Community Health Education Seminar

1
Community Health Education Seminar

• Diarrhea After Eating
• The Argument for
• Intermittent Maldigestion Condition
• and not just
• Irritable Bowel Syndrome-Diarrhea
• March 22, 2011
• M. E. Money, M.D., FACP
• Clinical Associate Professor Department of
  Medicine
• University of Maryland School of Medicine
• Office
• 354 Mill Street
• Hagerstown, MD
• 301-797-0210

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IRRITABLE BOWEL SYNDROME

• Brief Overview

M. E. Money. M.D.
3
Definition of IBS

• IBS is a functional bowel disorder in which
  abdominal pain or discomfort is associated with
  defecation or a change in bowel habit. Bloating,
  distension, and disordered defecation are
  commonly associated features.
• Irritable bowel syndrome a global perspective.
  World Gastroenterology Organizational Global
  Guideline. April 20, 2009

M. E. Money. M.D.
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Diagnostic Criteria (Rome III)

• Onset of symptoms at least 6 months before
  diagnosis
• Recurrent abdominal pain or discomfort for gt3
  days per month during the past 3 months
• At least two of the following features
• Improvement with defecation
• Association with a change in frequency of stool
• Association with a change in stool form
• NB What precedes the symptoms is not included.
• WGO Practice Guidelines Irritable bowel syndrome
  2009

M. E. Money. M.D.
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Sub Types of IBS
IBS-Diarrhea 33
IBS-Constipation 32
IBS-diarrhea and constipation 35
Executive Summary IBS in Women The Unmet Needs.
Society for Womens Health Research. 2003
M. E. Money. M.D.
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Mainstream concepts about IBS

• Exact cause of irritable bowel syndrome not
  known.
• Multiple factors thought to contribute to
  etiology.
• To date an 'IBS gene' has not been identified.
• The concept of IBS as a diagnosis of exclusion is
  not acceptable any more.
• The treatment of IBS is targeted at symptom
  relief.
• Cognitive behavioral therapy is very beneficial.

M. E. Money. M.D.
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Predisposing, and precipitating factors for
irritable bowel syndrome

• Predisposing factors
• Genetic predisposition
• Early life experiences
• Intergenerational transmission of illness
  behavior
• Gender

• Precipitating Factors
• Acute and chronic stress (life events)
• History of abuse
• Infection and inflammation
• Bacterial flora and small bowel bacterial
  overgrowth
• Intestinal gas and motility

M. E. Money. M.D.
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Perpetuating factors for irritable bowel syndrome

• Maladaptive coping
• Poor social support
• Psychological co-morbidity
• Somatization disorder
• Depression
• Anxiety
• Panic Disorder
• Gastrointestinal Disorders Irritable Bowel
  Syndrome. Journal of Clinical Outcomes Volume 1
  (4). 2007

M. E. Money. M.D.
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Irritable bowel syndrome impact

• Estimated 15 Million people in the U.S.
• Prevalence 10-20 of adults
• 2 Billion in direct annual costs
• 20 Billion in indirect annual costs
• Estimated only 1/3 patients seek medical
  attention for condition.
• Laudanum, U. Irritable Bowel Syndrome. Advanced
  Studies in Medicine. Vol. 4, No. 3. March 2004.
  Pages 128-134.
• Executive Summary IBS in Women The Unmet
  Needs. Society for Womens Health Research.2003.

M. E. Money. M.D.
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Mainstream treatment options for IBS-Diarrhea

• Antidepressants
• Anticholinergics (Bentyl, Levsin, etc)
• Bulking agents (metamucil, etc)
• Chinese Herbal therapies
• Cholestyramine

• Antispasmodics
• Lactase supplementation
• Antibiotics
• Serotonin modulators
• Antidiarrheals drugs (Lomotil, etc)
• Deodorized tincture of opium

M. E. Money. M.D.
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Treatment options conclusion in Prescire
International 2009

• There is currently no way of radically modifying
  the natural course of recurrent irritable bowel
  syndrome
• Patients frequently complain of occasional bowel
  movement disorders, associated with abdominal
  pain or discomfort, but they are rarely due to an
  underlying organ involvement. Even when patients
  have recurrent symptoms, serious disorders are no
  more frequent in these patients than in the
  general population, unless other manifestations,
  anemia, or an inflammatory syndrome is also
  present
• Irritable bowel syndrome a mild disorder purely
  symptomatic treatment. Prescrire.Int. 18(100),
  75-79. 2009

M. E. Money. M.D.
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Accuracy of symptom-based criteria for diagnosis
of IBS in primary care1

• Reviewed 25 primary diagnostic studies.
• 2 research questions
• Performance of symptom-based criteria in
  excluding organic GI
  disease.
• Performance of signs and symptoms in
  identifying IBS
• Conclusion organic disease cannot be
  accurately excluded by symptom-based IBS criteria
  alone.
• 1Jellema, P. et al. Systematic review accuracy
  of symptom-based criteria for diagnosis of
  irritable bowel syndrome in primary care.
  Alimentary Pharmacology Therapeutics. 7-3-09.
  DOI 10.1111/j.1365-2036

M. E. Money, MD
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How did this research get started?

• In September 2001, one of my patients came in
  demanding that I prescribe something to help
  with her diarrhea that would occur after she ate
  out in restaurants with her family By that time,
  I had given pancreatic enzymes to 2 patients in
  my practice for after meal diarrhea due to
  surgery on the pancreas with good results and
  decided to give it to her as a clinical
  experiment.
• She returned 4 weeks later, reporting that 1
  pill before the meal worked just fine, 4 made
  her constipated.
• By Christmas, I had prescribed it to another 10
  individuals and all but one had complete symptom
  relief.

M. E. Money, M.D
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How did this research get started?

• By Christmas, I had also researched the current
  recommendations for IBS-D and had discovered
  pancreatic enzymes were not mentioned. I had
  also checked with 2 specialists to assure there
  was no harm in using enzymes, and decided to do
  my own study comparing pancreatic enzymes to
  placebos.
• The study was approved by the Washington County
  Review Board in January 2002 and the first
  patients were enrolled in February.
• It concluded in 2003. 49 patients enrolled, 10
  dropped out, and 25/39 who did participate
  picked the enzymes as the effective agent.

M. E. Money. M.D
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DOUBLE BLIND, PLACEBO CONTROLLED TRIAL USING
PANCREATIC ENZYMES
Effectiveness of PAncreatic EnZyme in Reduction
of IrritAble Bowel Syndrome (IBS) Symptoms
PAZAS

• Hypothesis
• Symptoms of post prandial IBS-D are due to
  maldigestion and/or malabsorption of certain
  foods, thus causing the abdominal symptoms
  including diarrhea for some patients.
• Approved by WCH IRB 2/01, completed 11/03

M. E. Money. M.D.
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PAZAS Inclusion Criteria

• Meet the Rome II Criteria
• Be at least 18 and willing to give written
  informed consent,
• Have onset of symptoms before the age of 50
• Have symptoms occurring postprandial greater than
  90 of the time within 3 hours of the trigger
  food/meal. Ideally should be able to identify
  some of the foods/spices/ or types of meals that
  precipitate the symptoms. (i.e. restaurant
  dining, Italian, Chinese, specific foods, lactose
  based).
• Participants must have at least one other
  food/spice that causes symptoms in addition to
  Lactose based foods.
• Be willing to comply with all of the study
  protocol.
• Have had a normal Colonoscopy or barium enema
  within the same time period of current symptoms.
• Have had IBS postprandial symptoms for greater
  than 5 years.

M. E. Money. M.D.
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Methodology

• Study stages
• 1. Patients consumed 6 trigger meals recording
  symptoms (baseline)
• 2. Consumed same meals with blinded capsule.
• 3. Wash out period 2 weeks.
• 4. Consumed same meals with second blinded
  capsule.
• 5. Picked either drug 1 or 2 to use for another
  25-50 meals.
• 6. Unblinded to patient only after patient
  completed study unblinded to staff at study
  conclusion.

M. E. Money. M.D.
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Symptoms evaluated and scoring

• SYMPTOM POINTS POSSIBLE
• Cramping 0-10
• Bloating. 0-10
• Borborygami (gurgling, noises, churning) 0-10
• Nausea 0-10
• Intensity of the urge to have a bowel
  movement 0-10
• Other symptoms (sweating, chills, weakness) 0-10
• Global pain intensity 0-10
• Number of Bowel Movements after eating the meal
  
• 
  (1 point for each BM)
• Pilot study a randomised, double blind, placebo
  controlled trial of pancrealipase for the
  treatment of postprandial irritable bowel
  syndrome-diarrhoea. Money, ME Walkowiak,J
  Virgilio,C. Talley, NJ Frontline
  Gastroenterology.201124856.

M. E. Money. M.D.
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Summary of results

• Total number of patients enrolled in study
  49
• Number of patients who dropped out
  10
• Number of patients who selected Enzymes as the
  effective agent after trying both capsules
  25
• Number of patients who selected placebo as the
• effective agent
  10
• In an intention to treat analysis, overall, 30/49
  (61) would have chosen enzymes (p0.078)
• Pilot study a randomised, double blind, placebo
  controlled trial of pancrealipase for the
  treatment of postprandial irritable bowel
  syndrome-diarrhoea. Money, ME Walkowiak,J
  Virgilio,C. Talley, NJ Frontline
  Gastroenterology.201124856.

M. E. Money. M.D.
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Subset Analysis of Enzyme Patients Preliminary
Results I
M. E. Money. M.D.
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Subset Analysis of Enzyme Patients Preliminary
Results II
M. E. Money. M.D.
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Subset Analysis of Enzyme Patients Preliminary
Results III
M. E. Money. M.D.
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Quality of Life (QOL) survey

• Patients were asked to score how each of 34
  questions applied to their quality of life before
  and at conclusion of study.
• 0-Not at all,
• 1-slightly,
• 2-moderately,
• 3-quite a bit,
• 4-a great deal, extremely. 
• Used with the permission of  Dr. D. L. Patrick,
  University of Washington.

M. E. Money. M.D.
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Examples of QOL questions

• I feel helpless because of my bowel problems.
• I feel like Im losing control of my life because
  of my bowel problems.
• I feel depressed about my bowel problem.
• I feel isolated from others because of my bowel
  problems.
• Long trips are difficult for me because of my
  bowel problems.
• My bowel problems are affecting my closest
  relationships.

M. E. Money. M.D.
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QOL statistical analysisStudy enzyme subgroup

• Statistical T-test Procedure p values comparing
  QOL scores at baseline and end of study
• Helpless p lt.0001
• Losing control of life lt.0001
• Depressed .0002
• Worry lt.0001
• Avoid stressful situations .0065
• Affecting closest relationships .0062

M. E. Money. M.D.
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Effectiveness of pancreatic enzymes

• A retrospective review was recently completed of
  all of the patients in my practice who had the
  diagnosis of IBS and had been treated by me from
  2001-2010 to evaluate the effectiveness of the
  enzymes.
• 278 patients had received a diagnosis of spastic
  colon or IBS
• 134 excluded since they had been treated by
  another practitioner
• 144 seen by me, and 104 had been offered PEZ
• 86/104 patients returned for follow-up, and 82.5
  (71) reported positive improvement

M. E. Money. M.D.
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Examples of Food Triggers Among 49 users
Food Trigger Food Trigger
Mexican Food 36 74 Green Peppers 18 37
Cajun 33 67 Oranges 16 33
Iceberg Lettuce 27 55 Onion 16 33
Italian 27 55 Broccoli 16 33
Chinese 27 55 Garlic 13 27
Ice Cream 26 53 Beans 13 27
Milk 20 41 Apples 13 27
Corn 19 39 Tomatoes 12 25
M. E. Money. M.D.
UMD GI Grand Rounds
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Example of new patient

• 43 yr female seen by me as a new patient 7/24/09
• History Complains of intermittent increased
  loose stools after meals for 11 yrs, sometimes at
  night if eats late. She wonders if she has IBS.
  Symptoms may last for weeks once it gets started,
  otherwise only when eats out in restaurants.
  Worse with spicy foods, onions, garlicky Italian
  meals and tomatoes.
• Exam entirely normal. 64 tall, 161
• Chronic medical problems other than above Asthma
  
• Current meds Zyrtec, Advair Diskus, Ventolin
  inhaler
• Mother has similar digestion problem.
• Patient had never had a colonoscopy.

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M. E. Money. M.D.
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New patient continued

• Patient referred to gastroenterologist who wrote
  Patient states she has cramping, watery diarrhea
  alternating with constipation, up to 10x/day,
  mild in nature..symptoms are suggestive of IBS.
• Investigation by gastroenterologist
• Colonoscopy negative
• X-rays for the stomach and small intestine were
  normal
• Blood tests for Celiac disease was normal
• Biopsy of colon negative for pathology
• Treatment Patient encouraged to try probiotics
  by gastroenterologist.

M. E. Money. M.D.
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New patient continued

• Additional testing ordered by me
• Stool for fat SMALL amount (8/19/09)
• Fecal elastase-1 487 (normal gt200) (test for
  pancreatic insufficiency)
• Patient seen 9/4 in office. Probiotics tried by
  patient but did not prevent post restaurant
  dining diarrhea. I therefore gave the patient
  some samples of prescription pancreatic enzymes
  to try before restaurant meal or triggers.
  They worked with the first meal!
• Current treatment Pancreatic Enzymes before
  trigger meals eliminates both the abdominal
  pain and diarrhea.

M. E. Money. M.D.
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Why do the enzymes work?

• For the last 8 years, I have pursued trying to
  figure out why the pancreatic enzymes work. This
  presentation will focus on my current hypothesis
  and why making the diagnosis of irritable bowel
  syndrome-diarrhea may limit further research
  into this condition.

M. E. Money. M.D.
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Pancreatic Enzymes

• Composition
• Amylase, Lipases, Proteases, Co-lipases, other
  enzymes
• Known Action
• Initiates digestion of carbohydrates, lipids and
  proteins in the stomach
• Amylase potentiates the action disaccharidases by
  10-20x.
• (Quezada-Calvillo, R. et al. Contribution of
  Mucosal Maltase-Glucoamylase Activities to Mouse
  Small Intestinal Starch a-Glucogenesis. Journal
  of Nutrition. 1371725-1733, 2007

M. E. Money. M.D.
UMD GI Grand Rounds
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Sub types of IBS
IBS-Diarrhea 33
IBS-Constipation 32
IBS-diarrhea and constipation 35
Executive Summary IBS in Women The Unmet Needs.
Society for Womens Health Research. 2003
M. E. Money. M.D.
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Incidence of diarrhea occurring after eating

• 50 of patients suffering with the diarrhea or
  mixed form of IBS related symptoms to eating.
• However, the current definition of IBS does not
  encourage nor require the physician to inquire
  about any precipitating factor such as the
  condition occurring ONLY after eating.

M. E. Money. M.D.
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Differential diagnosis for IBS

• Celiac Sprue/gluten enteropathy
• Lactose intolerance (inherited or 2nd to mucosal
  damage)
• Inflammatory bowel disease
• Colorectal carcinoma
• Lymphocytic and collagenous colitis
• Acute diarrhea due to protozoa or bacteria
• Small-intestinal bacterial overgrowth (SIBO)
• Diverticulitis
• Endometriosis
• Pelvic inflammatory disease
• Ovarian cancer
• WGO Practice Guideline IBS 2009

M. E. Money. M.D.
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What is missing from this differential diagnosis?

• 1. Bile acid malabsorption diarrhea
• 2. Pancreatic insufficiency
• 3. Carbohydrate Malabsorption
• Alpha glucosidases (disaccharidases) deficiencies
  (maladigestion of starches)
• Congenital sucrase-isomaltase deficiency
• Fructase deficiency
• ? Possible disaccharidase inhibition

M. E. Money. M.D.
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Bile acid malabsorption

• Bile acid malabsorption can occur in patients
  with or without an intact gall bladder
• Bile acid malabsorption(BAM) may affect up to
  30-50 of patients with chronic diarrhea
• Can be treated with bile acid binding agents
  Welchol, Cholestyramine, Questran
• Diagnosis by measurement of serum 7alphaC4 (not
  available for routine testing)

M. E. Money. M.D
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Diarrhea predominant IBS (IBS-D) fact or fiction

• Dr. Saad Habba, gastroenterologist in NY,
  analyzed all patients seen by him over the last 8
  yrs for IBS-D.
• 575 patients seen, only 303 patients completed
  all of the studies. Of these 303 patients, 204
  (68) responded to bile acid binding agents with
  resolution of diarrhea.
• Diarrhea Predominant Irritable Bowel
  Syndrome-Diarrhea Fact or Fiction. Habba,S.,
  Medical Hypotheses 76(2011) 97-99.

M. E. Money. M.D
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Pancreatic insufficiency

• Pancreatic insufficiency was found in 6.1
  (19/314) patients who had been diagnosed as
  having IBS-D by the Rome Criteria. This was
  determined by the measurement of the fecal
  elastase-1 concentration in the stool. Patients
  were then treated with pancreatic enzyme
  supplements with a statistical improvement in
  stool frequency, consistency, and abdominal pain.
• Some Patient With Irritable Bowel Syndrome
  May Have Exocrine Pancreatic Insufficiency.
  Leeds, J et al, Clinical Gastroenterology and
  Hepatology 2010 8433-438.

M. E. Money. M.D
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Carbohydrate malabsorption

• Carbohydrate malabsorption and intolerance is
  suggested by the patients clinical history. The
  relation of symptoms to feeding and the
  occurrence of remission while fasting are crucial
  to the history. In older children and adults the
  symptoms can resemble those of dyspepsia or
  irritable bowel syndrome (IBS)The diagnosis of
  functional bowel disease usually is made without
  evaluation of carbohydrate digestion symptoms
  from IBS and carbohydrate intolerance can be
  confused easily.
• Disaccharide Digestion Clinical and Molecular
  Aspects. Robayo-Torres, C. et al Clinical
  Gastroenterology and Hepatology. 20064276-287

M. E. Money. M.D.
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1 Lactose malabsorption

• Frequency Isolated deficiency in 16-24 of
  patients with IBS and in 12 of patients with
  functional bowel complaints. (Autosomal
  recessive, CgtT 13910, Intron 13 or MCMG 6 gene.)
• Is usually combined with fructose, sorbitol,
  glucoamylase, sucrase, and maltase deficiency
  among patients with functional GI complaints.
• Disaccharide Digestion Clinical and Molecular
  Aspects. Robayo-Torres, C. et al Clinical
  Gastroenterology and Hepatology. 20064276-287

M. E. Money. M.D.
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Carbohydrate malabsorption syndromes

• 1 Lactose Maldigestion
• Due to Lactase deficiency,
• (a beta-glucosidase)
• Symptoms after the ingestion of milk products
• Abdominal pain
• Cramps
• Urgent diarrhea
• Time of onset variable depending upon quantity
  and sensitivity of patient

• Disaccharide Maldigestion
• Due to alpha-glucosidase(s) deficiency
• Symptoms after the ingestion of carbohydrates
• (lettuce, beans, corn, etc)
• Abdominal pain
• Cramps
• Urgent diarrhea
• Time of onset variable depending upon quantity
  and sensitivity of patient

M. E. Money. M.D.
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Digestion of starches

• Initial hydrolysis of starches begin with the
  action of amylase from the saliva. 95 of
  starches are not broken down until they reach the
  small intestine where pancreatic amylase breaks
  the starch into smaller units maltose,
  maltotriose, and limits dextran size.

M. E. Money. M.D.
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Digestion of disaccharidesalpha-glucosidases

• Further hydrolysis of carbohydrates after
  amylase involves the brush border disaccharidases
  also known as alpha-glucosidases
• Maltase
• Isomaltase
• Sucrase
• Trehalase
• Gluco-amylase

M. E. Money. M.D.
45
Alpha-glucosidase inhibition

• Drugs Acarbose ( a diabetic medication to
  reduce absorption of carbohydrates by preventing
  absorption).
• Side effect gt30 patients experience
  diarrhea
• Spices and foods
• gt1000 known to affect a-glucosidases
• Examples
• Clove extract
• Quercetin (found in onions, 5x more potent
  than acarbose)
• Some spices gt1000x more potent than acarbose
  (verbal report Dr. Buford
  Nichols)
• Bacterial Overgrowth

M. E. Money. M.D.
46
Sucrase-isomaltase deficiency in adults and
varied symptoms

• Sucrose-Isomaltose Malabsorption in an Adult
  Woman
• (Sonntag, W. M. et al, 1964, Gastroenterology
  4718.)
• 20 Greenlandic Eskimos found to have sucrose
  malabsorption
• 8 adults, only 1 with symptoms
• (McNair, et al. 1972, Sucrose malabsorption in
  Greenland, Br. Med J. 219.)
• Ringrose (1980) 13 adult patients with bx proven
  SI def.
• 5 had persistant or intermittent symptoms since
  childhood
• 2 symptoms in childhood, disappeared again until
  20 40.
• 3 symptoms first appeared in first or second
  decade.
• (1980, Dig. Dis. Sci. 25384)
• Gudmand-Hayer (1985) Studied 31 children, and 12
  adults hospitalized in Greenland. Of the 12
  adults, 8 had a long-lasting history of chronic
  diarrhea and abdominal complaints.

M. E. Money. M.D.
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Sucrase-isomaltase and glucoamylase deficiency in
children

• 1-2 of children with severe diarrhea from birth
  are found to have an inherited sucrase-isomaltase
  disaccarhidase deficiency
• Recent research by Dr. Buford Nichols (Baylor
  College, Houston, Texas) in collaboration with
  Dr. Susan Baker ( Woman and Children Hospital of
  Buffalo, NY ) have found 26 of children with
  digestion symptoms have difficulty digesting
  starch due to a deficiency of glucoamylase.

M. E. Money. M.D.
48
More support for maldigestion as possible cause
of diarrhea

• A very low-carbohydrate diet improves symptoms
  and quality of life in IBS-D patients. 2009
• Prospective Study
• 17 enrolled with moderate to severe IBS-D
• Initially had 2 weeks of standard diet, then 4
  weeks of very low (20gm carbohydrate/day).
• 13 completed the study. 10 (77) reported
  adequate relief for all 4 weeks on the low carb
  diet stool number decreased, QOL improved, and
  decrease in pain.
• Clin Gastroenterol Hepatol. Austin, GL Dalton,
  CB et.al. 2009 June 7(6) 706-708.el.doi10.10167
  /j.cgh.2009.02.023

M. E. Money. M.D.
49
More support for maldigestion as possible cause
of diarrhea

• In Indonesia, biopsies taken from the small
  intestine were examined for concentration of
  Lactase, Sucrase, and Maltase from 13 patients
  with chronic diarrhea, and compared to biopsies
  from 34 patients with dyspepsia.
• Results All of enzyme concentrations from the
  patients with chronic diarrhea were statistically
  lower than those with dypepsia.
• Examination of small bowel enzymes in chronic
  diarrhea. J Gastroenterol Hepatol. Simadibrata,
  m., et al.18(1) 53-6.

M. E. Money. M.D.
50
Working hypothesis

• Diarrhea occurring after meals may actually be
  a subclinical form of inherited or acquired
  maldigestion, possibly related to a bile acid
  malabsorption or a mild deficiency, relative
  ineffectiveness or suppression of one or more
  enzymes amylase, lipase, the disaccharidases, or
  others.

M. E. Money. M.D.
51
Summary

• The current Rome Criteria may be limiting
  appropriate research and treatment for a subset
  of IBS-D patients who recognize the direct
  association of symptoms with meals or triggering
  foods. The relationship to meals should be sought
  in obtaining the history from patients.
• A high percentage of these patients probably have
  a subclinical form of maldigestion which may be
  substantially improved by the use of enzymes or
  bile acid binding agents when taken immediately
  before eating the triggering meal.

M. E. Money. M.D.
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Proposed new diagnosis

• Intermittent Maldigestion Condition
• (IMC)
• Symptoms of increased bowel movement(s),
  occurring after eating a specific meal type or
  trigger according to the patient, which may be
  altered in form or consistency. Symptoms may
  occur immediately after eating or several hours
  later and do not have to occur daily.

M. E. Money. M.D.
53
Potential treatment options for patients with
diarrhea after meals

• Over the counter agents
• Fiber capsules (which absorbs extra liquids)
• Calcium (which slows down the motility
  naturally),
• Enzyme supplement Essential Enzymes 500 mg
  (by Source Natural), an over the counter
  supplement (1-3) before eating any trigger meal
  or daily as needed.
• Prescription medications from a physician
• Pancreatic enzymes examples ZenPep 20,000
  lipase, Creon 24 (1-3capsules) before eating any
  trigger meal or daily as needed.
• Bile acid binding drugs Questran 1-2
  packages/day Welchol 625 mg (1-3) before eating
  any trigger meal or daily as needed.

M. E. Money. M.D.
54
Future research questions

• What is the incidence of sucrase-isomaltase
  deficieny in adults with diarrhea after eating?
• Do over the counter enzyme supplements work as
  well as the prescription pancreatic enzymes?
• How/why do certain food items cause the diarrhea?
• Do the foods suppress the disaccharidase action
  or amylase from the pancreas or speed up the
  motility?
• Are there specific genes that are predispose a
  person to having this problem?

M. E. Money. M.D.
55
Funding opportunities

• Donations are welcomed to help fund this
  important research and can be made to the
• RESEARCH FUND
• at the
• Meritus Healthcare Foundation
• HUB Plaza 1101 Opal Court Suite 301,
• Hagerstown, MD 21740
• 301-790-8631 TDD 1-800-735-2258
  Foundation_at_meritushealth.com

M. E. Money. M.D.