Breadtag Sagas ©: Author Tony, 21 February 2016
Giulia Enders Gut: the inside story of our body’s most under-rated organ 2015.
Enders honesty about herself in the beginning of her Foreward is astonishing and endearing.
I was born by caesarean section, she says and goes on to say that she couldn’t breast feed and was lactose intolerant until the age of five. The point is: If I had known more about the gut then, I could have placed bets on what illnesses I would contract later in life.
I got fat then thin again. Then for a long time, I was fine. Until I got ‘the sore’.
When I was seventeen, I developed a small sore on my right leg, for no apparent reason. It stubbornly refused to heal, and after a month [more sores]…
No Doctor was able to help me…
Enders goes on to say that after an awful time she pulled herself together and started to do some research. She by chance came across a report about a man who had contracted the same thing after a course of antibiotics, which she’d also had about two weeks before her sore first appeared.
From that moment on, I ceased to treat my skin like that of a person with a dermatological problem, and begin to see it as the skin of a person with an intestinal condition.
Enders then begins some self-treatments and admits:
I also carried out some pretty crazy experiments on myself … if I had already been studying medicine at that time, I wouldn’t have dared do half of them…
With a few tricks, I finally managed to get my condition under control…
She then goes on to tell another story about being at a party at the beginning of her medical training and meeting a man with the ‘smelliest breath’ I had ever smelled. The next day he committed suicide.
She poses the question:
Could it have been a diseased gut creating that smell, and if so, could a diseased gut also have affected his psychological state?
It is not surprising that Enders is interested in the gut. The alimentary canal is the third major tube system of the body but is neglected (I’d include the skin as a fourth non-tube system also neglected). However, there has been much research on the gut over the last twenty years or so. Enders aim is to try to make this new knowledge available to a wider audience.
A confession and a description of my own gut problems
Denise gave me Guilia Enders book for Christmas. This may seem surprising, but it was an inspired present. I have a scientific mind and an interest in medicine, but more importantly I’ve had long-term gut problems, including a new gut experience in late 2015. I’ve realised sometimes unwillingly (I too want a ‘quick fix’ or alternatively to pass the problem over to a doctor) that doctors aren’t too good with chronic problems. I also haven’t been sick enough (fortunately) for a major intervention.
If you are merely curious about the gut and want a credible scientific point of view Enders book is a good read, charming and not difficult. But it is more useful to those who do have a gut problem. Other books cover the same scientific material without the advice (see Further information for a reference).
I’m now going to give you a brief outline of my gut history, similar to Enders confession, to provide another case study. When I talk to people on the topic, it is surprising the number I meet who also have chronic gut problems, mostly worse than mine. Skip this, if you aren’t interested.
Apart from back-packing in Asia, when your most intimate bowel problems are shared openly with strangers. Most of us were brought up to be reticent, when speaking about this intimate organ.
Many years ago, I developed strong colitis, which I was convinced was caused by a course of antibiotics. The doctor at the time was dismissive of this diagnosis. The colitis went away and I had the first of several colonoscopies (about every 5-7 years).
In 1995, Denise and I went to Thailand, Pakistan, China, India and Burma for a year. In Pakistan, in particular travelling up and down the Karakoram Highway for two and a half months, we had several bouts of Giardia and other gastric bugs, because of the water mostly, despite being very careful. I’ve always said that my guts were never the same afterwards. On several trips to India and elsewhere in Asia I’ve had the usual food poisoning and two more serious episodes caused by the build-up of bad bacteria in the gut.
In 1998, for three years I had IBS (or irritable bowel syndrome) — not very pleasant, where I developed diarrhoea and had to stop eating regular food for about two weeks each time I had a bout, until everything returned to normal. I experimented with various things, but a slightly more careful diet and probiotics, in particular yoghurt containing three bacilli and Yakult (a yoghurt drink laden with Lactobacillus casei Shirota strain) made the IBS go away and it didn’t return.
In late 2015, I had a bout of nausea and bowel pain (which seemed located in one spot). I couldn’t get in to see my own doctor (not unusual, unfortunately) and went to another doctor in the practice. I was diagnosed immediately as having diverticular disease (diverticula are little pockets in the large intestine, which can fill with faeces or bacteria and get infected). She sent me for a scan, which confirmed the presence of diverticula (as had my last colonoscopy in 2011, when we got around to looking at it).
The diverticula in the large bowel may be caused by weakening of the muscle-lining of the bowel or by pressure, but no-one really knows. Most of the population, over a certain age, have diverticula and three-quarters of these people have no symptoms. I was treated immediately with a course of two strong antibiotics for two weeks. The symptoms went away slowly. Unfortunately, a month later the same thing happened. I had a prescription so I began the course of antibiotics immediately. I was more than a bit freaked out, however. I went back to the doctor and managed to turn a 15-minute consultation into 40-minutes. We talked about the issues and she was very helpful. She said that I had to learn to manage things, but that having several courses of strong antibiotics a year, wasn’t either life or lifestyle threatening.
After the antibiotics and when I’d calmed down psychologically, I did some more serious reading than before. I realised that the diagnosis of diverticular disease wasn’t helpful: that the presence of diverticula though worth knowing about may not be that relevant. It was more useful to think of my condition as a continuation of my previous gut problems with new symptoms. I had to ‘bite the bullet’ and take the doctor’s advice. No-one else was going to manage this condition for me. I had to learn to manage it myself. My reading showed me that prebiotics, probiotics and a rather nasty drug (not recommended except in dire circumstances) were the only explored treatments.
I needed again to experiment with diet, fibre, maybe other prebiotics and possibly more probiotics than the two I was familiar with, if things got worse. And, to take the antibiotics if another bout occurred.
Perhaps, the major initial change I introduced was Psyllium seed husks sprinkled on my breakfast muesli. This has had a profound effect (more bowel motions) and seems effective. If you soak Psyllium husks (part of the seed) in abundant water and leave them for ten minutes they turn into a gooey porridge or jelly-like mucilaginous substance, which is meant to stimulate and massage the lining of the small and large intestine. Psyllium husks come from a plant Plantago ovata native to the Indian subcontinent.
I’m also more conscious of fibre in my diet and of the new understanding about resistant starches — cooked and cooled potatoes, beans and lentils, some breakfast cereals etc.
The state of play with gut problems
I’ve realised, hearing others’ stories of medical conditions, that one area in which modern medicine fails today is the treatment of chronic conditions. This is partly because of:
- A systemic failure in medicine;
- GPs’ time pressure — they are the frontline (there is no filtering mechanism, e.g. clinic nurses and paramedics) and their cost base has changed, and;
- Other complex societal issues.
Unfortunately, because of this failure of modern medicine many people seek ‘quick-fix’ solutions elsewhere, in alternative medicine and self-help. Whilst not all alternative medicine is bad, enough is run by charlatans and poorly trained practitioners that it is hard to find the wheat amongst so much chaff. Peer review is almost non-existent in alternative medicine and the self-help movement is worse. I’ve read several well-researched and savage indictments of self-help. A good one is Steve Salerno’s book Sham and the bottom-line is that it is more profitable writing self-help books than it is finding solutions.
Enders book, however, is a self-help book by a young medical researcher in an area that she had a passionate interest in before she started medicine. She wants to bring you up to date with the latest research in an area of medicine that is changing rapidly.
Modern medicine is also currently developing a more thoughtful holistic understanding of the gut as an organ, which is also closely linked to the brain.
Giulia Enders Book
Following her Foreward Giulia Enders embarks on her exploration of the gut. The writing is simple and informative backed up by her sister Jill’s drawings. Initially I didn’t like the drawings but I soon warmed to them and found them actually rather wonderful and an enhancement to the effervescent style of the text.
Enders has a difficult job to keep us engaged while describing the gut and our new understanding of it. She does this extremely well, but she has to keep up the pace and occasionally slips either in the content or the depth of treatment. Occasionally she diverts from fact into speculation. Despite this, the book as a whole is a tour de force.
She provides excellent academic references at the end, leaves us with a good description of the latest understanding of how the gut works and provides excellent advice and starting points for our journey into understanding our own gut and how best to nurture it.
The Book is divided into three parts with many sub-sections.
Part 1 Gut Feeling
She begins with the real basic: how pooing works, why it is important and how we might improve things by the way we sit. There are detailed illustrations on sitting for those who suffer constipation, but not only for them. Enders introduces the concept that you might be able to improve evacuation merely by posture on the toilet.
The gateway to the gut covers the mouth and salivary glands. Did you know that you produce 0.7 to 1 litre of saliva during the day but very little at night — the dry mouth syndrome and why mouth bacteria have an advantage at night? Our saliva produces a painkiller called opiorphin only discovered in 2006, which is stronger than morphine. It also contains anti-bacterial protections.
Psoriasis, a skin condition quite resistant to treatment and thought to be an over-reaction of the immune system, may be related to sore throats. The psoriasis of some patients clears up completely after a tonsillectomy, indicating that perhaps one bacteria causes both.
The next section is on the structure of the gut and what we really eat. The description of the gurgly oesophagus is important for later, as is the importance of the positioning of the lopsided stomach pouch. I liked description of the meandering small intestine (which she says is surprisingly clean) and the lovely the term for undigested food, which is chyme.
Enders covers allergies and intolerances: coeliac disease, gluten, lactose and fructose intolerance. Those with true intolerance for gluten get very sick if they ingest only tiny amounts. Other people sometimes feel better for not eating gluten, but this is a temporary thing. For a week or two their feeling of well-being improves and digestive problems may clear up, but then she recommends thorough medical examination. I suspect reading between the lines that Enders is critical of self-diagnosed gluten intolerance and does not believe it is a panacea.
There is a small section on facts about faeces before we proceed.
Part 2 The Nervous System and the Gut
Focus is given to how the various organs of the gut transport food. The next sub-section is on reflux and is one of the weakest from the perspective of reflux sufferers. However, again the mechanical aspects are emphasised; and sufferers can alleviate some aspects of reflux merely by understanding how the oesophagus enters the stomach and using physical positioning and pillows to alleviate symptoms.
The description and homage given to vomiting and how to reduce unwanted attacks is delightful, as is the thoughtful section on constipation.
The sub-section on the brain and the gut is thought provoking, particularly how the brain influences the gut and vice versa and the consequences for IBS (irritable bowel syndrome), stress and depression. Thinking about the gut and the brain also has consequences for understanding where the ‘self’ originates. Some of this topic is leading edge research and may take years to understand properly.
Part 3 The World of Microbes
Enders titles her first sub-section I am an ecosystem, which pretty much sums it up. The recent study of microbes has involved a seismic shift in understanding, which in retrospect appears blindingly obvious. The key acknowledgement is that microbes are important to our well-being, as well being a cause of disease in more ways than were previously accepted. Enders notes that work on an atlas of human bacteria did not begin until 2007.
The vast majority of our bacteria are harmless or even helpful. ‘Our gut’s biome can weigh up to 2 kilos and contains about 100 trillion bacteria.’ The bacteria are essential to the digestion of our food.
Enders gives a detailed description of the relation between our immune system and our bacteria, on how our gut flora develops and its constitution as an adult, before she gets onto the ‘bad guys’. These are harmful bacteria and parasites. She covers Salmonella, Helicobacter and Toxoplasma.
Two Australian doctors received the Nobel Prize for demonstrating merely thirty years ago that Helicobacter pylori causes stomach inflammations and gastric ulcers. Enders goes on to say that they discovered one of humankind’s oldest pets, which have been living inside human beings for over 50,000 years. She continues with an analysis of the good and bad characteristics of this long associated bacteria.
She then covers two parasites Toxoplasma gondii from cats and worms. Enders introduces the idea of parasites influencing our brains and behaviour to aid passing themselves on. This is a nice story, but I suspect that the medical world may be unwilling to accept it. Elsewhere parasitologists have documented biological control by parasites repeatedly (see Further information).
Enders finishes the book with a discussion of cleanliness, antibiotics, probiotics and prebiotics to give us some guidance on maintaining a healthy gut.
As part of this discussion she talks about faecal transplants, which have been a hot topic in the news over the past couple of years. The major and really only reason for this to date is to treat a particularly nasty infection or infestation of the bowel by Clostridium difficile, which is resistant to treatment with antibiotics or probiotics. Infected people may have bloody, slimy diarrhoea for many years. These patients and only these have been treated with faecal transplants, which have shown a success rate of around 90 per cent, which is very high for a medical treatment.
Enders does not provide an index, which I admire in this type of short popular work, but she does give a detailed reference base by chapter, for those who wish to pursue the subject further.
Yes, I know that people who consult the Internet for medical solutions tend to mis-diagnose themselves and sometimes treat non-existent conditions. Yes, I know people are stupid and have a tendency to be gulled by rogues and charlatans, offering snake oil solutions. Yes, I know we all want a quick fix and reassurance rather than objectively analysing what is wrong with us. Yes, I know that the large bulk of the population can’t understand how to use a percentage and don’t want to.
We are bombarded in the press everyday with bogus health statistics that are unqualified by information on sample size or reliability. Maybe there is a backlash in the offing.
The World Health Organisation certainly had its fingers burned over its list containing bacon and processed meats as cancer causing agents. The problem was that they came out with this list without qualifications or context. Someone’s bright idea. They made no attempt to distinguish between the mass-produced goods of Industrial food production and gourmet or local goods produced in countries such as Italy and France. There may be no difference but it is important to know. Similarly, are free-range heritage pigs any better than constrained genetic monsters? The same question needs to be asked about chickens.
And, in a world where manufactured breakfast cereals routinely contain one-third to 40 per cent sugar. Where most processed foods and fast foods are loaded with sugar and fat. Where food labelling laws do nothing to help inform people of the bad stuff they are eating. Where governments refuse to spend money on cost efficient preventative medicine. Yet, we are made to feel guilty because of the obesity epidemic, which is a direct result of the failures to inform. In this world, the WHO is part of the problem and not the solution.
What are we to do?
Given the current inability of modern medicine to helpfully treat and nurture those with chronic health conditions, we are frequently left to our own resources. If we take the time, stop looking for a quick fix and seek advice selectively, we can learn to manage our own health issues wisely.
We need books like Gut by Giulia Enders to help us sail the unchartered waters. Enders book is an interesting scientific appraisal of new information on this most under-rated organ, but it is also a users guide and gives us an entry point to self-management of gut problems for those with chronic conditions.
I heartily recommend this as a most useful and practical advice manual. It is well-written, not very long and packed with information.
Key Words: Guilia Enders, Gut, alimentary canal, colitis, diagnosis, modern medicine, chronic health conditions, research, antibiotics, IBS (irritable bowel syndrome), diarrhoea, Yakult, yoghurt, Lactobacillus, diverticular disease, colonoscopy, diverticula, large bowel, Psyllium seed husks, Plantago ovata, mucilaginous, evacuation, posture on the toilet, salivary glands, saliva, Opiorphin, Psoriasis, skin condition, sore throat, chyme, small intestine, stomach pouch, allergies, immune system, coeliac disease, gluten, lactose, fructose, intolerance, gut transport, digestive, panacea, reflux, oesophagus, stomach, symptoms, physical position, stress, depression, microbes, ecosystem, biome, bacteria, parasite, Salmonella, Helicobacter pylori, Toxoplasma gondii, worms, parasitology, probiotics, prebiotics, faecal transplant, Clostridium difficile, WHO, snake oil, self-diagnosis, quick fix, self-help movement, bogus health statistics, charlatans, peer review, Mary Roach, Gulp, Steve Salerno, Sham, Carl Zimmer, Parasite Rex
Jill Enders Illustrations are an integral part of the book and rather charming. They are copyright and have been used here for non-commercial purposes to illustrate the article about her sister’s book. (Jill Enders is no longer online See Web Archive of page)
Another book that also gets good reviews is Mary Roach Gulp: Adventures on the Alimentary Canal 2013, which is a witty American science journalist’s version of Enders book. It appears to be more focussed on the science and the scientists in a light hearted way, rather than being a users’ manual. I haven’t read it yet, however.
About Giulia Enders and Gut
Wikipedia gives a very basic outline
Giulia Enders (born 1990) is a German writer.
Giulia Enders is a two-time scholarship winner of the Wilhelm Undelse Heraeus Foundation and is studying medicine at the Institute for Microbiology in Frankfurt.
In 2012 she won the first prize at the Science Slam in Freiburg, Berlin and Karlsruhe with her talk Darm mit Charme (Charming Bowels). This talk was also published on YouTube. Enders received the offer to write a book about this subject that has sat atop the German paperback charts shortly after the release in March 2014. The drawings for the book were made by her older sister Jill Enders.
Gut rates highly on Goodreads with 3.98 some of the favourable reviews are worth reading
A five-star rated French Review in Goodreads by Julie says:
Having huge problems with digestion, I found in this book supplied answers to my questions. Everything is explained with clarity and humor. Special mention should be given to all the sections dealing with the time we spend on the throne. If you are interested in medicine and functioning of the human body, it must be read absolutely!
Lois Bujold 4-star is succinct:
Neat little owner’s manual for your digestive system, straightforward, humorous, and jargon-free. Complex ideas are presented as simply as possible, to reach as broad an audience as possible. It also included a lot of information I hadn’t known, either because it was new, or because I hadn’t been paying attention.
There many are other reviews worth reading.
News and articles
An ABC Australia, Lateline, 2 July 2015, news interview and transcript is a good example of Enders views
The following article in German is interesting
Other newspaper book reviews
The Independent 19 May 2015
The Australian 27 June 2015
The Self-help movement
Steve Salerno Sham: How the self-help movement made America helpless
Wikipedia provides an overview but without much critical analysis
A middle ground and thoughtful essay by Algis Valiunis gives some pros and cons. I must admit that I lean more towards Salerno’s critique. However, I don’t want to belittle certain methods that do help. For example, sufferers of chronic pain have secured help from such things as, mindfulness, self-hypnosis, yoga and meditation. These things can be as helpful as physical aids such as gym, general exercise, walking and Tai Chi.
Control by parasites
Carl Zimmer uses the example of a saltmarsh in California, where from one perspective the parasites seem to run the whole ecosystem. For example, a parasitised kill fish regularly shimmies, jerks and flashes its belly. This was shown experimentally to make it thirty times more likely to be taken by a predatory bird than an unparasitised fish. He also talks about parasites of game animals and speculates that wolves and lions don’t cull the young and the weak, but tend to take those the parasites have prepared for them.
Researching medical conditions
The Internet is a good field for researching medical conditions and research articles but care needs to be taken. There are plenty of charlatans out there promising snake oil treatments. Those with chronic conditions are prey to the unscrupulous. Avoid articles that take the view that the mainstream doesn’t understand, but I have a wonderful method that is the opposite of what everyone else says.
However, medical review articles are a good source for finding out what is known about a certain condition. Enders references are also good.
Wikipedia is often a good starting point. For example, Wikipedia says the following about colonoscopy, irritable bowel syndrome and Barrett’s Reflux or Esophagus (a rather nasty condition suffered by a friend).
Gastroenterology practices, societies and government agencies are also good starting points for some conditions.
(posted in Hyderabad, India)