xylitol. And those are in a lot of sugar-free items.

Julia Zumpano:

Yeah, those sneak into a lot of products. You have to be really mindful of those.

Dr. Donald Kirby:

Absolutely. So our patients really need to start reading the labels and understanding what they're really eating and drinking to benefit them. And we don't want to say, "You can't have this, you can't have that." No, we believe more in the “yes diet” — we want them to have stuff, but everything in moderation.

Julia Zumpano:

Absolutely. Yeah, that's a dietitian's role there, is just to expand someone's diet. I feel that we've been always given the name of the “food police,” and it's the opposite, really. We're just trying to expand people's diets, provide more nutrition, more nutrients, instead of being limiting.

Dr. Donald Kirby:

Absolutely. Yeah, we want you as the team member to absolutely help them expand what they can have and say, "Yes, you can have a little bit of this, you can have some of that. Well, you've got to be a little careful about this." So that education is absolutely key to their success.

John Horton:

Now, Dr. Kirby, it's not just about drinking more though, too, that sounds way too simple. So I'd imagine there's a mix. You had mentioned the hydration, salt, sugar. It's all about balancing that out to making sure somebody has the right mix for what their intestine can handle.

Dr. Donald Kirby:

Well, and it depends on their anatomy. So we will tailor what we prescribe as an oral rehydration solution amount based on what that patient can handle and their response to it. But we find that it's not always easy to drink these solutions. Some of them are a little salty. There are some different proprietary things that are available that you can take a powder and just shove into water and yep, that's great. We let them make it up themselves with water, salt, sugar and a flavoring. They can do that. But if they then say, "Oh, OK..." Well, I've got one patient who is absolutely addicted to coffee. I love my coffee, too.

John Horton:

I understand that.

Dr. Donald Kirby:

But if it's causing that much trouble, yeah, I'm going to cut it back a bit. But this gentleman has a pot of coffee every morning, and it took us two years to finally convince him that, "Gee, if you have a little less coffee and a little more of this other stuff, you might be in the bathroom a little less." And finally, he's cut down to two big cups a day, and the oral rehydration solution is doing much, much better. But it takes time to get through to someone who's used to doing things a certain way, and it's not easy to change.

Julia Zumpano:

I think you make a good point. And it's really meeting the patient where they're at. So trying to provide as much resources, much guidance and nutritional advice, but really have to meet them where they're at, too.

Dr. Donald Kirby:

Absolutely. Like you said, we're not to be the police. We're there to help them and we have to partner with them. We're not sitting there like Moses with all those wonderful commandments; we're saying, "This might help you. Let us work together and find what works best for you that you can agree to and live with."

John Horton:

Yeah. Now, Dr. Kirby, in that note there, or on that note, you had mentioned just a bit ago that a lot of what you guys do, it depends on what's working in the gut, which, it's a tough concept to wrap your head around. So the gut's obviously a very big place. So it sounds like what you see is, if certain parts are affected or not working right, you just can't absorb certain vitamins correctly, or you have to change how you're doing things to get the most out of what you're taking in?

Dr. Donald Kirby:

Sure. Let me give you a couple of examples. If someone has a colon removed for whatever reason, has an ostomy created, we expect them to have a liter to a liter and a half of stoma output. If people are having more than that, that's what we call “high ostomy output.” So what does your colon do? Think of the colon as a big sponge. It tries to reabsorb salt and water, and actually kicks out a little bit of potassium. And certainly, it's a reservoir for stool. So at the beginning of the colon, what goes into the beginning of the colon is very, very liquid. And for most people, what comes out isn't really liquid, it's much more solid, and it may be even more solid the longer it sits in that colon. So the colon is doing its job by pulling out salt and water. The longer it sits there, the more desiccated it becomes, et cetera, et cetera.

John Horton:

It's a very nice way to explain that process, too.

Dr. Donald Kirby:

We’ll try to use some ideas here. And then, what happens if you lose parts of the small bowel? Well, yeah, we have about 12 feet of small bowel or about 600 centimeters, 200 of that is the jejunum, and about 400 is the ileum. So if you lose your ileum, you're not able to absorb magnesium well because that's where the parking spaces for magnesium happen to be, and for vitamin B12 in particular and some bile acids. A lot of what we break down and absorb is absorbed very efficiently up in the upper small bowel called the jejunum.

But the jejunum is not very smart. If you take out a lot of the ileum, it just keeps on doing what it's doing, and it doesn't get the hormonal message that, "Hey, there's nothing below me. I'm just going to keep working and doing what I'm doing." So unless you physically, or from a medication standpoint, give something that's going to slow the gut, the jejunum doesn't get it. So if you got to lose an area, lose a little bit of jejunum because the ileum is much smarter. It can slow itself down with the help of some hormones, and has some other functions that the jejunum does not.

Julia Zumpano:

Dr. Kirby, I saw this map of the gut and I thought it was amazing, it was fascinating. It showed each section of the gut and what it absorbs and what is digested in that section. And it's crazy to think, there's so many different parts of it, so many different nutrients, and it's so hard to even pinpoint to a, understand that or to gather that from a basic understanding. But when you see it that way, it's so essential, our gut to be functioning in every way, but you can even target it to what area of the gut is being resected or you're having concerns or issues with, and you can target those nutrients and really replenish appropriately, which is really the most fascinating part.

Dr. Donald Kirby:

Absolutely. I gave a medical student a lecture this week on introduction to nutrition and vitamins and minerals, and showed exactly that picture with where different things are absorbed. And basically, imagine this, by the time you make the first turn around the duodenum, called the ligament of Treitz, you have seven to nine liters of fluid to absorb — seven to nine liters. And I got these really funny looks from the medical students going, "Really? Come on."

Julia Zumpano:

That's a ton.

Dr. Donald Kirby:

So I had to explain, on most days, we take in about two liters of food fluid, with the exception of Thanksgiving, Christmas and maybe a Super Bowl, a little bit more. And then, salivary juice, we actually make a liter and a half of salivary juice a day.

Julia Zumpano:

Wow.

Dr. Donald Kirby:

Your stomach makes two to three liters of fluid to start the digestive process. Your pancreas kicks in another liter to a liter and a half of bicarbonate solution, pancreatic enzymes.

John Horton:

Practically a water factory?

Dr. Donald Kirby:

Yeah. And then, your gallbladder empties out about 500 milliliters. So again, by the time you hit that first big turn, you've got all that fluid that needs to be reabsorbed. And your gut is amazing. You can reabsorb all except maybe a hundred ccs a day.

Julia Zumpano:

Wow, that's impressive.

Dr. Donald Kirby:

Just think of that, we have so much redundancy in that bowel that we can afford to lose some. And maybe we don't do quite as well when we lose some, but we're still able to meet our nutritional and fluid needs.

Julia Zumpano:

That really reinforces that thought of we're made up of 70 to 80% fluid. It explains how that concept is true.

Dr. Donald Kirby:

It is so true.

John Horton:

When we're talking about all this, and obviously, your intestines need to be working correctly to make sure you're getting the vitamins and the nutrients out of your food — and Julia, I want to ask you, because I know you work with this a little bit more — what kind of things do you see in people when they start getting these deficiencies, and they're not pulling in the nutrients that their body needs?

Julia Zumpano:

Right, so their body's showing them in different ways. We scan for malnutrition and different deficiencies. But just visually, you can look at things like hair, hair loss, nails not growing, your skin being more dry, and just not having the plumpness that it should normally have. You could see some hollowing out in the face. Even though someone's weight might be normal, they may have lost weight or still being malnourished. You could see more weakness, more muscle aches. So there's so many different symptoms. When you look at things like hair loss, one of the first things I think of is iron. And then when you think of breaking bones, someone's having many falls and breaking little bones and it's maybe not typical for that. When we think of calcium and protein, so vitamin D. So we think of all these little ailments and things that are going on, there are little ways and signs that our body's telling us, "You're not getting what you need through your foods."

John Horton:

And Dr. Kirby, I take it these are all things you see in the people who you're treating, and these signs are all there?

Dr. Donald Kirby:

Absolutely. And we screen for them on a regular basis. And even the patients that we're giving IV nutrition to, though we're giving them IV vitamins and some minerals, it may not be quite enough. We may have to do additional supplementation. Again, we may not be giving someone IV nutrition seven days a week. Our goal is to get them down to the lowest amount of support that they need, either IV and really get them the holy grail, which is called “enteral autonomy,” so they're off the IVs. So yes, it's something that we see and we screen for in our population probably twice a year.

Julia Zumpano:

So essentially, what we're trying to do is get their gut to work the best they can, and to be able to eat foods and assimilate and absorb and get their nutrients through food through their gut, through the use of their gut?

Dr. Donald Kirby:

Absolutely. Totally correct.

John Horton:

Now, Dr. Kirby, how common is it for this treatment, you adjust the diet, you make these changes, where people are able to get that gut going again and maybe no longer need the IV treatment?

Dr. Donald Kirby:

Well, and that's the whole concept of intestinal rehabilitation. And that's what our group really does, where we're trying to reteach all things about physical therapy. You're reteaching certain muscles to work. Well, we're trying to reteach the gut and use what's left and understand how well we can make someone absorb. But again, this is where the partnership with the patient comes in. They have to make the changes in their oral diet or their oral fluids to help themselves, and some people just don't do it.

John Horton:

When we were talking before the podcast, I was really struck by how you said you work hand in hand with dietitians in treating patients. And it's just so essential to the process. And it really underscores the whole reason we have a Nutrition Essentials podcast, which is to show that direct relationship between what you eat and basically your body functioning the way it should. And it sounds like that's really the point to drive home here.

Dr. Donald Kirby:

Absolutely. Think of the physician as the captain of the ship. Most physicians don't really have a good handle on nutrition. But if you partner with a registered dietitian and say, "I've got a patient with high cholesterol. I need them to be on a low-fat diet, a low-cholesterol diet. I need them to be doing something that's heart-healthy, maybe a Mediterranean diet — I know the basics of a Mediterranean diet," so say the physician, "But I need someone that can actually counsel them and give them particulars." So that's where the physician needs to partner with a registered dietitian for the benefit of the patient. And we do that with what we do with the specific diet that we look at and try to tailor to a patient based on what they've had resected, and what they can hopefully absorb.

Julia Zumpano:

And it's so specific. For what you do and your team, you're looking at specific areas of the gut that are resected and what nutrients and what percentage of calories are coming from carbs and fat and protein. And it's very specific, very individualized. So the dietitian creates that plan of the appropriate percentages and educates on the importance to reduce sugar and to look for sugar alcohols and the importance of the oral rehydration solution. So really, it's a key role essentially in your area, really. And I thank you, Dr. Kirby, for valuing the dietitian so greatly.

Dr. Donald Kirby:

Absolutely. If you're really smart and you learn very early in your medical career to appreciate the other members of the staff, dietitians, nurses, the secretaries, they're going to make your life easier. Again, we act like captains of a ship. We try to figure out globally how to help the patient, but maybe we don't have the absolute expertise to give the counseling that’s needed for a specific area. So when we're talking about patients with IV catheters and things, it's not going to be the physician who's going to be talking about the care of that, it's going to be a nurse. And again, diet and fluids, it's going to be one of our dietitians. So again, it takes a village. Our whole team works together for the benefit of this patient population.

John Horton:

Now, we've touched on maybe the difficulties in somebody adjusting to the diet. Julia, I know you work with so many different people. How do you counsel somebody through adjusting to these restrictions they might have to deal with, handling that, just navigating, maybe doing something they might not prefer to be doing, but they need to for their health?

Julia Zumpano:

Yeah, that's a hard thing to navigate through. For the patient, you try to put yourself in their shoes. And I do a detailed diet history, so I really get an understanding where they're coming from, what they're eating, their style of eating, how they're eating, who they're eating with, who's preparing their meals, who's purchasing the food — because all of those things play such an important role, because we may need to include more people to get this plan to be successful. So you just do a good inventory, and then you see where the patient's at. You educate them on what's necessary, what they need to be doing.

But really then, your goal as a dietitian is to be able to take where they're at, where they need to be, and create a plan to get them there that is feasible for them step by step. It may look slower for one patient and faster for the other, but it's about providing them those detailed steps, the resources that they need and be able to encourage them as well. So most people will feel better. So I try to use that a lot in educating, "Well, listen, this is going to be hard. It will be challenging at times, but you will feel better. So it's really important you give it a try." And I try to go in small increments of change, too, that helps.

John Horton:

That's where we can get to those amazing things that happen, like we were talking about right at the start with Dr. Kirby, and the things that happen in the office, the person getting up when they were in a wheelchair.

Julia Zumpano:

And I think some of the times, patients just feel like their hands are tied. They feel like their health is completely determined by the doctor or the team. And I think, when you think of nutrition and the food you eat, you control that. You control everything that goes in your mouth. So it gives the patient ownership. It gives them a say in what they're going to do and how they're going to eat. And we don't control everything; we just educate and provide the patient options. So it does give back some ownership.

John Horton:

So Dr. Kirby, if somebody has intestinal failure, or they're just having troubles down low and they need to get some things looked at and there's some worries about what's happening there, where do they start that process? Who should they go see? What's the overall process here?

Dr. Donald Kirby:

Not an easy process in the United States. First, you need to check in with your primary care doctor, usually. You may or may not be hooked up with a gastroenterologist that might be able to help you. Not every gastroenterologist wants to deal with nutrition issues, believe it or not.

John Horton:

Yeah, that's hard to believe. It seems essential with it.

Dr. Donald Kirby:

Yeah. Ongoing debate on that. I really think that it's important for gastroenterologists who take care of the organs of nutrition every day to also know how to feed them. However, many other of my GI colleagues just go to the dark side. And they see that endoscope and, "Yep, I'm going to work on taking out polyps for a living and not think about anything regarding nutrition." And I'm sorry, that's very narrow-minded. I like doing endoscopy, I've done endoscopy for 40 years, and I'm trying to stamp out colon cancer one polyp at a time, but I'm also telling those people how to decrease the risk of polyps by decreasing red meat and smoking and alcohol and get some exercise. And if you're overweight, you need to be losing weight. And there's a certain degree of genetics in there. We can't minimize that.

Julia Zumpano:

Sounds like you're saying know your risk factors. That's really important.

Dr. Donald Kirby:

Absolutely.

Julia Zumpano:

Know what those risk factors are, know what they are specific to you, and take actionable goals to reduce them.

Dr. Donald Kirby:

Agreed.

John Horton:

So Dr. Kirby, you had mentioned that in the United States, the treatment options, when you have intestinal failure, are pretty low. And obviously, at the Cleveland Clinic, we have a pretty robust program. I just want to give you a second to talk about what we do here and just where we are with things.

Dr. Donald Kirby:

Well, we actually have the largest home parenteral nutrition program in the United States. We have over 300 patients that are on home IV nutrition that we manage, believe it or not. That's more than some small countries in Europe. I can tell you that in Sweden, they have 200 people in the entire country, and they only have one center that really does intestinal rehabilitation. In France, there are two. If you look at London, they have two in London, but people have to go to these centers for treatment. Easier to do that in Europe than it is coming from all over the country.

We have patients that we see in 38 of the 48 contiguous states.

John Horton:

Wow.

Dr. Donald Kirby:

Well, I have had patients from Alaska, but nobody on IV nutrition presently, and I haven't had anybody from Hawaii. But the 38 of the other 48 states, we've had people that come to see us, and a lot that we still manage. So yes, it's a big program. You can find these programs. If you're lucky to have a program that has intestinal transplant, they're going to have an intestinal rehabilitation program associated with them, more on the East Coast and Midwest than the far West.

John Horton:

Well, I think it's safe to say we're glad that there's somebody out there doing it and that you are so active in it. And really, it sounds like making some advances and helping people figure things out and, hopefully, get off this IV therapy just by using nutrition and working through that process. So thank you so much for coming in today. This has been just an absolutely fascinating discussion.

Julia Zumpano:

Thank you so much, Dr. Kirby, for all that you do.

Dr. Donald Kirby:

Thank you. It's been a blast.

John Horton:

Julia, that was just a mind-blowing conversation. There's so much to unpack there. I'm still processing a lot of the things that we learned. It's going to take me a long time just to get past the notion that we have 12 feet of intestine inside us.

Julia Zumpano:

I know, that's so impressive. And I think the most valuable part that I got out of was the ownership that the patient or client can take in their nutrition, and really helping heal their gut and get back to feeling their best self.

John Horton:

It gets to what we talk about on this podcast all the time, which is how proper nutrition just does so much for the body. And you see it in everything. And it makes sense that it's such a big deal when you're talking about your gut.

Julia Zumpano:

Absolutely, plays such a key role. And all those nutrients are absorbed and digested in our guts, so we really need to pay attention.

John Horton:

Without a doubt.

So if you enjoyed today's podcast and liked what you heard, please hit the subscribe button and leave a comment to share your thoughts. Until next time, eat well.

Speaker 4:

Thank you for listening to Nutrition Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.