ACG Magazine | Vol. 6, No. 3 | Fall 2022

ACG MAGAZINE Fall 2022

MEMBERS. MEDICINE. MEANING.

GI at the Table: Using a Clinic-to-Farm-to-Table Approach in Gastroenterology

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THE AMERICAN COLLEGE OF GASTROENTEROLOGY

FALL 2022 // VOLUME 6, NUMBER 3

FEATURED CONTENTS

COVER STORY

GI at the Table: Using a Clinic-to-Farm-to-Table Approach in Gastroenterology Looking beyond the exam room to include farms, culinary kitchens, and integrated teams in the clinical pathway

PAGE 26

Law Mind Ann Bittinger, Esq., on how to counter inflationary impacts on your take-home pay PAGE 24

Trainee Hub Tips for a career in IBD from established faculty and recent advanced IBD fellows PAGE 15

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Attend an upcoming

ACG POSTGRADUATE COURSE 2022 ACG 2022 Annual Scientific Meeting and Postgraduate Course The Charlotte Convention Center | Charlotte, NC October 21–26, 2022

ACG Weekly Virtual Grand Rounds REGISTER NOW: GI.ORG/ACGVGR Plus now offering VGRs TWICE each Thursday, with a live broadcast at noon (ET) followed by an 8:00pm (ET) rebroadcast!

ACG’s Endoscopy School & Southern Regional Postgraduate Course Grand Hyatt | Nashville, TN December 2–4, 2022

2023 ACG’s Hepatology School & Western Regional Postgraduate Course Caesars Palace | Las Vegas, NV January 27–29, 2023

ACG/LGS Regional Postgraduate Course Hilton New Orleans Riverside | New Orleans, LA February 24–26, 2023

ACG/FGS Annual Spring Symposia Hyatt Regency Coconut Point | Naples, FL March 10–12, 2023

ACG’s Functional GI and Motility Disorders School & ACG Eastern Regional Postgraduate Course The Westin Hotel | Washington, DC June 2–4, 2023

MORE INFO: gi.org/acg-course-calendar

FALL 2022 // VOLUME 6, NUMBER 3

CONTENTS

“Gastroenterology practices and health systems can collaborate with local food system partners to benefit patients and communities. These collaborations can focus on effective interventions from lifestyle medicine, including an emphasis on a whole food plant-based diet or 'plant-forward' diet.”

—"GI at the Table: Using a Clinic-to-Farm-to-Table Approach in Gastroenterology” PG 26

6 // MESSAGE FROM THE PRESIDENT ACG President Dr. Samir Shah on developing professional partnerships and lifelong connections through the ACG

7 // NOVEL & NOTEWORTHY Professional accomplishments, advocating for patients, encouraging the future of GI & more

15 // TRAINEE HUB PEARLS & PERSPECTIVES ON ADVANCED IBD FELLOWSHIP Tips for a career in IBD from established faculty and recent advanced IBD fellows

21 // GETTING IT RIGHT 21 PRACTICE MANAGEMENT TOOLBOX Tips for mitigating prior authorization hurdles 24 LAW MIND How to counter inflationary impacts on your take-home pay by Ann Bittinger, Esq.

26 // COVER STORY

47 // EDUCATION

GI AT THE TABLE: USING A CLINICTO-FARM-TO-TABLE APPROACH IN GASTROENTEROLOGY Incorporating farms, culinary kitchens, and integrated teams into the clinical experience for GI patients

EDGAR ACHKAR VISITING PROFESSORSHIP EAVP brings experts to GI programs and enhances the initiative with the Visiting Scholar in Equity, Diversity, and Ethical Care

37 // ACG PERSPECTIVES 37 CULINARY CONNECTIONS A Fall special on fermented foods that are good for your gut 41 ACG PERSPECTIVES Insights on promoting diversity, sponsorship, and allyship for women in the field of GI 44 CONVERSATIONS WITH WOMEN IN GI Dr. Jill Gaidos interviews Dr. Guadalupe Garcia-Tsao on training internationally in the US and finding her voice as a woman leader in hepatology

51 // INSIDE THE JOURNALS 52 AJG Pickle Juice Intervention for Cirrhotic Cramps Reduction: The PICCLES Randomized Controlled Trial by Tapper, et al.

52 CTG Adjustable Intragastric Balloon Leads to Significant Improvement in Obesity-Related Lipidome and Fecal Microbiome Profiles: A Proof of Concept Study by Hussan, et al.

53 ACGCRJ Introducing the new ACGCRJ Editorial Board

54 // REACHING THE CECUM ACID REFLUX & GERD INFOGRAPHIC A new ACG infographic on acid reflux and GERD to share with patients

ABOVE: Fresh produce from Allegheny Mountain Institute Farm in Fisherville, VA is a centerpiece of a variety of clinically-integrated programs of the Augusta Health Digestive Wellness Center. COVER PHOTO: Dr. Vani Paleti in the garden. Cover story photos courtesy of Dr. Paleti, Dr. Christina Tennyson, Dr. Savita Srivastava, Allegheny Mountain Institute, and Augusta Health.

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ACG MAGAZINE MAGAZINE STAFF

CONNECT WITH ACG youtube.com/ACGastroenterology

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facebook.com/AmCollegeGastro Editor in Chief; Vice President, Communications Anne-Louise B. Oliphant

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BOARD OF TRUSTEES President: Samir A. Shah, MD, FACG President-Elect: Daniel J. Pambianco, MD, FACG Vice President: Jonathan A. Leighton, MD, FACG Secretary: William D. Chey, MD, FACG Treasurer: Amy S. Oxentenko, MD, FACG Immediate Past President: David A. Greenwald, MD, FACG

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Past President: Mark B. Pochapin, MD, FACG Director, ACG Institute: Neena S. Abraham, MD, MSc, MACG Co-Editors, The American Journal of Gastroenterology: Jasmohan S. Bajaj, MD, MS, FACG

DIGITAL EDITIONS

GI.ORG/ACGMAGAZINE

Millie D. Long, MD, MPH, FACG Chair, Board of Governors: Patrick E. Young, MD, FACG Vice Chair, Board of Governors: Dayna S. Early, MD, FACG Trustee for Administrative Affairs: Irving M. Pike, MD, FACG

ACG MAGAZINE Spring 2021

MEMBERS. MEDICINE. MEANING.

Leading the Way in

Advancing Health Equity ACG MAGAZINE Spring 2021

MEMBERS. MEDICINE. MEANING.

Leading the Way in

Advancing Health Equity

TRUSTEES Jean-Paul Achkar, MD, FACG Seth A. Gross, MD, FACG Immanuel K. H. Ho, MD, FACG James C. Hobley, MD, MSc, FACG Costas H. Kefalas, MD, MMM, FACG Paul Y. Kwo, MD, FACG John R. Saltzman, MD, FACG Nicholas J. Shaheen, MD, MPH, MACG Neil H. Stollman, MD, FACG Renee L. Williams, MD, MHPE, FACG

4 | GI.ORG/ACGMAGAZINE

American College of Gastroenterology is an international organization with more than 16,000 clinician members representing some 86 countries. The College's vision is to be the pre-eminent professional organization that champions the evolving needs of clinicians in the delivery of high-quality, evidence-based and compassionate health care to gastroenterology patients. The mission of the College is to advance world-class care for patients with gastrointestinal disorders through excellence, innovation and advocacy in the areas of scientific investigation, education, prevention and treatment.

CONTRIBUTING WRITERS

Elizabeth S. Aby, MD Dr. Aby is a transplant hepatology fellow at the University of Minnesota and is a member of ACG’s Women in GI Committee.

Lydia L. Aye, DO Dr. Aye is Associate Professor of Medicine and Program Director of GI Fellowship at the University of California, Irvine, and is a member of ACG’s Women in GI Committee.

Stephen T. Amann, MD, FACG Dr. Amann is a gastroenterologist at One GI in Tupelo, MS who serves as Chair of ACG’s Practice Management Committee and a member of the ACG Legislative and Public Policy Council.

Pat Banks Mr. Banks is Director of Farming and Project Advancement at Allegheny Mountain Institute.

Ann M. Bittinger, Esq Ms. Bittinger is a health law expert at Bittinger Law Firm in Jacksonville, FL. She regularly contributes to ACG’s publications on her areas of expertise, including legal relationships between hospital systems and physicians or physician groups. (bittingerlaw.com)

William J. Bulsiewicz, MD, MSCI Dr. Bulsiewicz is a gastroenterologist and author of Fiber Fueled and The Fiber Fueled Cookbook.

Daniel K. Chan, MD Dr. Chan is Medical Director of Gastroenterology at The Queen’s Medical Center in West O’ahu, HI.

Aline Charabaty, MD, FACG Dr. Charabaty is Assistant Clinical Director of the Division of Gastroenterology at Johns Hopkins School of Medicine and Clinical Director of IBD, Johns Hopkins-Sibley Memorial Hospital in Washington, DC. She is also the current ACG Governor for Washington, DC.

Lara T. Dakhoul, MD Dr. Dakhoul is Assistant Professor of Medicine in the division of Gastroenterology, Hepatology & Nutrition at University of Florida Health and is a member of ACG’s Women in GI Committee.

Katie A. Dunleavy, MB BCh BAO Dr. Dunleavy is a second-year GI fellow at Mayo Clinic Rochester and is a member of ACG’s Digital Communications and Publications Committee.

Corlan Kemi Eboh, MD Dr. Eboh is a gastroenterologist at Atrium Health in Charlotte, NC, and is a member of ACG’s Diversity, Equity & Inclusion Committee.

Jill K. J. Gaidos, MD, FACG Dr. Gaidos is Associate Professor at Yale School of Medicine Section of Digestive Diseases and Director of Clinical Research for the Yale IBD Program.

Guadalupe Garcia-Tsao, MD, FACG Dr. Garcia-Tsao is Professor of Medicine in the Section of Digestive Diseases at the Yale School of Medicine and Chief of Digestive Diseases at VA-CT Healthcare System.

Autumn P. Hines, DO Dr. Hines is Assistant Professor of Medicine at Emory University School of Medicine and is a member of ACG’s Women in GI Committee.

Pegah Hosseini-Carroll, MD, FACG Dr. Hosseini-Carroll is Assistant Professor of Medicine and Associate Program Director of Digestive Diseases Fellowship at the University of Mississippi Medical Center and is a member of ACG’s Women in GI Committee.

Asma Khapra, MD Dr. Khapra is a gastroenterologist at GastroHealth in Virginia and is a member of ACG’s Women in GI Committee.

Jami A.R. Kinnucan, MD, FACG Dr. Kinnucan is a Senior Associate Consultant in the Section of Gastroenterology and Hepatology at Mayo Clinic Jacksonville and is a member of ACG’s Women in GI Committee.

Paola López-Marte, MD Dr. López-Marte is a GI research fellow at the University of Puerto Rico School of Medicine and is a member of ACG’s Women in GI Committee.

Vani Paleti, MD Dr. Paleti is a gastroenterologist at Baylor Scott & White Health.

She is also a Diplomate in Lifestyle Medicine and in Obesity Medicine.

Shabana F. Pasha, MD, FACG Dr. Pasha is Professor of Medicine at Mayo Clinic Arizona and currently serves as the ACG Governor for Arizona and on ACG’s International Relations Committee.

Samir A. Shah, MD, FACG Dr. Shah is the 2021-2022 ACG President, Clinical Professor of Medicine at Alpert Medical School at Brown University, Chief of Gastroenterology at the Miriam Hospital, and is a partner with Gastroenterology Associates, Inc.

Savita Srivastava, MD Dr. Srivastava is a gastroenterologist at Augusta Health Gastroenterology in Fishersville, VA.

Christina A. Tennyson, MD Dr. Tennyson is a gastroenterologist at Augusta Health Gastroenterology in Fishersville, VA.

Shifa Umar, MD Dr. Umar is Editor of ACG MAGAZINE’s Trainee Hub section and an Advanced Endoscopy fellow at the University of Chicago. Dr. Umar is also member of the ACG Digital Communications & Publications Committee, the ACG Diversity, Equity & Inclusion Committee and is an ACG Institute Young Physician Leadership Scholar.

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MESSAGE FROM THE PRESIDEN

HOME

ACG: OUR PROFESSIONAL

IN 1996 AS A SECOND-YEAR FELLOW, I joined the ACG as a Trainee member only so I could present my research at the ACG meeting in New York City that October. I had no idea then that the ACG would become my professional home and that 25 years later, I would have the incredible honor of serving as President in its 90th year.

A few years after I accepted my first (and only) job in 1997 in Providence, RI, with a private practice group, I wrote to the Rhode Island ACG Governor, Dr. Brad Lavigne, with a request to get involved with the College. He placed me on the Practice Management Committee — my first official role in the ACG. I was, frankly, in over my head, being a fresh graduate from an academic GI fellowship and no experience in practice management. Nonetheless, I was welcomed to the Committee by the chair and all the more experienced members, mentored by the likes of Dr. Harry Sarles, Dr. Ron Vender, Dr. David Johnson, and Dr. Irving Pike (past ACG Presidents), and encouraged to participate. My group had started in-office infusions of biologics that I spearheaded and we had recently incorporated a PA into our practice, so I ended up sharing those experiences with the Committee and at the Practice Management Course.

Fast forward to 2006, while serving as Vice Chair of the Board of Governors and Chair of the Membership Committee, we proposed a new category of membership to allow PAs, NPs and GI nurses to become members of the College and now this valued group make up over a thousand of our members. As of June 2022, ACG had over 17,500 active members making us the largest (and of course best) GI organization in the world.

As I reflect on what makes the ACG unique and special to me, three characteristics stand out: collegiality, community, and clinical excellence. ACG is, at its heart, an inclusive organization that respects all its members, regardless of background or practice situation: private, academic, hybrid, APP, international, etc. Our focus on clinical GI and improving patient care is a strong shared value reflected in our meetings, journals, research, website, membership, staff, and our multiple initiatives. The “vibe” at any of our events is a family type atmosphere where everyone, regardless of background, gender, level of expertise, or subspecialty is welcomed and supported.

I simply love this and am so fortunate to consider the ACG my professional home. Ideally, home is a place where one should feel secure, supported, and comfortable being who one is while striving to be the best one can be.

My involvement with the ACG has helped me grow as a physician, colleague, leader and supported my hybrid career in private practice incorporating some clinical research focused on IBD and mentoring medical students, residents, and GI fellows. I hope that all our members feel equally supported in their career

6 | GI.ORG/ACGMAGAZINE

“The 'vibe' at any of our events is a family type atmosphere where everyone, regardless of background, gender, level of expertise, or subspecialty is welcomed and supported.

I simply love this and am so fortunate to consider the ACG my professional home.”

development as part of the “greatest gut club on earth.” The friendships and connections through the ACG are lifelong.

One of the perks of serving as Governor was the unique opportunity to connect with and learn from colleagues around the country/world and to discus common challenges and search for common solutions.

Furthermore, I know firsthand how the Board of Governors helps keep our Board of Trustees well-informed about your concerns and creates a direct connection to ACG leadership so you feel supported and heard.

Finally, although I expected professional growth within the ACG, I never expected personal growth and support including connecting with others with a love of music and forming a band — the Beacons — now ACG’s official band (thanks for indulging us)! Listen to our version of the Beatles' classic, “A Little Help From My Friends” at bit.ly/beacons-little-help.

As we continue to grow, one thing will remain constant: our commitment to our membership and our values keeping the ACG a safe and welcoming place for all those interested in clinical GI. Please join me in making the ACG your professional home and growing together. Our home will be in fantastic hands come October 24, 2022, when I officially hand the reins over to Dr. Daniel Pambianco. We look forward to seeing you in person or virtually in Charlotte, NC, for our Annual Scientific Meeting where we will connect, collaborate, and celebrate together our mission of “Advancing Gastroenterology and Improving Patient Care.”

Like the TV show Cheers, “the ACG knows your name, and they’re always glad you came!”

“Home is not where you live, but where they understand you.” –Christian Morganstern And finally, some life/career advice (since this is my final piece as ACG President): “Be the change you wish to see in the world.”

–Mahatma Gandhi “Be yourself, no matter what they say.”

–Sting “Be bold.” –ACG President-Elect, Daniel Pambianco, MD, FACG

­­—Samir A. Shah, MD, FACG

Note hy wor t ACG MAGAZINE is proud to share professional news and celebrate the accomplishments of ACG members. Featured here are those honored by an NIH award and recognized by patient and professional organizations.

ACG Past President Dr. Edgar Achkar connected with Dr. Tyler Berzin who participated in a visiting professorship named in honor of Dr. Achkar.

Increasingly, ACG members are using social media effectively as advocates and educators, as is the notable case for Dr. Tauseef Ali, ACG’s PR Committee Chair. A team of social media ambassadors led by Dr. Joseph Sleiman, a fellow-in-training, are taking to Twitter each week to share the latest articles from ACG’s new publication, Evidence-Based GI. Send your news or story ideas to ACGmag@gi.org.

Novel & Noteworthy | 7

N&N GI EYE: ARTWORK FROM ACG MEMBERS

KA’ENA POINT TRAIL Sunset Hike, Oahu, Hawaii About the Location One of the prettiest sunset hikes on Oahu, Hawaii, the Ka’ena Point Trail, when taken along the northern approach, traverses through ocean spray and crosses wide swaths of seagrass, volcanic rock, and even sand dunes, to end at the westernmost point of Oahu in an albatross nesting sanctuary. From Ka’ena Point you can frequently see these majestic birds soaring overhead, encounter endangered monk seals resting, and frequently catch a humpback whale breaching off the coastline.

What equipment did you use?

Camera: Canon EOS 5D Mark IV, Lens: Sigma 24-35mm f/2 DG HSM Art Lens 24-35mm, ƒ/9.0, 1/320s, ISO 100, 4 Frame Panorama Stitched with Adobe Lightroom and Photoshop.

What captured your attention?

This was taken on a family hike, and if you note the small figures heading towards the setting sun in the middle of the frame, these are the silhouettes of my wife and four sons walking ahead of me as I captured this shot. Often known as “the traffic Isle,” Oahu, which is home to Honolulu and the famous Waikiki Beach, often has a reputation for being the least pretty of the Hawaiian Islands, as it is the most developed. However, beauty abounds everywhere in this tropical paradise that we are fortunate to call home. Ka’ena Point is certainly one of the best-kept secrets of Oahu and our favorite sunset hike on the island.

8 | GI.ORG/ACGMAGAZINE

Comment upon any technical challenges: It has been said that “the best camera is the one that you have on you,” and while I have resorted much more to using my iPhone for photos in recent years, none of my landscape photography has been achieved without the use of a dedicated DSLR camera. To capture the nuances of light and color and to allow for a wide framing of my shots, I usually take multiple sets of overlapping photos

in RAW and stitch them to panorama afterward. I shoot these images handheld because ocean shots must be captured quickly to be able to stitch waves together accurately. The challenge of not knowing when a great photo opportunity will come up means that I have spent many years hiking with a lot of camera gear on my back, but the photos and the memories of these hikes are well worth it.

Share your thoughts on the personal significance of this photo or photography in general, reflecting briefly upon why you pursue photography as a hobby and personal passion: I started landscape photography as a personal hobby during the ten years of my medical training at Mayo Clinic in Rochester, Minnesota. These photos served to commemorate the punctuated periods of family vacations against the busy and hectic life of medical training.

The photos I took serve as souvenirs that still adorn the walls of our home to remind us of the joy in the journey that we had. Now established in practice at The Queen’s Medical Center in Oahu, Hawaii, my photos continue to celebrate the happiness that our journey continues to bring, but highlights much of the beauty around us in the destination that we achieved. You can see my complete landscape panorama portfolio of our family’s adventures at: 500px.com/p/danchanphotography

Daniel K. Chan, MD, Medical Director of Gastroenterology, The Queen’s Medical Center, West O’ahu, HI. Dr. Chan lives in Oahu, HI, with his wife and four sons and enjoys spending time with them exploring the outdoors, cooking and eating, sports, movies, and playing cooperative video games.

Novel & Noteworthy | 9

// N&N

[GUT-BRAIN]

[PATIENT ADVOCATE]

DAVID J. LEVINTHAL, MD, PHD, of the University of Pittsburgh was awarded a National Institute of Neurological Disorders and Stroke (NINDS) R21 grant for his study entitled, “Characterization of Gastric Evoked Potentials.”

This grant provides two years of funding and will support Dr. Levinthal in using non-invasive methods of brain stimulation that can influence stomach function via the “gut-brain connection.”

Results from this study may provide a scientific foundation for future lines of work that could use transcranial magnetic stimulation-based methods of neuromodulation to treat a wide variety of chronic stomach disorders.

DR. TAUSEEF ALI, ACG’s Governor for Oklahoma and Chair of the ACG Public Relations Committee, was quoted in AMA News about his advocacy via social media on the challenges and frustrations of prior authorization.

Dr. Ali coined the hashtag #RespectMyPrescription and consistently advocates for patients in light of frustrating delays and denials. Follow Dr. Ali on Twitter @ibdtweets.  Read the article: bit.ly/ama-news-tauseef-ali

[EA AT EAVP]

EDGAR ACHKAR, MD, MACG, presents Tyler M. Berzin, MD, FACG, with a plaque for a program named in Dr. Achkar’s honor. Dr. Berzin’s talk at the Cleveland Clinic in April marked a return to the in-person experience of the Edgar Achkar Visiting Professorship, a program of the ACG Institute for Clinical Research and Education. Dr. Achkar, ACG Past President (2001-2002), also served as the Institute’s Director from 2004 to 2014.

[SUMMER SCHOLARS SPOTLIGHT]

THE SUMMER SCHOLARS PROGRAM is an initiative of the ACG Committee on Diversity, Equity & Inclusion that pairs medical students from groups underrepresented in medicine with mentors for a research project and provides a stipend of $5,000.

Under the leadership of DEI Committee Chair Sophie M. Balzora, MD, FACG, and the management of committee member Somaya Albhaisi, MD, “the program is a translation of the ACG's dedication to develop future leaders in GI by providing unique mentorship experiences,” according to Dr. Albhaisi.

Sophie M. Balzora, MD, FACG

Somaya Albhaisi, MD

This formalized mentorship and clinical research program is one pipeline to increase representation of underrepresented groups in medicine in academic GI careers. An 8- to 10-week structured clinical research experience for U.S. medical students connects them with mentors sharing similar clinical research interests. "The ACG Summer Scholars Program is emblematic of the mission of the ACG DEI Committee and the principles of the College – to cultivate and enrich the future of GI by providing opportunities for collaboration and mentorship that work to advance our field," commented Dr. Balzora.

"We’re so proud to see how the program has grown, and is supported and celebrated by the ACG."

[TWEETORIALS]

[KUDOS]

JOSEPH SLEIMAN, MD, a fellow-in-training at the University of Pittsburgh, is leading a group of trainees in a weekly social media blitz that puts the spotlight on ACG’s new member publication, Evidence-Based GI each Wednesday at 6 pm Eastern. You can see the educational tweets and topline insights by following ACG on Twitter @AmCollegeGastro and the hashtag #EBGI. To explore the new publication on the ACG website, visit gi.org/EBGI. Login is required for ACG members.

DR. NEILANJAN NANDI of the University of Pennsylvania received the Chair’s Citation Award from the Crohn’s and Colitis Foundation Philadelphia/Delaware Valley Chapter in June.

Dr. Neil Nandi recognized by The Crohn’s and Colitis Foundation

10 | GI.ORG/ACGMAGAZINE

Here is feedback from the three current ACG Summer Scholars and their faculty mentors:

Mentor: Helen Burton Murray, PhD, Massachusetts General Hospital “It is rewarding to have a mechanism that exposes aspiring gastroenterologists formally to biopsychosocial research early in their career—the future is bright for our field’s multidisciplinary efforts."

Daniel Huynh, Renaissance School of Medicine at Stony Brook University "I am grateful to have been selected as an ACG Summer Scholar. This opportunity has brought me a unique experience in gastroenterology and has allowed me to network and develop research skills pertinent to my career.

Mentorship has always been important to me and it's amazing that my mentors have dedicated so much time to train me."

Mentor: Christopher Vélez, MD, Massachusetts General Hospital/Harvard Medical School “Mentors at crucial stages in career development can have a profound influence on people's trajectories; I am so happy to participate as a mentor in the ACG Summer Scholars Program as it shows the College’s devotion to the development of the next generation of leaders in gastroenterology.”

[CONGRATULATIONS]

PATRICK E. YOUNG, MD, FACG, is now a Master of the American College of Physicians. Dr. Young serves as Chair of the College’s Board of Governors and Director of the Division of Digestive Diseases at the Uniformed Services University of Health Sciences. He is a gastroenterologist at Walter Reed National Military Medical Center who has been active in ACP for many years.

Working through The Picky Eater’s Recovery Book like sitting down is in a comfortable office with three the most skilled of and approachable ARFID clinicians the planet. Drs. on Thomas, Becker, and Eddy usher through a step-by-ste you p proven approach to broaden your food horizons and conquer your food fears.

THE PICKY EATER RECOVERY BOO ’S K

Joseph Chebueze, Lewis Katz School of Medicine at Temple University “The most meaningful part of my experience as an ACG Summer Scholar has been getting the opportunity to connect and work alongside doctors finding innovative ways to improve digestive health outcomes in vulnerable communities."

Are you a picky eater?

Do you worry that food will make you vomit or choke?

Do you find eating to be a chore?

If yes, this book is for you! Your struggles could be caused Avoidant/Restrictive by Food Intake Disorder (ARFID), a disorder characterized by eating a limited variety or volume You may have been of food. told that you eat like a child, but ARFID affects people right across the lifespan, and this book is specifically written the first to support adults.

Join the authors ARFID experts at – three Harvard Medical School – to learn beat your ARFID how to at home and unlock a healthier relationship with food. Real‑life examples show that you are not practical tips, quizzes, alone, while worksheets, and structured activities you step‑by‑step lead through the latest evidence‑based treatment techniques to support your recovery.

Thomas, Becker, and Eddy

Mentor: Sameer Prakash, DO, University of Iowa Carver College of Medicine "I have really enjoyed this wonderful opportunity with ACG's support to mentor and collaborate with motivated, hardworking students like Marie-Lise Chrysostome in gastroenterology research!”

THE PICKY EATER’S RECOVERY BOOK: OVERCOMING AVOIDANT/ RESTRICTIVE FOOD INTAKE DISORDER 9781108796170: Thomas, Becker, and Eddy: Cover: CMYK

Marie-Lise Chrysostome, Drexel University College of Medicine “This experience is so exciting because it is my first time performing research that contributes to the GI community, and I feel incredibly lucky to be doing so guided by Dr. Prakash and with the support of the ACG!”

[BOOK REVIEW] Jennifer J. Thomas , Kendra R. Becker, and Kamryn T. Eddy

THE PICKY EATER’S RECOVERY BOOK

Cynthia M. Bulik,

PhD, FAED, Distinguished Professor of Eating Disorders, University of North Carolina at Chapel Hill

Online Resources www.cambridge.org/ARFID

Downloadable worksheets from the book

Cover image: Dina Belenko Photography Moment / Getty / Images Cover design: Andrew Ward

UK £12.99 US $16.99

Overcoming Avoida nt/Restrictive Food Intake Disorde r

Jennifer J. Thomas, PhD; Kendra R. Becker, PhD; and Kamryn T. Eddy, PhD Cambridge University Press, 2021 Reviewed by Helen Burton Murray, PhD Avoidant/restrictive food intake disorder (ARFID) has been under the spotlight in GI over the last few years. A major concern about ARFID diagnosis in GI patients is that diet restriction can be a normative (and often prescribed) symptom management strategy. However, diet restriction can become a problem for a subset of individuals for whom eating becomes paired with anxiety or feels like a chore.

Consequent nutritional needs not being met, difficulties gaining weight (which does not necessarily mean being at a low body mass index), and/or impaired food-related quality of life are possible indicators for considering the role of ARFID—a problematic line that may be clearer in GI functional/motility disorders than in other GI conditions. I view ARFID recognition as only important if it gets a patient to a treatment that helps them.

If you have an adult patient who has become fearful of or has lost interest in eating, The Picky Eater’s Recovery Book may help. This new book makes evidence-based techniques accessible, set to help patients eat more flexibly, worry less about food, and get back to their lives. Leading ARFID experts Dr. Jennifer Thomas, Dr. Kendra Becker, and Dr. Kamryn Eddy link treatment techniques with relatable case examples (including one patient with ARFID in the context of celiac disease). The included prompts for patients to consider if the treatment is right for them may be particularly useful, such as, “Do you think making changes to your eating would make you healthier or happier?”

Dr. Helen Burton Murray is Director, GI Behavioral Health Program, Center for Neurointestinal Health and Staff Psychologist, Department of Psychiatry at Massachusetts General Hospital. She is an Assistant Professor of Psychology (Psychiatry) at Harvard Medical School.

Dr. Pat Young (third from left) with several military medicine colleagues at ACP in April.

Novel & Noteworthy | 11

ACG PRACTICE MANAGEMENT

Toolbox

NEW! Members Only

Billing & Coding FORUM

ACG’S

ACG members and GI practices continue to face mounting financial and reimbursement pressures. Complex coding and documentation requirements only add to these burdens. The ACG Practice Management Committee is pleased to announce the new member benefit: professional coding and documentation assistance for ACG members, tailored to your individual practice’s questions and needs.

HAVE A QUESTION? Email coding@gi.org

Arlene Morrow, CPC, CMM, CMSCS, is now available to answer your questions!

ACG members will receive an answer and guidance within a few business days.

Start Building Success Today gi.org/practice-management

12 | GI.ORG/ACGMAGAZINE

BRIEF SUMMARY: Before prescribing, please see Full Prescribing Information and Medication Guide for SUTAB® (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use.

INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon in preparation for colonoscopy in adults.

DOSAGE AND ADMINSTRATION: Split Dose (2-Day) Regimen: Dose 1 – On the day prior to colonoscopy: A low residue breakfast may be Packaging and consumed. After breakfast, only clear liquids may be consumed until after the tablets not shown colonoscopy. Early in the evening prior to colonoscopy, open one bottle of actual size.

12 tablets. Fill the provided container with 16 ounces of water (up to the fill line).

Swallow each tablet with a sip of water and drink the entire amount over 15 to 20 minutes. Approximately one hour after the last tablet is ingested, fill the provided container a second time with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Approximately 30 minutes after finishing the second container of water, fill the provided container with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Dose 2 - Day of colonoscopy: Continue to consume only clear liquids until after the colonoscopy. The morning of colonoscopy (5 to 8 hours prior to the colonoscopy and no sooner than 4 hours from starting Dose 1), open the second bottle of 12 tablets. Fill the provided container with 16 ounces of water (up to the fill line). Swallow each tablet with a sip of water and drink the entire amount over 15 to 20 minutes. Approximately one hour after the last tablet is ingested, fill the provided container a second time with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes.

Approximately 30 minutes after finishing the second container of water, fill the provided container with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Complete all SUTAB tablets and required water at least 2 hours before colonoscopy.

CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Serious Fluid and Electrolyte Abnormalities: Advise all patients to hydrate adequately before, during, and after the use of SUTAB. If a patient develops significant vomiting or signs of dehydration after taking SUTAB, consider performing post-colonoscopy lab tests (electrolytes, creatinine, and BUN). Fluid and electrolyte disturbances can lead to serious adverse events including cardiac arrhythmias, seizures and renal impairment. Correct fluid and electrolyte abnormalities before treatment with SUTAB. Use SUTAB with caution in patients with conditions, or who are using medications, that increase the risk for fluid and electrolyte disturbances or may increase the risk of adverse events of seizure, arrhythmias, and renal impairment; Cardiac arrhythmias: Use caution when prescribing SUTAB for patients at increased risk of arrhythmias (e.g., patients with a history of prolonged QT, uncontrolled arrhythmias, recent myocardial infarction, unstable angina, congestive heart failure, or cardiomyopathy). Consider pre-dose and post-colonoscopy ECGs in patients at increased risk of serious cardiac arrhythmias; Seizures: Use caution when prescribing SUTAB for patients with a history of seizures and in patients at increased risk of seizure, such as patients taking medications that lower the seizure threshold (e.g., tricyclic antidepressants), patients withdrawing from alcohol or benzodiazepines, or patients with known or suspected hyponatremia; Use in Patients with Risk of Renal Injury: Use SUTAB with caution in patients with impaired renal function or patients taking concomitant medications that may affect renal function (such as diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or non-steroidal anti-inflammatory drugs). These patients may be at risk for renal injury.

Advise these patients of the importance of adequate hydration with SUTAB and consider performing baseline and post-colonoscopy laboratory tests (electrolytes, creatinine, and BUN) in these patients; Colonic Mucosal Ulcerations and Ischemic Colitis: Osmotic laxative products may produce colonic mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Concurrent use of stimulant laxatives and SUTAB may increase these risks. Consider the potential for mucosal ulcerations resulting from the bowel preparation when interpreting colonoscopy findings in patients with known or suspect inflammatory bowel disease (IBD); Use in Patients with Significant Gastrointestinal Disease: If gastrointestinal obstruction or perforation is suspected, perform appropriate diagnostic studies to rule out these conditions before administering SUTAB. Use with caution in patients with severe active ulcerative colitis. ADVERSE REACTIONS: Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. POTENTIAL FOR DRUG ABSORPTION: SUTAB can reduce the absorption of other co-administered drugs. Administer oral medications at least one hour before starting each dose of SUTAB. Administer tetracycline and fluoroquinolone antibiotics, iron, digoxin, chlorpromazine, and penicillamine at least 2 hours before and not less than 6 hours after administration of each dose of SUTAB to avoid chelation with magnesium. Pregnancy: There are no available data on SUTAB use in pregnant women to evaluate for a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. No reproduction or developmental studies in animals have been conducted with sodium sulfate, magnesium sulfate, and potassium chloride (SUTAB). Lactation: There are no available data on the presence of SUTAB in human or animal milk, the effects on the breastfed child, or the effects on milk production.

Pediatric Use: Safety and effectiveness in pediatric patients has not been established. Geriatric Use: Of the 471 patients who received SUTAB in pivotal clinical trials, 150 (32%) were 65 years of age or older, and 25 (5%) were 75 years of age or older. No differences in safety or effectiveness of SUTAB were observed between geriatric patients and younger patients. Elderly patients are more likely to have decreased hepatic, renal or cardiac function and may be more susceptible to adverse reactions resulting from fluid and electrolyte abnormalities. STORAGE: Store at 20º to 25°C (68º to 77°F). Excursions permitted between 15º to 30°C (59º to 86°F). See USP controlled room temperature. Rx only. Manufactured by Braintree Laboratories, Inc. Braintree, MA 02185 See Full Prescribing Information and Medication Guide at SUTAB.com.

References: 1. SUTAB® [package insert]. Braintree, MA; 2020. 2. Di Palma JA, Bhandari R, Cleveland M, et al. A safety and efficacy comparison of a new sulfate-based tablet bowel preparation versus a PEG and ascorbate comparator in adult subjects undergoing colonoscopy. Am J Gastroenterol. Published online November 6, 2020. doi: 10.14309/ajg.0000000000001020 3. Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM; ACG. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol. 2009;104(3):739-750. 4. IQVIA. National Prescription Audit Report. November 2020.

For additional information, please call 1-800-874-6756 ©2021 Braintree Laboratories, Inc.

All rights reserved.

201-133-v1-A January 2021

Novel & Noteworthy | 13

!

W! E NEW N

A NEW TABLET CHOICE A BOWEL NEW TABLET CHOICE IN PREPARATION IN BOWEL PREPARATION

• NO SODIUM PHOSPHATE1

• SAFE AND EFFECTIVE1,2 1 • NO SODIUM PHOSPHATE • ACG-RECOMMENDED1,2 SPLIT-DOSE REGIMEN3 • SAFE AND EFFECTIVE 1 – Two SUTAB doses are required for a complete preparation

Dose 1 consists of 12 tablets and 16 oz of water REGIMEN3 • ACG-RECOMMENDED SPLIT-DOSE Dose 2 consists of 12 tablets and 16 oz of water 1 – Two are required for a complete preparation EachSUTAB dose isdoses followed by two additional 16 oz of water Dose 1 consists of 12 tablets and 16 oz of water Dose 2 consists of 12 tablets and 16 oz of water Packaging and tablets not shown size.

Each dose is followed by actual two additional 16 oz of water

92% OF PATIENTS IN TWO PIVOTAL TRIALS ACHIEVED SUCCESSFUL BOWEL CLEANSING WITH SUTAB1,2* 91% OF PATIENTS IN ONE PIVOTAL TRIAL RATED SUTAB AS TOLERABLE TO VERY EASY TO CONSUME2† 1,2 ® 1,2‡ 92% OF PATIENTS IN TWO PIVOTAL TRIALSreported ACHIEVED SUCCESSFUL CLEANSING SUTAB * • 52% of all SUTAB and MoviPrep patients at least one selectedBOWEL gastrointestinal adverseWITH reaction • More SUTAB patients reported experiencing nausea and vomiting than competitor, with ≤1%TO of these reports2† 91% OF PATIENTS IN ONE PIVOTAL TRIAL RATED SUTAB AS TOLERABLE TO VERY EASY CONSUME 2‡ Packaging and tablets not shown actual size.

considered severeand MoviPrep® patients reported at least one selected gastrointestinal adverse reaction1,2‡ • 52% of all SUTAB

2† 78% OF PATIENTS ONE reported PIVOTALexperiencing TRIAL WOULD REQUEST SUTAB AGAIN FOR A FUTURE • More SUTAB IN patients nausea and vomiting than competitor, with ≤1% ofCOLONOSCOPY these reports

considered severe * Success was primary endpoint and was defined in noninferiority trials as an overall cleaning assessment of 3 (good) or 4 (excellent) by the blinded endoscopist; scores were assigned on withdrawal of colonoscope.

OF PATIENTS IN ONE PIVOTAL TRIAL WOULD REQUEST SUTAB AGAIN FOR A FUTURE COLONOSCOPY2† † Patients completed preference questionnaire following completion of study drug to capture the subject’s perceptions of the preparation experience. This * questionnaire has not undergone formal validation.

Success was primary endpoint and was defined in noninferiority trials as an overall cleaning assessment of 3 (good) or 4 (excellent) by the blinded endoscopist; ‡ scores were assigned on withdrawal of colonoscope.

Patients were queried for selected gastrointestinal adverse reactions of upper abdominal pain, abdominal distension, nausea, and vomiting following completion †of study drug, rating the intensity as mild, moderate, or severe.

Patients completed preference questionnaire following completion of study drug to capture the subject’s perceptions of the preparation experience. This questionnaire has not undergone formal validation.

ACG=American College of Gastroenterology ‡ ® Patients were queried for selected gastrointestinal adverse reactions of upper abdominal pain, abdominal distension, nausea, and vomiting following completion is a registered trademark of Velinor AG. MoviPrep of study drug, rating the intensity as mild, moderate, or severe.

ACG=American College of Gastroenterology MoviPrep® is a registered trademark of Velinor AG. IMPORTANT SAFETY INFORMATION 2‡

78%

SUTAB® (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use is an osmotic laxative indicated for cleansing of the colon in preparation for colonoscopy in adults. DOSAGE AND ADMINSTRATION: A low residue breakfast may be consumed. After IMPORTANT SAFETY INFORMATION breakfast, only clear liquids may be consumed until after the colonoscopy. Administration of two doses of SUTAB (24 tablets) are required ® SUTAB (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use is an osmotic laxative indicated for cleansing of the for a complete preparation for colonoscopy. Twelve (12) tablets are equivalent to one dose. Water must be consumed with each dose colon in preparation for colonoscopy in adults. DOSAGE AND ADMINSTRATION: A low residue breakfast may be consumed. After of SUTAB and additional water must be consumed after each dose. Complete all SUTAB tablets and required water at least 2 hours breakfast, only clear liquids may be consumed until after the colonoscopy. Administration of two doses of SUTAB (24 tablets) are required before colonoscopy. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, for a complete preparation for colonoscopy. Twelve (12) tablets are equivalent to one dose. Water must be consumed with each dose bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Risk of fluid and electrolyte of SUTAB and additional water must be consumed after each dose. Complete all SUTAB tablets and required water at least 2 hours abnormalities: Encourage adequate hydration, assess concurrent medications and consider laboratory assessments prior to and after each before colonoscopy. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, use; Cardiac arrhythmias: Consider pre-dose and post-colonoscopy ECGs in patients at increased risk; Seizures: Use caution in patients bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Risk of fluid and electrolyte with a history of seizures and patients at increased risk of seizures, including medications that lower the seizure threshold; Patients with abnormalities: Encourage adequate hydration, assess concurrent medications and consider laboratory assessments prior to and after each renal impairment or taking concomitant medications that affect renal function: Use caution, ensure adequate hydration and consider use; Cardiac arrhythmias: Consider pre-dose and post-colonoscopy ECGs in patients at increased risk; Seizures: Use caution in patients laboratory testing; Suspected GI obstruction or perforation: Rule out the diagnosis before administration. ADVERSE REACTIONS: with a history of seizures and patients at increased risk of seizures, including medications that lower the seizure threshold; Patients with Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. DRUG renal impairment or taking concomitant medications that affect renal function: Use caution, ensure adequate hydration and consider INTERACTIONS: Drugs that increase risk of fluid and electrolyte imbalance. laboratory testing; Suspected GI obstruction or perforation: Rule out the diagnosis before administration. ADVERSE REACTIONS: Please see Brief Summary of Prescribing Information on reverse side. See Full Prescribing Information and Medication Guide at Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. DRUG SUTAB.com.

INTERACTIONS: Drugs that increase risk of fluid and electrolyte imbalance.

Please see Brief Summary of Prescribing Information on reverse side. See Full Prescribing Information and Medication Guide at SUTAB.com.

From the makers of SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution for adults—

THE #1 MOST PRESCRIBED, BRANDED BOWEL PREP KIT4

From the makers of SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution for adults—

THE #1 MOST PRESCRIBED, BRANDED BOWEL PREP KIT4

TRAINEE HUB

B:11.25"B:11.25"

S:9.75" S:9.75"

T:10.75"T:10.75"

Pearls & Perspectives on

Advanced IBD Fellowship By: Katie Dunleavy, MB BCh BAO, Second-Year GI Fellow, Mayo Clinic, Rochester. Editor: Shifa Umar, MD, Advanced Endoscopy Fellow, University of Chicago

WHILE LEARNING THE ART OF GASTROENTEROLOGY AND ENDOSCOPY, we spend time evaluating the types of patients we enjoy caring for, the sub-specialty we are most passionate about, and start to plan for our future careers. In this Q&A, Dr. Katie Dunleavy, secondyear GI fellow at Mayo Clinic, shares some tips for a career in the sub-specialty of inflammatory bowel disease (IBD). Through interviews with faculty and recent advanced IBD fellows, we get an inside look at this innovative, exciting, and rapidly changing field of IBD. — Dr. Katie Dunleavy & Dr. Shifa Umar

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

MUST DO’S WHEN APPLYING FOR AN ADVANCED IBD FELLOWSHIP 1. DON’T BE AFRAID to change paths! If IBD is your passion, take the leap, apply for Advanced IBD Fellowship.

2. IMMERSE yourself in all things IBD by attending conferences and joining GI societies as a trainee member.

3. LEARN through IBD educational opportunities (see ‘Essential IBD Resources').

4. DISCOVER a mentor and a sponsor, consider applying for the ACG mentorship program. Remember, peer mentors can be your closest allies.

5. LISTEN & READ to develop interesting research topics that put patients first.

Ask for opportunities to write and learn from IBD experts at/away from your institution.

6. SEEK OUT experiences that expose you to industry, insurance processes, diverse health systems, and IBD patient experiences in different countries/cultures.

These moments will make you a better IBD doctor!

7. MAKE YOUR PRESENCE KNOWN. Start by emailing programs during your second year of GI fellowship, reach out to current fellows, use social media to learn about research, and meet up with faculty at conferences!

8. PREPARE & APPLY. Update your CV, gather letters of recommendation, and present your physician story through your research and clinical interests and demonstrate how an IBD year will impact your career.

Fellow Responses Why pursue an Advanced IBD Fellowship?

“The additional clinical experience gained during this year has greatly expanded the knowledge base needed to take care of sick and complex patients with IBD. I would choose a program that complements one’s strengths and weaknesses while providing a diverse education.” – Sumona Bhattacharya, MD, Advanced IBD Fellow, NYU Langone

“I wanted to become an expert not just in IBD, but also in managing short bowel syndrome and intestinal failure. I structured my year to get extra experience with our inpatient nutrition support service and our home TPN program. The most complex IBD patients often have nutrition issues and I wanted to learn how to take care of these patients well.”

– Martin Gregory, MD, Advanced IBD Fellow, Barnes-Jewish Hospital/Washington University School of Medicine

“It was a great opportunity to gain more experience in complicated IBD cases learning from world experts. Most importantly, it gave me time to develop my research portfolio and identify a niche.” – Guilherme Piovezani Ramos, MD, Advanced IBD Fellow & Mayo Clinic Scholar, Mayo Clinic, Rochester

“IBD management has become increasingly difficult with its ever-increasing pharmacologic options as well as new dietary and surgical considerations. For those thinking about a career in inflammatory bowel disease, doing a year of advanced IBD fellowship can be truly transformative. I was fortunate to have incredible mentorship and dedicated research time that allowed me to conduct impactful research. Moreover, I was able to hone clinical skills and learn about the intricacies of management when it comes to complex situations such as refractory disease, surgical complications, and pregnancy considerations.” – Rishika Chugh, MD, Advanced IBD Fellow, University of California San Francisco

16 | GI.ORG/ACGMAGAZINE

Any advice for current Advanced IBD applicants?

“I recommend emailing the programs you are interested in as soon as you have made the decision to pursue this track (I started emailing in the middle of my second year GI fellowship).

In addition, ask your mentors to ask their colleagues about open positions, and follow Twitter for open positions. Having experience in IBD research as well as letters of recommendation from IBD faculty are helpful. I would recommend applying to 3 to 5 programs you are very interested in.” – Samantha Zullow, MD, Advanced IBD Fellow, Beth Israel Deaconess Medical Center

“Shoot for the stars! Don't rule out anywhere because it's a big name. I think midway through your second year you should start thinking about whether you want advanced IBD training.

Seek out guidance from multiple mentors, even outside your institution. Get involved in research projects early.” – Dr. Martin Gregory “Start early! As IBD advanced fellowship slots are outside The Match, they can fill fast — I began exploring options in early fall of my second year. In your application materials, highlight your commitment to IBD and what you hope to gain from the extra year of training.” – Katie Falloon, MD, Advanced IBD Fellow, Cleveland Clinic Foundation

How can GI fellows learn about how insurance impacts IBD care?

“The basics of prior authorization and appeal should be taught during fellowship so you are able to explain the process to your patients.

The most important thing is to keep pushing for what you and your patient feel is the best medication for them; continue to appeal and ask for peer-to-peers until there are no further options.” – Dr. Samantha Zullow “The first step is a shared decision-making conversation between a patient and provider about what type and route of medication is preferred, and the second is working through what medications will be approved by the insurance or covered at a cost that is not prohibitive. Since treating an IBD patient means getting the medication approved, rather than just prescribing it, I believe learning how to navigate insurance requirements and advocate for patients is an essential part of fellowship.” – Dr. Katie Falloon

Any tips for finding an IBD-focused job?

“Make sure you know what administrative support you are getting. Salary is important, but there is so much administrative work in taking care of IBD patients that you can get buried easily. Location, culture, protected time, quality of other providers, cost of living, proximity to family are all important. You finally get to choose where you want to go.”

– Dr. Martin Gregory

“If you’re looking for an academic position, have your mentor reach out to IBD specialists at your target institutions to determine if they are looking for IBD-focused physicians. For private practice positions, get in touch with former colleagues from your institution who have gone into private practice to learn about their experience.” – Dr. Samantha Zullow

Faculty Responses Why did you choose IBD? “Because IBD is a chronic condition, it allows me to form long-lasting bonds with my patients, which for me is very gratifying. You get to see them at their worst and their best, during very special milestones of their lives and be a part of that. Specializing in IBD also allows me to combine the cerebral parts of medicine with the more manual parts, i.e., endoscopy, which helps to break up my work week.”

– Sunanda V. Kane, MD, MSPH, FACG, ACG Past President (2018-2019), Mayo Clinic, Rochester, MN

“During my residency training, I was drawn to gastroenterology.

But I always thought, 'where are the patients with IBD?' The lack of representation of these patients in my training experience absolutely played a role. But at the heart of that curiosity was having close people around me who suffered from IBD and seeing their suffering from a personal perspective definitely drove me towards wanting to get a better understanding of how to help patients with IBD live better.”

– Sophie M. Balzora, MD, FACG, Clinical Associate Professor of Medicine, NYU Grossman School of Medicine, Division of Gastroenterology and Hepatology, NYU Langone Health

“I was originally going to specialize in infectious disease after internal medicine residency. I was selected to be a Chief Resident at University of Chicago and was accepted into the infectious disease

fellowship and would start after 2.5 years of internal medicine residency. However, in my last two months of IM training, I was assigned to GI and began working with Dr. Joseph Kirsner. We bonded and, by the end of November, I “saw the light”! At that time, it was behind a proctoscope. I asked to give up the ID fellowship and Chief Residency to start GI and Dr. Kirsner convinced the powers-thatbe to allow me to do GI. Pierce Gardner, the ID fellowship director and Chief Resident director, stated one of the most influential comments to me that he was "there to facilitate my career, not direct it.” In GI fellowship, I spent time on the “K” service with Dr. Kirsner where he focused on IBD because NO ONE ELSE wanted to take care of the complex patients. I would spend extra time with the patients, often holding ‘seances’ during the evening with patients, hearing their concerns. Many patients were admitted for TPN and were in the hospital for weeks at a time. I became a ‘cheerleader’ for the patients who had to deal with chronic, embarrassing, and disabling symptoms. I remain a ‘cheerleader’ and supporter, showing compassion for their lives with embarrassing/ disfiguring disease starting as teenagers. I have had the privilege of being part of their lives and families over decades, and now take care of their parents and children who have developed IBD.” – Stephen B. Hanauer, MD, MACG, Professor of Medicine, Northwestern University Feinberg School of Medicine, ACG Past President (2016-2017)

How early in GI fellowship do we need to decide about advanced fellowship or future careers?

“The luxury of our profession is that one can always change their mind based on their preference, values, and circumstance.

I encourage fellows, as early as their first year, to explore all types of opportunities and to chat with people not only in academics or private practice, but also other less traditional career avenues like industry, advocacy, administrative, or a combination of all of these. What our careers 'look like’ has changed over time, and it's exciting to see.” – Dr. Sophie Balzora



ESSENTIAL IBD RESOURCES EDUCATION: • IBD 101 – A one-day educational course for 1st year GI fellows brought to you by NYU Langone and ACG to learn about the basics of IBD • Crohn’s & Colitis Foundation Visiting IBD Fellow – Accepts qualified gastroenterology 2nd & 3rd year fellows for a one-month, (most) expenses-paid observation at a leading IBD center • The MILESTONE initiative (Merging IBD Leaders Education to Standardize Training, Organize Networks, and Implement EPAs) – Education Innovation for Advanced IBD Fellows in the USA • Cornerstones IBD Xcel – Annual program designed for gastroenterologists within five years post-completion of their fellowship training • IBD Live – Weekly IBD case conference from Cleveland Clinic with participants from all over the world

TWITTER is the preferred social media platform for most gastroenterologists, and there are many opportunities to collaborate, share research/ data, attend educational webinars and network with IBD experts around the world.

• @ibdclub – Dr. Tauseef Ali’s virtual journal club focused on critical appraisal of clinical studies and research in the field of IBD • @MondayNightIBD – Dr. Aline Charabaty’s weekly session on IBD basics, advanced conversations with experts, and a focus on patient experience

“There’s no absolute cutoff and everyone’s path is a bit different but, typically, having some idea by the end of first year GI fellowship would be helpful. Applications for an advanced IBD fellowship occur early within second

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year, so having an idea about academics (research or clinical), or private practice can help you choose the right program and path.” – Adam Faye, MD, MS, Assistant Professor of Medicine & Population Health, IBD Center at NYU Langone

“Early in the second year, you should start exploring and understanding what type of practice suits you. I had to jump from academic practice to private practice and now run my IBD clinical practice very successfully in a private health care system.

Unfortunately, there is a significant disparity between academic and private practices in the United States. Unless fellows rotate through community practices and learn about them, their experiences and impression about private practices are typically limited as they are being taught by academic institutions.”

– Tauseef Ali, MD, FACG, Executive Medical Director, SSM Health Digestive Institute, SSM Health Crohn's and Colitis Center, Oklahoma City, OK

“I would encourage fellows to spend their first year learning clinical gastroenterology and hepatology and focusing on that. In the second year, with increasing elective and outpatient time, the fellow should really be considering their career trajectory and ensuring they have access to appropriate sub-specialty and research training, if appropriate.”

– Millie D. Long, MD, MPH, FACG, Director, Gastroenterology and Hepatology Fellowship Program, University of North Carolina at Chapel Hill, Co-Editor-inChief, The American Journal of Gastroenterology

“I decided late in medicine training for GI and then IBD. Frankly, I do not believe that fellows entering training will know their ultimate sub-specialty interests. I have written on this.* Every single fellow applying for GI training states they want 'academic medicine.'

This is because all they have been exposed to in college/medical school is in an academic setting. However, once they are accepted, things change. They

18 | GI.ORG/ACGMAGAZINE

are often in debt, are married, have children and expenses, and are seeing very high salaries in private practices compared with academic programs. Many academicians have become discouraged by RVUs or the distractions of research/writing; as Dan Podolsky states, your publications are 'the coin of the realm' in academics. But these take away from leisure and family time. A mentor from medical school would describe how students would be 'chromatographed' into their various careers. I have also taught around the globe and lectured to academicians and private groups. Traveling, I see that individuals are motivated by different things (not just money), and no two doctors have the same 'life agenda.'

GI offers the entire spectrum, including cognitive and procedural skills.”

– Dr. Stephen Hanauer *Hanauer, S. Another one bites the dust. Nat Rev Gastroenterol Hepatol 2, 435 (2005). https://doi.org/10.1038/ncpgasthep0295

Is an IBD Advanced Fellowship year essential for GI fellows hoping to work in IBD? “I might have been on the fence if someone had asked this question a few years back. Now I feel like it is critical to receive advanced training in IBD to develop a solid understanding of these disorders and take care of these patients more comprehensively and precisely.

Unless you work in an IBD center with the ability to have on-the-job training and learning opportunities, IBD fellowship training can help you clinically and academically. You will be able to take care of patients with enhanced learning, and job market opportunities will also be better for you when finding a job in competitive academic and private health care systems.” – Dr. Tauseef Ali “I think this truly depends on what your long-term career goals are, as well as where you’ve completed your GI fellowship training and how robust your IBD clinical experience was. Regardless, I genuinely believe the Advanced IBD fellowship provides invaluable opportunities to not only enhance your clinical skills and acumen in managing complex disease at centers of excellence but gives you the opportunity to participate in clinical trials and IBD research, as well as network and collaborate with internationally renowned experts in the

field. Having Advanced IBD training is becoming more coveted by both academic centers and private practices and will open many doors for you and your career, so if your goal is to have an IBD-focused clinical practice and/or participate in clinical trials/grantfunded investigator-initiated research or even work with industry, I’d strongly encourage pursuing an IBD fellowship.”

– Joshua M. Steinberg, MD, Gastroenterology of the Rockies

Is there a standard curriculum among IBD fellowship programs?

“Although there is not necessarily a universal curriculum for IBD fellowships, there has been a concerted effort by IBD fellowship program directors/faculty to establish milestones and curriculum across fellowship programs (see paper

by Ben Cohen and colleagues).* In addition, there are various Advanced IBD Fellow-centered meeting/events and educational conferences where fellows and faculty across many institutions meet to share research, collaborate, and learn throughout the academic year.” – Dr. Joshua Steinberg *Cohen BL, Gallinger ZR, Ha C, Holubar SD, Hou JK, Kinnucan J, Mahadevan U, Moss AC, Raffals LE, Regueiro M, Szigethy E, Wolf D, Dubinsky MC, Patel A, Shah BJ, Ehrlich OG, Hanauer SB. Development of Entrustable Professional Activities for Advanced Inflammatory Bowel Disease Fellowship Training in the United States. Inflamm Bowel Dis. 2020 Aug 20;26(9):12911305. doi: 10.1093/ibd/izaa177. PMID: 32820340.

What advice would you give to GI fellows interested in IBD? “When seeing patients with IBD in clinic, remember that there are always two experts in the room. You bring your expertise about these diseases and management, and patients bring their expertise about living with Crohn's disease or ulcerative colitis. Ask questions and listen to your patients — they will be the ones to teach you far more about IBD than any book chapter or manuscript.”

– Corey A. Siegel, MD, MS, Section Chief, Gastroenterology and Hepatology, Co-Director, Inflammatory Bowel Disease Center, Constantine and Joyce Hampers Professor of Medicine, Geisel School of Medicine at Dartmouth

“Read, read, and read more, to understand where you might be able to find an interesting question that you want to answer in your research time during your fellowship. Ask for opportunities to write! If you don’t ask, we do not know you are interested.

Many of us get asked to write reviews, editorials, book chapters, and just don’t have the time without a junior person helping us.” – Dr. Sunanda Kane Would you recommend North America-based fellows to consider international fellowships or electives?

“If you can study abroad, do it! How IBD is managed in countries that don’t have private insurance to deal with, i.e., national health insurance, will be eye-opening. Just getting to see how other cultures think about their disease also could help you better understand how to treat your own patients.” – Dr. Sunanda Kane “Absolutely. With the globalization of health care, it becomes prudent for North American fellows to receive international training whenever the opportunity arises. This is especially important in the care of IBD patients to learn new diagnostic techniques (such as bedside intestinal ultrasound), unique phenotypes of different patients from various parts of the world, and their response to therapy. This is all extremely helpful when we take care of a diverse patient population in the United States.” – Dr. Tauseef Ali How can GI fellows leverage mentorship to help their future careers?

“The mentee-mentor relationship can be a sacred, fulfilling one when the match is ideal. Mentors can serve as soundboards, sponsors, and advocates, depending on the situation. Thoughtful advice and critique can be hard to find, especially as we advance in our career, and having a mentor that is invested and honest is gold.” – Dr. Sophie Balzora “Having different mentors to guide and help through different aspects of career and life — clinical work, research, equity, health, to name a few — is helpful.

Learning from different perspectives

and experiences will help develop one's own. Peer mentorship is critical. In my opinion, colleagues and friends are our most valuable resource and collaboration is key.”

– Manasi Agrawal, MD, MS, Assistant Professor of Medicine, The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai

“Definitely reach out to faculty early on both at your institution and beyond. Faculty are always willing to make time and happy to help in any way possible. If you have a sense of your goals and 10-year timeline, they can help mentor you or connect you with others who may align more closely with what you are looking for. Also, having several mentors is often essential, including outside of GI, depending on your interests.”

– Dr. Adam Faye

“I would encourage GI fellows to participate in the mentoring programs available through the national GI organizations, such as the ACG’s mentoring program. I would also encourage fellows to join the IBD Circle, sponsored by the ACG and the Crohn’s and Colitis Foundation. This involvement opens doors to participation in the national societies.” – Dr. Millie Long “Mentorship is a two-way street. Both mentors and mentees should gain from the experience. I look at myself as a ‘sweeper’ in the sport of curling. The mentee needs to tell me the ‘targets’ they want, and my job is to sweep the path in front of them to allow them to ‘hit their targets.’ But each fellow has a different target, each one being relevant for their lives/families/careers (the ordering is intentional).”

– Dr. Stephen B. Hanauer

Dr. Dunleavy – Dr. Katie Dunleavy is a secondyear gastroenterology and hepatology fellow at Mayo Clinic, Rochester. She received her medical degree from the Royal College of Surgeons in Ireland and completed her internal medicine residency at Icahn School of Medicine at Mount Sinai Hospital in New York. Her area of clinical interests includes the overlap of inflammatory bowel disease and neurogastroenterology, ergonomics in endoscopy, and clinical trials research. She is passionate about academic medical education and, as a former coloratura soprano, she mentors several students with interests in music and medicine. On the weekends you can find her at the farmer’s market, singing, and doing yoga.

Dr. Umar – Dr. Umar is an Advanced Endoscopy fellow at the University of Chicago and a member of the ACG Digital Communications & Publications Committee and the ACG Diversity, Equity & Inclusion Committee. Dr. Umar was one of the ACG Institute’s Young Physician Leadership Scholars in 2021 and 2022.



CONTRIBUTORS FELLOWS

• Sumona Bhattacharya, MD, Advanced IBD Fellow, NYU Langone • Rishika Chugh, MD, Advanced IBD Fellow, University of California San Francisco • Katie Falloon, MD, Advanced IBD Fellow, Cleveland Clinic Foundation • Martin Gregory, MD, Advanced IBD Fellow, Barnes-Jewish Hospital/ Washington University School of Medicine • Guilherme Piovezani Ramos, MD, Advanced IBD Fellow & Mayo Clinic Scholar, Mayo Clinic, Rochester • Samantha Zullow, MD, Advanced IBD Fellow, Beth Israel Deaconess Medical Center

FACULTY • Manasi Agrawal, MD, MS, Assistant Professor of Medicine, The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai • Tauseef Ali, MD, FACG, Executive Medical Director, SSM Health Digestive Institute, SSM Health Crohn's and Colitis Center, Oklahoma City, OK • Sophie M. Balzora, MD, FACG, Clinical Associate Professor of Medicine, NYU Grossman School of Medicine, Division of Gastroenterology and Hepatology, NYU Langone Health • Adam S. Faye, MD, MS, Assistant Professor of Medicine & Population Health, IBD Center at NYU Langone • Stephen B. Hanauer, MD, MACG, Professor of Medicine, Northwestern University Feinberg School of Medicine, ACG Past President (2016-2017) • Sunanda V. Kane, MD, MSPH, FACG, ACG Past President (2018-2019), Mayo Clinic, Rochester, MN • Millie D. Long MD, MPH, FACG, Director, Gastroenterology and Hepatology Fellowship Program, University of North Carolina at Chapel Hill, Co-Editor-in-Chief, The American Journal of Gastroenterology • Corey A. Siegel, MD, MS, Section Chief, Gastroenterology and Hepatology, Co-Director, Inflammatory Bowel Disease Center, Constantine and Joyce Hampers Professor of Medicine, Geisel School of Medicine at Dartmouth • Joshua M. Steinberg, MD, Gastroenterology of the Rockies

Trainee Hub | 19

ACG VIRTUAL GRAND ROUNDS Weekly on Thursdays at 12 pm and 8 pm ET Live Presentation by an ACG Expert Plus Q & A #GIhomeschooling

https://gi.org/acgvgr

https://gi.org/acgvgr

https://gi.org/acgvgr

Even as all aspects of practice have changed due to COVID-19, your need to stay up to date on clinical GI does not stop. ACG is committed to your professional education. Our goal is to help the GI community embrace #GIhomeschooling with quality speakers and presentations.

ACG has launched Virtual Grand Rounds weekly on Thursdays at 12 pm and 8 pm ET. Each week an expert faculty member will present live on a key topic followed

by Q & A.

 Learn More and Register: GI.ORG/ACGVGR

20 | GI.ORG/ACGMAGAZINE

GETTING IT WHY DO WE NEED A PRIOR AUTHORIZATION TOOLBOX?

Tools to Help

Manage Prior Authorization:

Concepts to Help Decrease the Hurdles!

Stephen T. Amann, MD, FACG, One GI, Tupelo, MS and Shabana F. Pasha, MD, FACG, Mayo Clinic Arizona, Scottsdale, AZ, ACG Prior Authorization Task Force

 THE PRIOR AUTHORIZATION (PA) QUAGMIRE CONTINUES to impact our ability to care for our patients, erodes the physician-patient relationship, and has expanded far beyond its original intent.

Health plans are likely to continue to use this process to control resource utilization and drug spending. PA has a significant impact on physician practices. More importantly, the delay in care is harmful to our patients.

Based on feedback from the ACG Board of Governors, the ACG Practice Management Committee, and members across the United States, the ACG Legislative & Public Policy Council created a survey to gauge the burden of prior authorizations in gastroenterology. Over 150 ACG physicians from 43 states and Puerto Rico highlight the significant

Getting it Right | 21

// GETTING IT RIGHT

problems that PA causes for patient care and our practices. For example, the survey found that over 50 percent of respondents cited at least one serious adverse event due to PA delays.

The ACG has therefore formed a Task Force to create resources for members, with the goals of obtaining approval for therapies chosen by ACG members in concert with their patients, as well as easing the significant administrative and practice management burdens during the PA process.

IMPACT OF PRIOR AUTHORIZATION: Prior authorization is a cost control process by which providers must obtain approval from a health plan before a specific therapy or service will be covered. Other terms for PA include preauthorization, precertification, prior approval, prior notification, prospective review, and prior review. PA was introduced by payers as a strategy to reduce utilization of overused or low value services, reduce costs of healthcare, ensure high-quality evidence-based care, and protect patient safety. However, it has evolved into a cumbersome and redundant process that impacts patient care and significantly adds to health care providers’ administrative burden.

A recent U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) report found issues the with Medicare Advantage process for prior authorization. Medicare Advantage Organizations (MAOs) sometimes delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules. MAOs also denied payments to providers for some services that met both Medicare coverage and billing rules. The OIG noted that “denying requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers.” This recent HHS OIG report echoes a similar HHS OIG report in 2018. Highlights of the 2018 report include: • When beneficiaries and providers appealed preauthorization and

22 | GI.ORG/ACGMAGAZINE

payment denials, insurers overturned 75 percent of their own denials from 2014-2016, overturning approximately 216,000 denials each year.

• This is especially concerning because beneficiaries and providers rarely used the appeals process, which is designed to ensure access to care and payment.

During 2014-2016, Medicare beneficiaries and providers appealed only 1 percent of denials to the first level of appeal.

All payers have utilization management programs to help limit drug spending and overutilization of services under the stated goal of “appropriate care for patients.” These determinations are reviewed internally and can be proprietary.

However, insurers may have a coverage determination process and explain the rationale for any PA policy. It is important to participate in this process when available.

Gastroenterologists face growing challenges with PA requirements for inflammatory bowel disease (IBD) biologics and other prescription medications, radiologic tests, as well as endoscopic and motility procedures. In addition to the increasing denials raised by ACG members, “step therapy” or fail first policies are also used to require lower cost medications prior to more expensive medications/biologics, often resulting in delayed care and worse outcomes. Lack of a standardized process and different submissions among the different payers only add to this administrative burden and complexity.

This article is designed to offer useful tools and suggestions to facilitate timely approval of therapies for your patients.

TIPS & TRICKS: 1. GET IT RIGHT THE FIRST TIME: Take time upfront to submit all requirements. It is much easier to get PA the first time around than go through the appeals process.

2. DOCUMENTATION IS KEY: Clearly list the indication, prior failed medication(s), and reasons why medication failed, as well as the clinical rationale for choosing the desired medication/test.

3. PROVIDE SUPPORTING EVIDENCE: Make sure to provide the treatment guidelines and references that support your choice of medication/dosing/test.

Guidelines are especially important.

Then provide other important literature/supporting evidence.

4. TRAIN YOUR PA TEAM: It is important to have a pharmacy technician/manager who can initiate the PA process and is familiar with the appeals process among the different payers.

5. AUTOMATE THE PROCESS: According to the ACG survey, the average number of PA requests gastroenterologists must deal with on a weekly basis is 14. An automated process will help to save time and effort without reinventing the wheel for each request/appeal.

6. PREPARE FOR PEER-TO-PEER: Request this as soon as possible but recognize this consultation may be with a non-GI provider. Be well prepared to support your request.

7. MULTIPLE APPEALS CAN WORK: Don’t give up if it’s the right medication/test for your patient!

Your patient can participate in the appeals process as well.

STEP-BY-STEP GUIDE: • For medical services, check the payer’s PA requirements prior to providing the service, if possible.

This will help with denials and lost payments.

• Formulate an office protocol to routinely document data and medical necessity requirements for the PA. • The PA office team should educate providers on key elements and terms to help in this process.

Be sure to use EHR common terminology to make this more efficient. For example, in patients with IBD, note the severity and scale of disease, associated extraintestinal disease effects, and other comorbidities and treatment failures. See Table 1.

• You can use ACG’s recent Practice Management Toolbox article on how to create EHR documentation/terminology shortcuts: bit.ly/pm-toolboxhighlights-2022.

• If possible, consider an automated process for PAs.

• Electronic PA submissions • eRx for use with e-prescribing • Do not settle when other drugs are contraindicated in certain situations.

• Use the payer portals • There may be limited availability, portals can be payer-specific, and not in the usual office workflow • Use multi-payer portals if available • Typical methods are slow, time consuming, inefficient, and include fax, phone, and email • Keep and record all phone calls and faxed PA documents, with date and time stamps • Record full name of payer personnel with whom you met, as well as the date and time • Follow up regularly on the process and document this follow-up • Encourage staff to use EHR reminders • Inappropriate denials • Submit a concise appeal with supporting clinical information (see below) • If denied the first time, resubmit the appeal • Peer-to-Peer • This remains the most contentious issue. These calls are often not set up based on your availability, but instead, require you to wait until the “reviewer” is available. The reviewer may not have the myriad of documents you have already submitted as part of your review. In addition, they are not likely to be in the same specialty as you. According to the ACG survey, the average number of peer-to-peer consultations with a gastroenterologist over the span of a week was zero.

• Ensure you are familiar with the patient chart and case.

• Make sure to use the clinical guidelines to support your request. Know the guidelines and quote the relevant recommendations/references during this call.

• However, if the guidelines are not applicable, state the specific reasons why your patient's condition does not strictly fit the guidelines, such as comorbidities or overlap diseases. Be prepared to support this course of treatment.

• You can ask for a specialty review by a gastroenterologist in your appeals, but

please note, this may further delay treatment. Thus, plan ahead.

• Request the reviewer’s name and document every conversation in the patient chart/notes.

• Be firm but cordial.

• Request the medical literature and/or guidelines the reviewer used in any denial.

• Your letters can ask for a timeframe or date by which you/ your patient needs this decision.

TABLE 1. Typical Information for EMR Documentation Date and method of diagnosis Disease severity and use accepted descriptors, severity, or stage from accepted guidelines Treatment failures or side effects of prior treatments, if known, in brief narrative Document good outcome on current therapies or treatment

FOR PRIOR AUTHORIZATION DENIALS AND REQUESTS FOR LETTERS/FURTHER DOCUMENTATION In addition to the information included in Table 1, also consider: • Keep the narrative brief and be concise.

• Cite clinical practice guidelines to support the treatment plan whenever possible. Conversely, be prepared to discuss why guidelines are inapplicable in this case.

• Detail why the patient should be on the specific agent/drug or test.

• Describe why the specific therapy is the preferred therapy and why other agents are not helpful, contraindicated, or have side effects.

• If you are looking for approval of off-label use, you must describe why and provide supporting evidence.

Stephen T. Amann, MD, FACG Dr. Amann is a gastroenterologist at One GI in Tupelo, MS who serves as Chair of ACG’s Practice Management Committee and a member of the ACG Legislative and Public Policy Council.

• Detail the contraindications when switching a current therapy, as well as the risks associated in any with a switch in therapy.

• Use peer-reviewed articles as support (use more than 1 article).

CONCLUSION Please encourage your patients to get involved in the process, have them engage their primary care or any other providers, ask them to engage their employer’s human resources (HR) departments, and contact your state insurance commissioner, as well as federal/state representatives. The PA process is not likely to go away. It is paramount that we, as physicians, continue to be staunch advocates for our patients’ needs.

ADDITIONAL GUIDANCE The list of ACG guidelines can be found here: gi.org/guidelines In addition to the ACG guidelines, other guidelines and medical literature: • American Association for the Study of Liver Disease (AASLD) guidelines: aasld.org/publications/ practice-guidelines • American Gastroenterological Association (AGA) guidelines: gastro.org/clinical-guidance/ • American Society for Gastrointestinal Endoscopy (ASGE) guidelines: asge.org/home/ resources/key-resources/guidelines • National Institutes of Health (NIH) PubMed: pubmed.ncbi.nlm.nih.gov/ • World Gastroenterology Organisation (WGO) guidelines: worldgastroenterology.org/guidelines

Shabana F. Pasha, MD, FACG Dr. Pasha is Professor of Medicine at Mayo Clinic Arizona and currently serves as the ACG Governor for Arizona and on ACG’s International Relations Committee

Getting it Right | 23

// GETTING IT RIGHT: LAW MIND

Addressing Your Real Worth: How to counter inflationary impacts on your take home pay By Ann Bittinger, Esq. Ann M. Bittinger, Esq. is an attorney with The Bittinger Law Firm who specializes in advising healthcare entities in their business transactions. She can be reached at ann@bittingerlaw.com.

Inflation has outpaced gastroenterologists’ compensation this year and in years past, according to some sources. The United States' annual inflation rate was 9.1 percent for the 12 months that ended in June 2022, according to U.S. Labor Department data published July 13, 2022. That was the largest annual increase since November 1981.

Although Medscape’s Salary Survey published in April 2022 shows that gastroenterologists’ salaries increased by 12 percent between 2020 and 2021 to an average of $453,000, MGMA’s Data Dive shows that from 2019 to 2021, gastroenterologists’ median total compensation has risen only two to four percent per year. The median total compensation for gastroenterologists was $539,000 in 2020, increasing only four percent to $561,000, per MGMA. Another report, Doximity’s 2021 Physician Compensation Report released in

24 | GI.ORG/ACGMAGAZINE

December 2021, stated that in the last year gastroenterologists’ average compensation increased 3 percent, from $485,817 to $500,400.

If your compensation isn’t keeping up with inflation, what do you do?

Addressing inflation can be a challenge in a system in which physicians’ pay increases only if physicians bill for more services. You have to work harder to make more, and have to work magnitudes harder to make up for inflation. If you don’t do something, your spending power will suffer.

The Employer’s Perspective. To fix your compensation to adjust for inflation, it’s helpful to put yourself in your employer’s position. Your employer likely did not factor for eight percent inflation in its 2022 budget. It may or may not be collecting more money, yet its equipment and materials costs have likely risen. The employer’s revenues are likely locked in to payer contract fixedfee schedule formulas and amounts, as well as Medicare and Medicare fixed rates per CPT code.

To overcome these obstacles, you must emphasize your leverage. Are you dispensable to your organization or will the organization make concessions to keep you as an employee? Acknowledge the phenomenon called the Great Resignation — the high number of physicians who are dissatisfied with work-life balance, compensation, and high stress and have decided to leave their jobs for another. There is nothing wrong with looking at the withoutcause termination provision in your contract and speaking with your employer about the fact that you can leave for no reason with just a few months’ notice. (Most physician employment agreements allow the physician to terminate without cause so long as a few months’ notice [generally 30 to 90 days] is given). That’s tremendous leverage in many organizations. Before having that discussion, however, plan any potential offboarding by getting advice from a healthcare attorney about your non-compete, tail insurance, loan repayment, bonus timing, and other offboarding issues.

The usual objection by employers to a physician compensation increase is that they need to get their compliance department to approve the increase. Their concern is that your increase could be construed as a kickback in exchange for referral of cases or patients elsewhere in the employer’s health system, which could violate the federal criminal Anti-Kickback Statute. You can counter that by saying that you know that fair market value is a range, not one figure, and that you are asking for a slight increase that is likely within the fair market value range for your position, experience and specialty. Use of market indicators like the surveys discussed above is also persuasive.

The most frequently used objection by employers is that of uniformity. They argue that the conversion factor (or bonus collections threshold or some other factor) is uniform among all gastroenterologists they employ. One approach to that is to explain how you are unique and therefore need a unique factor applied to your pay. Often, though, you have to find another way to get the increase, by adding or changing a nonuniform factor, like those discussed below.

Educate Yourself. One approach is to make an argument that, regardless of inflation, your compensation doesn’t reflect the fair market value for your services. One way to do this is to consult with a physician

mind escalator clauses tied to the government’s COLA index — are few and far between. This can be very problematic in the physician employment realm, as many contracts are for a term of two to five years. Many perpetually renew (what we call an “Evergreen Clause”) until one party affirmatively terminates the agreement.

You could be locked into a flat base salary for years as inflation increases 8 or more percent.

employment agreement attorney or other consultant who has access to objective, third-party survey data like the MGMA Data Dive. With that access, the attorney can analyze the data and produce a report indicating fair pay for your location, practice setting, experience, and skills. With that data, you are armed to meet with the physician enterprise leaders to make the case for a higher compensation. A good attorney will assist you in making the case using not just the data but also your unique contributions to the organization, creatively maximizing any leverage you may have to promote a mutually beneficial solution. In exchange for a 4 percent annual increase in your base salary, for example, you might agree to extend the term for an additional two years.

Questions that a good attorney will walk you through after analyzing your contract: • Is your base salary in line with the threshold wRVUs or collections for a bonus?

• Is the conversion factor an amount appropriate for your specialty and other components of your compensation package?

• Does your compensation formula grow as you become more productive?

• What non-productivity factors impact your take home pay?

Also educate yourself on your worth to the organization. Do you analyze your monthly productivity reports? Do you compare your metrics to your colleagues? Are you the top performer of a certain procedure that is important to the practice? Do you add value in non-financial ways? Can you develop and articulate to your employer a plan for improvement to make yourself more productive without costing the employer more than your salary increase?

An Easy Fix? Another option is to try to negotiate an “escalator clause” into your employment agreement.

An escalator would be something like: “The Base Salary shall increase by three percent (3%) per year” or “The Base Salary shall increase by the Cost of Living Adjustment (“COLA”) Index published by the Labor Department for the 12 months prior to the renewal date of this Agreement.”

Another escalator approach is to tie it to the dollars-per-wRVU that may appear in your productivity compensation formula rather than to a base salary. Most of these formulas pay a certain amount of money per wRVU that you earn. This number is often referred to as the “conversion factor.”

In your employment agreement it may look something like: “For each wRVU generated over 3,000, you will receive $40/wRVU (the “Conversion Factor”) per fiscal year.” You could add that “the Conversion Factor will increase by four percent (4%) each fiscal year.”

As someone who reviews hundreds of physician employment agreements, escalator clauses — never

“One approach

is to make an argument that, regardless of inflation, your compensation doesn’t reflect the fair market value for your services.”

A Fix. Sometimes the best approach is the simplest.

Ask for a retention bonus. This is a one-time payment to you not for quality metrics or productivity, but simply to keep you employed there in light of things like the impact inflation has caused to your agreement.

It can be phrased as a retention bonus for reaching a milestone year. I frequently see retention bonuses in physician employment agreements. As we continue to live in the Great Resignation, a retention bonus can certainly be justified considering it will save costs to the organization by not having to pay a recruiter, advertise, court and train a new physician.

Collaboration. Sometimes there is strength in numbers. Although it may seem taboo to discuss your compensation with your colleagues, teaming up and sharing information may be more common than you might think. This approach is often helpful in combating institutional racism and sexism in physician employment compensation. Be mindful, though, about any provisions in your employment agreement that prohibit you from sharing information about your contract details.

Communication. Establish good relationships with the physicians and executives who make decisions on compensation. Many organizations have a physician compensation committee. Although the committee roles are typically advisory only, understanding your organization’s particular aspects of its compensation plan development and execution can be very valuable, as is face time with those committee members and executives.

In closing, don’t sit back and let your earning power decrease as compensation increases and your compensation formula remains static. Understand all your employment agreement terms that directly and indirectly impact your compensation. Create a case for your value to your employer. Understand your leverage.

Know your worth from survey sources. Consult with counsel. And go for it. It doesn’t hurt to ask.

Getting it Right | 25

// COVER STORY

GI at the Table: Using a Clinic-to-Farm-to-Table Approach

in Gastroenterology By: Christina A. Tennyson, MD; Savita Srivastava, MD; Vani Paleti, MD; and Pat Banks

26 | GI.ORG/ACGMAGAZINE

Cover Story | 27

// COVER STORY

A

As gastroenterologists, our interactions with patients most often occur in office examination rooms or in the endoscopy unit. Innovations in gastroenterology have traditionally been developed in these settings, including expensive endoscopic devices, novel diagnostics, and pharmaceutical therapies. But another opportunity for innovation in the field is for gastroenterologists to meet patients at the table, focusing on the role of diet and lifestyle factors in gastrointestinal diseases. Our gastroenterology practices have created programs to extend the clinical experience outside of the exam room with farms, culinary kitchens, and integrated teams to help incorporate ‘food as medicine’ into medical treatment plans. This has the potential to improve patient outcomes and reduce healthcare costs.

The cost of healthcare in the United States has continued to rise exponentially and was recently estimated at $4.1 trillion, almost 20% of the nation’s Gross Domestic Product, according to the U.S. Centers for Medicare and Medicaid Services (CMS).

Chronic diseases have typically accounted for 85% of health care costs. Despite increased spending on health care in the U.S., 1 in 6 adults is estimated to have a chronic disease according to the Centers for Disease Control and Prevention (CDC). The majority of the burden of chronic disease results from lifestyle-related risk factors such as poor diet, elevated stress levels, physical inactivity, tobacco use, and excessive alcohol ingestion.

Lifestyle risk factors contribute to chronic diseases encountered on a regular basis by gastroenterologists in clinical practice, such as obesity, metabolic-associated fatty liver disease (MAFLD), gastroesophageal reflux, gastrointestinal cancers, alcohol-related liver

28 | GI.ORG/ACGMAGAZINE

L to R: Dr. Savita Srivastava; Pat Banks, Director of Farming and Project Advancement, Allegheny Mountain Institute; Dr. Christina Tennyson; and Kim Davidson, Executive Director, Allegheny Mountain Institute.

"An integrated lifestyle gastroenterology practice model can address underlying causes and potentially decrease the burden of costly gastrointestinal diseases requiring more intensive interventions.”

disease, and more. U.S. health care spending for gastrointestinal, liver, and pancreatic diseases is substantial at $135.9 billion annually and is expected to continue to increase.(1) The costs for gastrointestinal diseases include inpatient and outpatient settings for acute and chronic diseases, endoscopic procedures, organ transplantation, and pharmaceuticals, including expensive biologic therapies.

Gastroenterologists in rural and urban areas can work towards improving patients’ intake and access to healthy foods by providing multidisciplinary clinical services.

Collaboration with local community organizations can enhance the quality of care for GI patients. An integrated lifestyle gastroenterology practice model can address underlying causes and potentially decrease the burden of costly gastrointestinal diseases requiring more intensive interventions.

What is Lifestyle Medicine?

Lifestyle medicine is an evidence-based field that incorporates lifestyle interventions to prevent, treat, and in some cases, reverse chronic disease. The basic pillars of lifestyle medicine include a whole-food plant-predominant diet, regular physical activity, optimizing sleep, addressing stress management, avoiding risky substances, and promoting social connections. The practice of lifestyle medicine also includes strategies for behavior change such as health coaching, motivational interviewing, and cognitive behavioral therapy. By utilizing these strategies, physicians and clinical teams advise patients about clinical guidelines and also work towards empowering patients to make sustainable and impactful behavior changes. The American College of Lifestyle Medicine (ACLM), a professional organization with membership across numerous medical specialties and allied health fields, advocates for a high-fiber, nutrient-dense eating pattern based predominantly on a variety of minimally processed vegetables, fruits, whole grains, legumes, nuts, and seeds to treat, reverse, and prevent lifestyle-related chronic disease.(2) Lifestyle interventions have been well studied and known to play an important role

in gastroenterology, particularly for colon cancer prevention. Colon cancer prevention guidelines have advocated for increased physical activity, a dietary pattern high in fruits, vegetables, and whole grains while limiting alcohol and red and processed meats. Along with standard therapy, gastroenterologists and their patients could benefit from integrating lifestyle medicine approaches and incorporating culinary education. This may be particularly important for young adults who are experiencing an increase in colon cancer incidence potentially related to lifestyle factors, including diet.

Other diseases commonly managed by gastroenterologists, including inflammatory bowel disease, irritable bowel syndrome, and MAFLD, also can benefit from treatment strategies incorporating medical nutrition therapy.

Food as Medicine: Food, Fiber, and the Microbiota

Recent research provides a scientific rationale for the role of diet and lifestyle in chronic digestive diseases due to effects on the gut microbiota and the trillions of organisms within our gastrointestinal tract, especially the colon, which play a pivotal role in human health. In addition to bacteria, the microbiota also includes fungi, viruses, protozoa, archaea, and more. The microbiota has several important roles, including communication with the brain, production of short-chain fatty acids (SCFA), synthesizing metabolites and vitamins, and assisting in the development of the immune system. An alteration in the gut microbiota is defined as dysbiosis and may influence pathways that interconnect the endocrine, immune, and enteric nervous systems with the brain and gut.(3) While factors early in life influence the microbiome, as adults, diet, physical activity, smoking, alcohol, poor sleep hygiene, and stress affect our communities of microbes.

These factors can cause alterations in the microbiota composition, genetic expression, and cellular stress resulting in downstream inflammation. Diet, in particular, helps shape the microbiome and offers potential therapeutic targets. The gut microbiota can

change within days of a new dietary intervention, but it is not yet known if these changes persist upon terminating a therapeutic diet.

A diverse microbiota appears beneficial to human health. Western populations have experienced a loss of diversity in the microbiota that is linked to the rise of modern diseases such as obesity, diabetes, inflammatory bowel disease, allergies, and autoimmune diseases.

The Western lifestyle, environment and, importantly, diet have been implicated as a likely reason for the loss of diversity of the microbiome. The traditional Western diet is high in fat, sugar, red meat, processed ingredients, and refined grains, while lacking in plant fiber and diversity.

The American Gut Project, a crowdfunded citizen-science project, has examined stool samples from over 10,000 participants and found a more diverse microbiota was associated with a greater diversity of plants in the diet.

(4) Participants who ate more than 30 plants per week had a more diverse gut microbiota, with the overall dietary pattern influencing composition. In addition to plant diversity, other dietary factors can be incorporated to recultivate a diverse microbiota. In a small recent study, the intake of fermented foods was recently found to decrease markers of inflammation, such as IL-6, and increase the diversity of the microbiota.(5) In this clinical trial, 36 healthy adults were randomly assigned to a 10-week diet that included either fermented or high fiber

"Gastroenterology practices and health systems can collaborate with local food system partners to benefit patients and communities.

These collaborations can focus on effective interventions from lifestyle medicine, including an emphasis on a whole food plantbased diet or ‘plantforward’ diet. "

Photo right: Dr. Savita Srivastava (center) and Pat Banks (green shirt) with visitors to Allegheny Mountain Institute Farm at August Health on the Augusta Health Campus in Fishersville, Virginia.

Cover Story | 29

// COVER STORY

FARMER PAT BANKS’ FERMENTATION CORNER Fermentation is defined as the chemical breakdown of a substance by bacteria, yeast, and fungi. By definition, this seems a bit daunting and intimidating, however, making fermented vegetables is as simple as combining four main components: a clean vessel, vegetables, clean water, and salt.

All of that combined with a bit of time and proper temperature and you’ll have a tastier, healthier product. With these simple tools at hand, you, the fermenter, are able to control the bad bacteria and yeast from getting in, while promoting an environment for your good bacteria to thrive.

These vegetables taste great, are good for you, and they will store extremely well. After your vegetables have gone through the initial fermentation process, they can be kept in a cool environment (ideally your refrigerator) where the fermentation process is slowed to a near halt. Given the cool environment and the salt brine conditions of your vegetables, most ferments will keep up to a year!

Before you start, here are my basic rules of fermenting: 1. Have fun and experiment. Does it sound cliché? Because it is. However, having fun and experimenting is what makes fermenting vegetables fun. Yes, there are countless recipes online for you to try out, but don’t be afraid to get creative and try a new one! You never know what you’ll discover. That’s the fun.

2. Make a mess. Channel your inner child and make a mess in your kitchen. What’s more satisfying than having a clean kitchen, dirtying said kitchen, then cleaning it again? Nothing.

All this for the pleasure of having 2 small quart jars of sauerkraut. Your kids will love it.

3. When in doubt, throw it out. Read it and weep. If your senses tell you anything is amiss, throw it on out. Whether it be the smell, look, taste or touch. Trust yourself and your senses.

Pat Banks is the Director of Farming and Project Advancement at the Allegheny Mountain Institute

FARMER PAT BANKS’ BASIC FERMENTED VEGETABLES (see Culinary Connections section “Fall for Ferments” on PG 37 for additional recipes)

 Material: Quart mason jar  Ingredients: • (Yields 1 quart) • 2-3 lbs of any root vegetable • 1 Tbsp of sea salt • ½ onion • 2 garlic cloves • cabbage leaves • filtered water

 Steps: 1. Peel and cube root vegetables and set aside.

2. Mince garlic and set aside.

3. Dice up onions and set aside.

4. Using a clean mason jar, place the root vegetables into the mason jar until half full.

5. Put half of the garlic and onion in the mason jar.

6. Continue filling the mason jar with root vegetables until ¾ full.

7. Use the remainder of onions or garlic to fill jar (there should be about 2 inches remaining).

8. Put salt in the jar and fill with filtered water.

9. Seal the mason jar and shake it thoroughly to help the salt dissolve.

10. Once the salt is dissolved, open the jar back up and place cabbage leaves inside of the jar to hold down the ferment.

You want the vegetables to be below the brine.

11. Ferment for 5 to 7 days on the countertop (70°F, ideally), checking and “burping the ferment” daily.

12. Once the ferment is done, place it inside a refrigerator. It will keep for 6 to 8 months.

About Allegheny Mountain Institute Allegheny Mountain Institute (AMI) is an educational non-profit organization in Virginia with the mission to cultivate healthy communities through food and education. AMI implements an 18-month, tuition-free, experiential Farm and Food System Fellowship that empowers individuals to become leaders in and advocates for a food system that is socially, environmentally, and economically just. In addition, the organization supports schools, hospitals, and organizations to integrate farming, nutritious vegetables, and related education into their food systems and outreach initiatives. In addition to the AMI Farm at Augusta Health, the organization also manages several other projects within the community, including a ½ acre vegetable production farm with the Waynesboro City School district and courtyard gardens at Staunton City Schools. If you are interested in learning more about AMI, visit amifellows.org or youtube.com/watch?v=iA7r7nzHrtw.

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foods. Eating fermented foods in this dietary intervention, such as yogurt, kefir, fermented cottage cheese, vegetable brine drinks, kombucha, kimchi, and other fermented vegetables, increased overall microbial diversity that increased with serving size.

The Sonnenburg Lab has also studied the role of fiber and diversity of the microbiome in traditional hunter-gatherer tribes — in particular, the Hazda in Tanzania, who eat a low fat, high-fiber diet, with over 100 grams of fiber daily from sources including berries and tubers(6). The Hazda demonstrate greater diversity, as well as seasonal variation, in the microbiome as compared to those in industrialized societies. Dr. Denis Burkitt first proposed low-fiber diets to address the increased the risk of common diseases in Western populations, and subsequent research has confirmed that a high fiber diet is associated with decreased risk of cardiovascular disease, obesity, diabetes, and colon cancer. When rural South Africans were fed a high-fat, low-fiber Western diet, mucosal biomarkers of cancer risk increased with deleterious changes in the microbiota and metabolome.

(7) These markers included lower fecal butyrate levels and increased levels of mucosal proliferation, bilophilic bacteria, and bile acids. Conversely, African Americans fed a traditional rural South African low-fat high-fiber diet demonstrated markers associated with a lower risk of colon cancer.

Dietary fiber is vital for the microbiome and human health, but the majority of Americans are deficient, with only 7% of Americans meeting the adequate intake for fiber: 14g/1000 kcal.(8) In averagerisk individuals, decreased colorectal cancer risk is associated with increased intake of fiber, soy, and fruits and vegetables, while an increase in colorectal cancer risk is associated with meat and alcohol consumption.

(9) Strategies to improve diet and other lifestyle factors must move from the bench to the bedside in clinical gastroenterology as new scientific

evidence emerges. Collaboration with farms and culinary programs have been utilized to achieve this in our practices.

Farm Integration

Gastroenterology practices and health systems can collaborate with local food system partners to benefit patients and communities. These collaborations can focus on effective interventions from lifestyle medicine, including an emphasis on a whole food plant-based diet or “plant-forward” diet. This dietary pattern additionally benefits gut microbiota with increased diversity and access to prebiotic fiber, also referred to as microbiota-accessible carbohydrates (MACS).

Our (Dr. Srivastava, Dr. Tennyson) GI practice, called the Augusta Health Digestive Wellness Center, is located in rural Virginia and provides a team-based approach to chronic digestive diseases that incorporate GI and lifestyle medicine physicians, registered dietitian nutritionists, health coaches, behavioral health specialists, exercise physiologists, chefs, and farmers. Rural health systems, in particular, have the unique opportunity to collaborate with regional agricultural organizations to elevate patient experience.

A one-acre vegetable production farm managed by an educational nonprofit organization called the Allegheny Mountain Institute (AMI), in partnership with Augusta Health, is located on the campus of our health system and is a hub, providing clinical integration initiatives and community outreach programs. This clinic-to-farmto-table paradigm in our practice model enables patients to move beyond clinical recommendations provided in clinic towards integrated programs to implement effective dietary changes. The result is collaborative, interactive, and impactful. Through our Digestive Wellness Programs, we have extended our practice onto the farm, culinary kitchen, and wellness spaces located in our health system.

Patients develop a more sophisticated understanding of modern food systems and the interconnection between the microbes in the soil and human gut microbiota.

Soil contains up to 1 billion bacteria in a teaspoon, and microbes affect plant nutrient composition and resiliency, particularly in the soil surrounding plant roots, called the rhizosphere. Soil health has deteriorated with modern farming practices with a downstream impact on nutrient density, food quality,

"This clinic-to-farmto-table paradigm in our practice model enables patients to move beyond clinical recommendations provided in clinic towards integrated programs to implement effective dietary changes."

and gut microbiota health. The health of the modern farm is a clear influencer of human health. Our aim by working with farmers is to emphasize to patients the importance of understanding where food comes from and the importance of food source and quality in human health.

The farm serves many roles within our clinic, the health system, and the community.

It provides locally grown, seasonal produce to a variety of clinically-integrated programs.

The farm also serves as an educational center, hosting community workshops with local farmers, physicians, registered dietitian nutritionists, health coaches, and chefs through in-person and virtual formats.

Programs specifically designed for GI patients within our Digestive Wellness Center focus on more intensive education in a group format about the human and plant microbiomes, the importance of plant diversity for microbiome health, disruptors of gut microbiota health, fermented foods, herbs that may benefit gut health, and regenerative agriculture.

In 2022, our farmers and GI physicians are hosting a multi-part program on fermented

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"Culinary medicine is a new evidencebased field that blends medical nutrition science with culinary arts to help patients access and cook high-quality, delicious food to maintain health but also to prevent and treat disease."

foods and their benefits for gut microbiota and the metabolome. The series will include hands-on workshops to create ferments including pickles, sauerkraut, beverages including kombucha and kefir (see PG 30 for Tips by AMI Director of Farming and Project Advancement Pat Banks, and Culinary Connections on PG 37 in this issue for additional recipes by gastroenterology colleagues.) Patients can also participate in a monthly event called ‘Physicians on the Farm: Walk and Talk’ to learn about how sustainable farming practices can support gut health.

The farm also assists patients in the community and gastroenterology clinic with food insecurity, defined by The U.S. Department of Agriculture (USDA) as a lack of consistent access to enough food for an active, healthy life. Food insecurity is common, affecting approximately 15 percent of respondents in data from the National Health and Nutrition Examination Survey (2007-2016). Food insecurity negatively affects patients with gastrointestinal diseases such as celiac disease and IBD. All patients are screened during GI clinic visits for food insecurity using two validated questions called the Hunger Vital Sign (See Table 1).

The farm provides for those with food insecurity and diet-related chronic diseases access to a “Food Farmacy,” a 12-week prescription-based program ordered by

physicians to complement patient care. The program includes nutrition education, cooking demonstrations, and an allotment of freshly harvested produce. The farm also provides bi-weekly produce boxes to food-insecure patients in the Shenandoah Valley. Boxes are packed with fresh vegetables from the farm, local meat, and eggs from other area farmers and then delivered by hospital and farm staff to patients’ doorsteps. Lastly, the farm supplies fresh produce to an on-site food pantry established on our hospital campus. Patients who are identified as food insecure when visiting their doctors are referred to the on-site food pantry, where there is fresh produce from the farm and canned goods from a local food bank.

TABLE 1. Screening for Food Insecurity (Adapted from Gundersen C., Engelhard E.E., Crumbaugh A.S., Seligman H.K. Public Health Nutr. 2017;20:1367–1371)

For the following statements, please answer if the statement was often true, sometimes true, or never true for you or your household in the last 12 months.

1. I (We) worried whether (my/our) food would run out before (I/we) got money to buy more.

2. The food that (I/we) bought just didn’t last and (I/we) didn’t have money to get more.

An answer to either question as often true or sometimes true is considered a positive screen for food insecurity

Working alongside the AMI Farm at Augusta Health has been an incredible way to translate the work at the bench in microbiome science and provide translational applications for clinical care. Furthermore, it is an important way to bring health coaching, cooking, and lifestyle medicine interventions to the forefront of GI clinical practice. Using a garden or collaborating with local farms or farmers markets, health systems can engage physicians, staff, and patients about the importance of food as medicine for the prevention and management of chronic diseases. For more information on the partnership of AMI and Augusta Health, visit: youtube.com/watch?v=iA7r7nzHrtw Photo left: Dr. Christina Tennyson at a community workshop at the AMI Farm at August Health Photo above: The AMI Farm at Augusta Health

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Dr. Srivastava (front row third from left) and Dr. Tennyson (far right) with Augusta Health office staff nurses, MAs, office manager and farm fellow, Grant (back right), on a farm tour. Dr. Tennyson sponsored a CSA vegetable share for her staff so they all receive fresh vegetables

Culinary Medicine

In addition to introducing patients to farms and gardens, our practices (Dr. Paleti, Dr. Srivastava, Dr. Tennyson) have started incorporating culinary medicine programs to meet patients in the kitchen, reinforcing that healthy food can be delicious and simple to prepare. Culinary medicine is a new evidencebased field that blends medical nutrition science with culinary arts to help patients access and cook high-quality, delicious food to maintain health but also to prevent and treat disease.(10) Culinary medicine bridges the gap between simply recommending dietary changes to help individuals make appropriate lifestyle changes by focusing on skills such as meal planning, shopping, storage, budgeting, and cooking for successful implementation.

Culinary medicine helps patients learn simple, efficient, and cost-effective ways to foster healthy enjoyment of food. The field is also a gateway for healthcare professionals to learn and incorporate food as medicine while educating patients on practical aspects of nutrition.

There are proven benefits to home cooking and using a clinic-to-kitchen approach.(11) Home cooking has been associated with a healthier diet, whether or not one is trying to lose weight, as home-cooked meals contain less sugar, fat, and calories. Cooking at home has been associated with improved diet quality among both low and high-income adults. When individuals cook at home, there is also improved dietary guideline compliance



without increasing the amount of money spent on food, particularly important given recent rising food costs.

Community-based culinary education programs increase confidence in cooking and use of new ingredients among participants.

Although a suboptimal diet is an important preventable risk factor for noncommunicable diseases, typically only 20 hours are spent on nutrition education during medical school education.(12) Physicians are often ill-equipped to offer nutrition advice or introduce culinary arts for the promotion of health. Culinary medicine curricula do not provide comprehensive nutrition education but can highlight important nutrition topics and focus on preparing simple healthy, inexpensive meals at home. Culinary medicine programs help teach about the nuances and importance of cultural diversity, food insecurity, food deserts and sustainability while promoting food as a social connection. Culinary medicine programs promote a “plant-forward” approach that can be adapted to diverse cultures and eating patterns with an emphasis on limiting processed foods and animal products. One strategy advocated by the Culinary Institute of America is a “protein flip,” where a greater emphasis is placed on vegetables and other plant proteins as the dominant portion in a meal rather than animal protein.

"The evolving field of nutrigenomics that studies the relationship between nutrients, the diet, and gene expression, may tailor diet interventions to the individual using precision health and personalized nutrition in the future."

FOLLOW #ACGFOODIES on social media for drool-worthy photos, recipes, tips, and to connect with fellow ACG foodies!

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// COVER STORY

Patients with gastrointestinal diseases, including those with certain dietary requirements, may benefit from a culinary medicine curriculum.

A cooking-based intervention improved quality of life and glutenfree diet adherence in patients with celiac disease.(13) In a recent small study of patients with ulcerative colitis, a low-fat, high-fiber diet decreased markers of inflammation and dysbiosis.(14) Although a treatment option could include a catered diet, a culinary medicine curriculum could empower and educate patients to cook these meals easily and inexpensively at home.

Recently, several medical school and residency programs have started to incorporate culinary medicine into medical curriculum and rotations to effectively equip and train physicians.

When health care professionals are provided the necessary education about the role of food as medicine along with culinary medicine skills, studies have demonstrated a positive impact on the well-being of health

care professionals, patients, and the community, causing a ripple effect of improved population health.(15) For gastroenterologists in clinical practice or academics, there are several culinary resources and training opportunities available for healthcare professionals (see Table 2). Collaborations can occur within health systems or communities by partnering with local chefs. Dr. Michelle Hauser, a physician and trained chef, has a well-compiled culinary medicine curriculum that is freely downloadable for use as a resource and teaching manual. Health Meets Food is a hands-on and virtual culinary curriculum from the nation’s first culinary medicine program at Tulane University School of Medicine. Fifty-five medical schools, residency programs, and nursing schools have adopted this curriculum.

Healthy Kitchens Healthy Lives is an annual hands-on culinary conference

by Harvard Medical School, the Harvard T.H. Chan School of Public Health, and the Culinary Institute of America that brings together chefs, nutrition science experts, and clinicians. The conference

includes demonstrations and handson kitchen teaching sessions. CHEF Coaching, a program directed by Harvard-affiliated physician and chef Dr. Rani Polak, is offered through the Institute of Lifestyle Medicine. It offers a virtual culinary medicine curriculum combined with coaching techniques to facilitate behavior change. In addition, Culinary Connections, a column of ACG MAGAZINE, features contributions from gastroenterology community members interested in food and health. #ACGfoodies is the hashtag to follow on social media.

For those interested in starting a culinary medicine program, the Teaching Kitchen Collaborative (TKC) is a network of organizations using teaching kitchen facilities. The TKC summarizes best practices among member organizations, offers resources and provides practical instruction including design of teaching kitchens.

Figure Legend: (clockwise from top) Sustainable farming practices to enhance gut microbiome; culinary medicine and dietetics; home cooking and social connections; physical activities; health coaches; better quality of sleep; behavioral health services; physician-led health care team

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Conclusion

An integrated lifestyle gastroenterology practice model incorporates diet and lifestyle interventions with gastroenterologists, in partnership with registered dietitian nutritionists, behavioral health specialists, health coaches, exercise trainers, culinary chefs, and farmers (See Figure). This model embraces food as medicine to modulate the gut microbiota positively and can incorporate partnerships with farms, local gardens, and culinary medicine education platforms.

Nutrition-based therapy is an evolving field in gastroenterology.

Given the importance of prebiotic fiber for gut microbiota health, future studies will need to address optimal nutrition therapy for longterm health, including the short and long-term effects of limiting FODMAPs on the gut microbiota.

Specialized gastrointestinal dietitians can optimize outcomes of dietary interventions, monitor for nutritional adequacy, and screen for disordered eating in patients with IBS as well

as other gastrointestinal conditions.

The evolving field of nutrigenomics that studies the relationship between nutrients, the diet, and gene expression, may tailor diet interventions to the individual using precision health and personalized nutrition in the future.

Incorporating group visits for those with a specified medical condition or during dietitian visits along with culinary lessons can contribute to additional cost savings. Group visits also promote social connection, community, and accountability. This form of innovation in gastroenterology will help to provide more costeffective care in a field that is traditionally focused on high-cost interventions. Future studies can examine the value-based impact of treating, reversing, and preventing chronic gastrointestinal diseases with diet, lifestyle, and microbiome modulation approaches. An integrated lifestyle gastroenterology practice can help shape the future of gastroenterology and health care.

References and Further Reading 1. Peery AF, Crockett SD, Murphy CC et al. Burden and Cost of Gastrointestinal, Liver, and Pancreatic Diseases in the United States: Update 2018.Gastroenterology. 2019 Jan;156(1):254-272.

2. Lianov L, Johnson M. Physician competencies for prescribing lifestyle medicine. JAMA. 2010 Jul 14;304(2):202-3.

3. Dong TS, Gupta A. Influence of Early Life, Diet, and the Environment on the Microbiome. Clin Gastroenterol Hepatol. 2019 Jan;17(2):231-242.

4. McDonald D, Hyde E, Debelius JW, et al. American Gut: an Open Platform for Citizen Science Microbiome Research. mSystems. 2018 May 15;3(3):e00031-18.

5. Wastyk HC, Fragiadakis GK, Perelman D, et al.Gut-microbiota-targeted diets modulate human immune status. Cell. 2021 Aug 5;184(16):41374153.

6. Smits SA, Leach J, Sonnenburg ED, et al. Seasonal cycling in the gut microbiome of the Hadza hunter-gatherers of Tanzania. Science. 2017 Aug 25;357(6353):802-806.

7. O'Keefe SJ, Li JV, Lahti L, et al. Fat, fibre and cancer risk in African Americans and rural Africans. Nat Commun. 2015 Apr 28;6:6342.

8. Miketinas D, Tucker W, Patterson M, Douglas C. Usual Dietary Fiber Intake in US Adults with Diabetes: NHANES 2013–2018. Current Developments in Nutrition 2021. (5), Issue Supplement_2, June 2021: 1061.

9. Chapelle N, Martel M, Toes-Zoutendijk E, Barkun AN, Bardou M. Recent advances in clinical practice: colorectal cancer chemoprevention in the average-risk population. Gut. 2020 Dec;69(12):2244-2255.

10. Hauser ME, Nordgren JR, Adam M, et al. The First, Comprehensive, Open-Source Culinary Medicine Curriculum for Health Professional Training Programs: A Global Reach. American Journal of Lifestyle Medicine. 2020;14(4):369-373.

11. Tiwari A, Aggarwal A, Tang W, Drewnowski A. Cooking at Home: A Strategy to Comply with U.S. Dietary Guidelines at No Extra Cost. Am J Prev Med. 2017 May;52(5):616-624.

12. Adams KM, Kohlmeier M, Zeisel SH. Nutrition education in U.S. medical schools: latest update of a national survey. Acad Med. 2010;85(9):15371542.

13. Wolf RL, Morawetz M, Lee AR, et al. A Cooking-Based Intervention Promotes Gluten-Free Diet Adherence and Quality of Life for Adults with Celiac Disease. Clin Gastroenterol Hepatol. 2020 Oct;18(11):26252627.

14. Fritsch J, Garces L, Quintero MA, et al. Low-Fat, High-Fiber Diet Reduces Markers of Inflammation and Dysbiosis and Improves Quality of Life in Patients with Ulcerative Colitis. Clin Gastroenterol Hepatol.

2021 Jun;19(6):1189-1199.

15. Pang B, Memel Z, Diamant C, et al. Culinary medicine and community partnership: hands-on culinary skills training to empower medical students to provide patient-centered nutrition education. Med Educ Online. 2019;24(1):1630238.

TABLE 2. Culinary Medicine: Resources for Gastroenterologists and Health Care Professionals PROGRAM

DESCRIPTION

Health Meets Food culinarymedicine.org

A hands-on/virtual culinary curriculum from the nation’s first culinary medicine program at Tulane University School of Medicine. Fifty-five medical schools, residency programs, and nursing schools have adopted this curriculum.

ACLM Culinary Medicine lifestylemedicine.org

Dr. Michelle Hauser, a physician and trained chef, has a well-compiled culinary medicine curriculum that is freely downloadable for use as a great resource and teaching material via the ACLM website.

Healthy Kitchen Healthy Lives www.healthykitchens.org

An annual hands-on culinary conference by Harvard Medical School and the Harvard T.H. Chan School of Public Health, in collaboration with the Culinary Institute of America, that aims to empower health care professionals to be advocates of lifestyle changes that begin in our kitchens.

CHEF coaching

The Institute of Lifestyle Medicine, affiliated with the Spaulding Rehabilitation Hospital and Harvard Medical School, offers a tele-culinary medicine curriculum combined with coaching techniques to facilitate behavior change.

Culinary Connections issuu.com/amcollegegastro/docs/21acgmag-summer-web/34

Column of ACG MAGAZINE with culinary contributions from gastroenterology community members interested in food and health. #ACGfoodies is the hashtag to follow along on social media.

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APPLY for an

ACG Clinical Research Award Deadline: Monday, December 5, 2022 ACG Junior Faculty Development Award $150,000 a year for three years

Established Investigator Bridge Funding Award Up to $150,000 a year for two years

Clinical Research Award Up to $50,000 for clinical research

Clinical Research Pilot Award Up to $15,000 for pilot projects

Health Equity Research Award

Up to $75,000 (50k year-one, 25k year-two based on progress) for actionable science that will reduce health and/or healthcare disparities

ACG/ASGE Epidemiologic Research Award in Gastrointestinal Endoscopy Up to $50,000 for research utulizing the GIQuIC database

Resident Clinical Research Award Up to $10,000

Medical Student Research Award

Up to $5,000 for 6–10 week summer project

Learn more about ACG 2023 Clinical Research Opportunities and Submit Your Application: GI.ORG/GRANT-ANNOUNCEMENTS LEARN MORE ABOUT THE ACG INSTITUTE The Clinical Research Awards are a project of the ACG Institute and are supported by charitable contributions to the G.U.T. Fund. The G.U.T. Fund is the Institutes campaign whose mission is to Grow, Uplift, and Transform GI Research and Education.

Visit gi.org/gutfund for more information.

36 | GI.ORG/ACGMAGAZINE

Culinary Connections:

Love Fermented Foods

“Fall” In with

By Vani Paleti, MD, Alexander Perelman, DO, and Christina A. Tennyson, MD

STEPPING INTO THE SECOND YEAR OF #ACGFOODIES, we are super excited to share personal culinary connections of Dr. Aline Charabaty, Dr. Corlan Eboh, and Dr. Will Bulsiewicz.

We will be exploring the world of fermented foods. Fermentation is the art and process of preserving foods and increasing shelf life. Cultures throughout history and across the world have perfected the art of controlling the anaerobic fermentation process by bacteria and yeast.

From fermented alcoholic beverages (wine/ mead), sauerkraut, yogurt, kefir, and kombucha to kimchi, the world of fermented foods has exploded exponentially for its live cultures and probiotic benefits. Did you know? Louis Pasteur demonstrated microbial basis for the fermentation process, leading to development of germ theory and pasteurization.

— Dr. Vani Paleti, Dr. Christina Tennyson, Dr. Alexander Perelman ACG Perspectives | 37

// PERSPECTIVES

CORLAN EBOH, MD

Atrium Health, Charlotte, NC

Growing up as a child of immigrants in Toronto, Canada, I was fortunate to see how food is a passport to one's culture and experiences. You can travel the world at the table of friends. Eating a meal together allows individuals to commune, love, laugh, and expose one to another's life and experiences. Individuals can use food to comfort and heal. Whether using ginger to help treat nausea or kiwi to treat constipation, as a gastroenterologist, I appreciate how I can use available resources to teach, support, educate, and treat. Having my patients consume fermented foods (including, but not limited to, yogurt and kefir) is a fantastic way to use the foods around us to introduce probiotics into the diet.

Regarding fermentation, I had thought my awareness of fermentation began in the academic setting by studying the bacteria lifecycle. I now realize that my exposure to fermentation started as a child through consuming fermentable foods.

My father is Nigerian, and Garri (derived from the fermentation of roasted cassava root) was regularly prepared in our home growing up. Garri is a staple in West African cuisine. Nevertheless, my mother, who is Jamaican, used the same fermented cassava to make Bammy (a Jamaican cassava flatbread).

Watching the same product used by two cultures in two very different ways was terrific. However, both were taking full advantage of the benefits

“I had thought my awareness of fermentation began in the academic setting by studying the bacteria lifecycle.

I now realize that my exposure to fermentation started as a child through consuming fermentable foods.”

—Dr. Corlan Eboh

OVERNIGHT “MUESLI” OATS 4 SERVINGS  Ingredients • 4 oz. unsweetened plain Greek yogurt • 2 Tbsp unsweetened almond butter (may substitute with sunflower butter if tree nut allergy) • 2 Tbsp sliced almonds (pumpkin seeds, if tree-nut allergy) • 1 tsp. ground cinnamon • 2 Tbsp dried cranberries • 2 Tbsp raisins • 4 Tbsp chia seeds • 3/4 cup rolled oats • 4 Tbsp maple syrup • 8 oz. unsweetened original whole milk kefir • 1 cup water • One apple (your preference) • 1/4 tsp salt

 Steps 1. Coarsely shred apple

2. Toast nuts in a dry pan, remove once fragrant and lightly browned. [TimeSaving Tip: no time to toast nuts/pumpkin seeds? Are no nuts/pumpkin seeds available? Substitute the smooth nut butter with a crunchy version to provide crunch and add flavor.]

3. Combine kefir, 1 cup water, nut butter, and maple syrup 4. Add the shredded apples, chia seeds, dried fruit, salt, cinnamon, and all the oats to the sweetened kefir mixture. The liquid should just cover the oat mixture.

5. Cover bowl and place in the fridge overnight 6. When ready to eat, remove marinated oats, stir to incorporate ingredients, and mix in Greek yogurt. Top with toasted nuts and adjust sweetness with maple syrup.

7. Enjoy!

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of fermentation. Little did I realize that eating Garri with the Nigerian Egusi stew (fermented melon seed) or eating Bammy with Jamaican Escovitch fish (fried fish soaked in a spicy pickled sauce) were traditional feasts in fermentation.

Even now, the tartness of fermentable foods often brings a familiarity to food profiles from my childhood. As a full-time gastroenterologist and mother of two toddlers, I seek opportunities to take full advantage of the benefits of whole foods. However, I appreciate nutritious meals that are timeefficient.

One of my go-to breakfast recipes combines oats with fermented, probiotic-rich Greek yogurt and kefir overnight. This combination creates "overnight oats." Combine the oats with nuts, seeds, and fresh and dried fruits to give it a "Muesli" spin. This dish can become your new early morning grab-and-go breakfast. It provides you the peace of mind that you are providing your body with the benefits of fiber and fermentation.

Overnight "Muesli" Oats are creamy, hearty, sweet, and tart – a satisfying and delicious way to start your day.

ALINE CHARABATY, MD, FACG

Assistant Clinical Director of the Division of Gastroenterology, Johns Hopkins School of Medicine; Clinical Director of IBD, Johns Hopkins-Sibley Memorial Hospital, Washington, DC

In Lebanese culture, cooking and sharing a multicourse meal with others is an integral part of how you show love, care, friendship, hospitality. You cook big, you cook plenty, you cook generously, and gather a large table to share more than a meal: stories, dreams, plans, challenges, laughter, tears, and all the emotions in between! You exchange tips on perfecting a dish and start planning the next meal and family and friends gathering, all while getting overfed by the hosts. When I step into my kitchen and start prepping ingredients, it brings me back to my Teta Souad, to my grandmother’s kitchen.

I remember how much I felt loved and cared for when she made a favorite dish for me, when she would pull a stool so I could reach the countertop to help cut vegetables or mash garlic, when she would make me taste the dish in progress and ask me, “What do you think is missing?” Then she would add spices and ingredients on-the-go. No measuring cups or spoons, no cookbooks, just experience, instinct, and lots of generous, inclusive love!

Lebanese cooking includes lots of stews with vegetables and legumes, garlic and onions, and mixed spices, served with rice; red meat

“Now that I told you all about my love for Lebanese food, and its goodness, why am I sharing with you an Asian inspired soup recipe?

Because cooking is also about exploring cultures and awakening the infinite (and amazingly inclusive and diverse) taste buds we have!.”

—Dr. Aline Charabaty

ALINE’S ASIAN-INSPIRED SOUP WITH MISO AND

 Ingredients • 6 cups vegetable broth • 2 cups water • 1 to 2 packs tofu (soft or semi-firm , non-GMO), cubed • Vegetables and more goodness: baby bok choy, zucchini, yellow squash, mushroom s (enoki, oyster mushroom or, my favo rite, shiitake), scallions, sliced • Noodles of choice (udon noodles, soba noodles, glass noodles, egg noodles) • 6 Tbsp (or to taste) miso paste (cho ose a brand without added MSG) • 1 to 2 cups organic kimchi (and its juice) • 4 eggs • Dried seaweed square sheets • Add to taste: pepper, ground ging er, garlic powder, chili pepper flakes, Roas ted sesame seed

is added in some stews in small amounts, almost like a flavoring, but less as the main attraction.

Stews are often served with sides of homemade Lebanese yogurt and a mix of pickled turnips, shallots, and cucumbers, which I now know are fermented superfoods. With this right balance of fiber, pre- and probiotic ingredients, and a zest of spices and love, Lebanese cooking builds resilient gut microbiomes for resilient people!

Now that I've told you all about my love for Lebanese food and its goodness, why am I sharing with you an Asian-inspired soup recipe? Because cooking is also about exploring cultures and awakening the infinite (and amazingly inclusive and diverse) taste buds we have! And because this recipe brings back my Teta Souad’s kitchen spirit, cooking together with the kids, getting creative with ingredients, tasting and adjusting flavors every time, and ending up with a favorite meal on a chilly fall and winter night, that is both healthy and feel-good. You can add in any vegetables and mushrooms you like or have available and elevate them with the taste of two fermented foods: Japanese miso and Korean kimchi. I buy organic miso and get my kimchi from one of the wonderful GI nurses, Andrea Desouza, who makes her own full-of-flavor organic kimchi. One tip when making this soup: add the miso and kimchi at the end of the cooking process, after you turn down the heat, knowing that live probiotic cultures are destroyed at a temperature above 115°F. In other words, don’t let the fluid boil after you add the miso and kimchi. You can adjust the ratio of vegetable broth and water depending on how much you want to limit salt intake, and how big your soup bowl (and appetite) is! Have fun with this and bon appétit!

KIMCHI 4 SERVINGS

 Steps 1. Heat water and vegetable broth 2. Add cut vegetables and bring to boil 3. Add any additional spice to taste and some kimchi juice 4. Add tofu and mushrooms, let simmer 5. Lower heat and add noodles, let simmer until soft 6. Add miso and kimchi and let cook for a few minutes (keep heat below boiling) 7. Equally divide soup into 4 large bowls with a ladle

8. Scramble each egg separately and add raw to each bowl, while soup is hot so the egg will cook 9. Garnish with a few seaweed squa res and sesame seeds

ACG Perspectives | 39

// PERSPECTIVES

WILL BULSIEWICZ, MD, MSCI Gastroenterologist, Author of Fiber Fueled and The Fiber Fueled Cookbook

Ten years ago, I emerged from a health crisis by changing my diet. I lost 50 pounds, dropped my blood pressure and cholesterol, liberated myself from anxiety and depression, and altogether transformed my life.

It happened, but I can’t say that I understood why it happened, so I turned to the medical literature (good ole PubMed) and discovered something unexpected. There were literally thousands of articles illustrating the relevance of nutrition to health and disease. How was this not emphasized in my twelve years of medical education?

So I dove in with a voracious appetite, eager to learn and bring this new knowledge to my patients in the clinic. In 2014, Lawrence David’s Nature paper connected food choices to rapid changes in the gut microbiome. Whoa… Into the rabbit hole of fiber, prebiotics, probiotics, and short chain fatty acids I plunged.

In the world of food and microbes, all roads eventually lead to fermentation sitting at the crossroads. But I didn’t really know where to start until a patient walked into my clinic and told me that he transformed his digestive health by eating several servings of fermented food daily. He recommended that I read The Art of Fermentation by Sandor Katz.

“Our food and our microbes are inseparable.

Fermented foods are their intersection, and the new science suggests that fermented foods should be part of a healthful, microbiota supporting diet.”

My wife thought I was nuts (and a bit reckless) when I had briny cabbage sitting on the kitchen counter for two weeks before sticking my fork into it. But it was safe, not to mention crunchy, complex, and vibrant. I felt energized by it. Her skepticism eventually faded, and one day I discovered that someone had raided my sauerkraut stash. Soon, I couldn’t keep up with her daily sauerkraut demands.

Until recently, the evidence to support fermented food for digestive health was scant, even if the unique exopolysaccharide prebiotics, probiotic microbes, and their bioactive metabolites made it rational. But in August 2021, Professors Hannah Wastyk, Justin Sonnenburg, and Christopher Gardner from Stanford University published an interventional trial showing that 10 weeks of fermented food consumption increased microbiota diversity and decreased inflammatory markers.* Our food and our microbes are inseparable.

Fermented foods are their intersection, and the new science suggests that fermented foods should be part of a healthful, microbiota supporting diet.



—Dr. Will Bulsiewicz

We would love to hear from you. If you have personal connections with GI and gastronomy.

Contact ACG MAGAZINE staff at acgmag@gi.org to share your story with the ACG community.

You can also tweet using #ACGfoodies to connect with the community. Wishing you all good health and great meals from our Culinary Connections #ACGfoodies team.

TO SALSA MAKES 1 QUART SMOKY PINEAPPLE & TOMA kbook Coo led

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40 | GI.ORG/ACGMAGAZINE

 Steps

mic bowl, place tomatoes, 1. In a large plastic or cera lic, and coriander pineapple, onion, chilies, gar well combined and is salt il 2. Add salt and mix unt ed mix ingredients are gar and stir 3. Add lime juice and vine into salsa and blend; add back 4. Remove about ¼ of the the bowl ssing with blended mixture, pre 5. Pack salsa into the jar veg the ve s abo down so that the brine rise You it to sit out for 3 to 5 days. w allo and jar the se Clo 6. pop a r rise in the jar or hea will see bubbles form and release the lid or latch. you n whe nd or burping sou If be tangy and slightly fizzy.

7. Taste the salsa. It should it give y, salt still is it or ed the fizziness hasn’t develop are ready to eat, store in another day or so. When you 1 month. the fridge and use within s. Cell 184, late human immune statu iota-targeted diets modu * Wastyk et al., Gut-microb ll.2021.06.019 6/j.ce 10.101 .org/ ://doi https 4137–4153. August 5, 2021.

and providing education when the opportunity arises. Many people have no malintent but still commit microaggressions.

I gently correct the patient that calls my colleague “young lady” by stating she is the physician. Any time I am involved with organizing an event or inviting speakers, I strive to make these events equitable and suggest women experts, too. For example, Scoping Sundays has always had and will always have representation for women.

I mentor and sponsor women, including trainees and my peers.

Paving the Way Forward: Women in Gastroenterology

By Elizabeth S. Aby, MD; Lydia L. Aye, DO; Lara T. Dakhoul, MD; Autumn P. Hines, DO; Pegah Hosseini-Carroll, MD, FACG; Asma Khapra, MD; Jami A.R. Kinnucan, MD, FACG; Paola López-Marte, MD

FEWER THAN 20 PERCENT OF PRACTICING GASTROENTEROLOGISTS ARE WOMEN. However, the number of female fellows graduating from GI fellowships is nearing 50 percent.

There is an increased need to promote, support and advance women in the field of gastroenterology. These past few years we have seen the birth of various organizations to further these goals. With the formation of the society “Women in Endoscopy,” the “Ladies of the Gut” (LOTG) Facebook group and the first annual women in GI conference, Scrubs and Heels, the female gastroenterology community is leaning in and demanding to be heard.

So how do we continue to address issues that concern women in GI and create an actionable pathway forward? We have had an opportunity to interview some prominent gastroenterologists to share their insights on promoting diversity, sponsorship, and allyship in the field.

We are fortunate to be able to share the highlights of their

recommendations with you. In addition, our colleagues in the LOTG community have given us pearls of wisdom on surviving the many challenges of being a woman in GI. Our hope is that all who read this, find a way to promote, support and nurture their female counterparts in gastroenterology.

DR. MOHAMMAD BILAL: PROMOTING ALLYSHIP FOR WOMEN IN GI Mohammad Bilal, MD

Dr. Bilal was born to a mother and father in GI, and he is a brother to a woman advanced endoscopist. He has witnessed his mother and sister face challenges in the field, so allyship is close to his heart.

What is your approach to allyship?

Dr. Mohammad Bilal: I talk to female colleagues and ask about the biases they face. I become a better ally as I learn more. The knowledge empowers me to help in effective ways. For example, I am an “upstander.” This means calling out and standing up to any gender-related microaggressions

How can women identify allies?

Dr. Mohammad Bilal: I take a proactive approach in that my communications and actions show that I am an ally. For instance, I include pronouns in my email communications and public forums so that it is clear I am inclusive and supportive. I actively recruit underrepresented minorities to increase diversity, and advocate for policies that support women, such as maternity leave.

As I mentioned before, I am an upstander against gender-related microaggressions, sexual harassment, and discrimination. Being passive or a bystander is not acceptable! I believe in “He for She” and actively practice and model this for all to see. My goal is for my actions and everyday behaviors to communicate my support proactively.

What is your advice regarding the struggles women face?

Dr. Mohammad Bilal: Recognize that many want to do the right thing but don’t know how. I have learned to engage in dialogue and make investments in becoming educated on these issues. Having crucial conversations at conferences and within our local institutions is key. I encourage everyone to speak up when you recognize inequities, and we must encourage those making an impact. Our leaders, such as program directors, division chiefs, etc., need to have training on DEI issues to combat unintentional bias and the leaky pipeline.

Most importantly, we must set an example for trainees so that they model behaviors that are inclusive and welcoming for all.

“I am an upstander against gender-related microaggressions, sexual harassment, and discrimination. Being passive or a bystander is not acceptable!” – Dr. Mohammad Bilal ACG Perspectives | 41

// PERSPECTIVES

DR. FOLASADE MAY & DR. DOMINIQUE HOWARD: IMPORTANCE OF MENTORSHIP AND SPONSORSHIP How does sponsorship compare with mentorship?

Dr. Folasade May: I think of the relationship between mentorship and sponsorship as overlapping circles in a Venn diagram. Mentors can be sponsors and vice-versa; however, there are distinct attributes that separate the two. Sponsors use their social capital or influence to promote or advocate for someone junior.

Sponsorship often has more focused goals and occurs episodically, while mentorship is a continuous relationship over time which often consists of, but is not limited to, advice, guidance, and feedback.

Dr. Dominique Howard: Both sponsorship and mentorship are professional relationships, usually between a more senior leader and a person more junior in their career. They are both individuals who can help with career goals and advancement.

A sponsor usually has some influence or is a leader in the same organization as the junior person they are sponsoring.

A sponsor is generally an advocate who will directly help with career pipeline for advancement, forming connections, and networking.

A mentor serves more as a role model and advisee to the mentee. A mentor helps the mentee to guide them in career decisions. A mentor often facilitates working through career challenges and decisions, as well as helping to develop skill sets useful in career advancement.

Sponsor Directly helps in promoting Assists in networking Opens doors

42 | GI.ORG/ACGMAGAZINE

Dominique E. Howard, MD, FACG

“Both mentorship and sponsorship relationships can be equally important and are not exclusive of each other."

– Dr. Dominque Howard Of note, not every junior faculty wants career advancement. Some people want more of a sounding board on how to navigate through difficulties or in making decisions in their work environment. Some junior members, I find, want to create a different narrative, for example, with redefining the workplace to be conducive to work-life balance and want guidance in strategies to accomplish that. Both mentor and sponsor relationships can be very important and meaningful.

Folasade P. May, MD, PhD, MPhil

“The mentors who stand out are those who truly believed that I could succeed and weren’t just going through the motions or meeting with me out of obligation.

Those who provided strong mentorship provided guidance based on a careful assessment of my goals and unique situation, instead of trying to have me follow their path or fit within the status quo.” – Dr. Folasade May

Mentor Advisor Advocate

Serves as Role Model Guides in career decisions Gives feedback

How do you approach mentorship for trainees and junior faculty?

Dr. Folasade May: I meet with everyone who expresses interest in being a mentee at least once. In the first meeting, the discussion is centered around what the May lab focuses on and what projects are ongoing. No commitments are made during that first meeting, which allows for individuals to be more thoughtful about what they commit to and engage in. I even encourage potential mentees to meet with other potential mentors. After joining the May Lab, there are frequent lab meetings, structured near-peer mentorship, and goal setting to help ensure that individuals feel ownership of their projects but also have the support they need to succeed and the opportunity to participate in others’ projects.

Dr. Dominique Howard: If there is a junior trainee or colleague who asks me for any guidance, I am always willing to listen and offer the best advice I can give. I am always honored and humbled to be asked.

DR. JENNIFER CHRISTIE AND DR. RACHEL ISSAKA: SUPPORTING DIVERSITY, EQUITY, AND INCLUSION FOR WOMEN IN GI Jennifer A. Christie, MD

“We need to commit to support and develop our new URiM faculty members, to give them the tools to be successful and to attain leadership positions.

Resources need to be allocated for professional development; this includes opportunities to participate in faculty development programs, national committees, and leadership within the organization.” – Dr. Jennifer Christie

What can we do to create a more inclusive environment to attract a more diverse workforce in GI? Dr. Jennifer Christie: There should be an intentionality and commitment from leadership to recruit a diverse workforce but to also create and sustain a culture in which diversity and inclusion are valued and promoted.

Leadership needs to reflect this diverse workforce and provide role models for underrepresented minorities in medicine (URiM).

Additionally, there needs to be an expectation that our leaders will promote and advance URiM to be successful in the organization and beyond. Most importantly, there needs to be accountability in creating and sustaining an inclusive culture.

Dr. Rachel Issaka: There is a lot of attention on diversity and inclusion, but retention of a diverse workforce is equally important.

Resources to retain and promote a diverse workforce should be distributed based on the individual’s goals. Additionally, mentors with similar lived experiences, which may initially be from outside the division, can help with faculty retention. Ultimately, the goal should not only be to recruit a diverse workforce but also to provide the support and resources to retain them.

What advice would you give to a URiM fellow or new faculty when interviewing at a program/job?

Dr. Jennifer Christie: Pay attention to what individuals in a program/organization look like, not just at a faculty level but also the medical students, residents and fellows, as well as senior leadership. Ask specifically about what policies are in place to promote diversity and support URiM. Ask administrative and support staff what the culture is like at the institute. Consider whether the key values of the institution align with your values?

Dr. Rachel Issaka: Remember your value! Institutions are not doing you a favor by interviewing or hiring you.

Your ability to persevere, despite being one of a few, makes you a “unicorn” and you will bring immense value wherever you go. Speak with existing faculty members and take note of who is in the division, who is promoted, and who is leading. Evaluate this not on just the division level but across the institution, including chairs of departments, deans, the board directors, etc. This will provide valuable insight about the institution’s culture and may guide how you design the career you wish to have.

Rachel E. Issaka, MD, FACG

“Keep the frame of mind that you are valuable and you bring value to any institute/job that you are interviewing for.”

– Dr. Rachel Issaka

PEARLS ON ACHIEVING WORK-LIFE BALANCE FROM THE “LADIES OF THE GUT”

The Scrubs and Heels conference in Florida in March brought together women in the GI community for networking, learning, and a chance to refresh and connect with colleagues.

Scrubs and Heels Panel Discussion L to R: Dr. Aline Charabaty, Dr. Anita Afzali, Dr. Jennifer Christie, Dr. Carol Burke, Dr. Marla Dubinsky, Dr. Millie Long.

ACG Perspectives | 43

Conversations with Women in GI Jill K. J. Gaidos, MD, FACG in Conversation with Guadalupe Garcia-Tsao, MD, FACG Dr. Jill Gaidos talks to Dr. Guadalupe Garcia-Tsao, Professor of Medicine in the Section of Digestive Diseases at the Yale School of Medicine, about her incredible journey from medical training in Mexico City to becoming a world-renowned expert in hepatology.

Gaidos: After completing your residency and fellowship in gastroenterology and hepatology in Mexico City, you decided to research liver disease abroad. You accepted a three-year research fellowship position at the West Haven Veteran’s Affairs Medical Center. Was this a repeat of your fellowship training?

Garcia-Tsao: No, not at all. The GI fellowship in Mexico was clinical. At that time, research was not part of the curriculum of either medical school or residency/ fellowship. However, in the last year of medical school (the “social service” year), I had the opportunity to do research at the Instituto Nacional de la Nutrición under Dr. David Kershenobich, who had gone abroad and trained with Sheila Sherlock in the U.K. I worked in research on collagen synthesis in cirrhosis and also became involved in a randomized controlled trial of colchicine in the treatment of cirrhosis. I was just a medical student but I was in charge of the randomization of patients (provided sealed envelopes) and data collection. I ended up being a co-author of the New England Journal of Medicine article that resulted from this study! Actually, in the very nice introduction that Dr. Tamar Taddei made for my recent ALF award (Dr. Garcia received the 2021 Distinguished Scientific Achievement Award from the American Liver Foundation on November 19, 2021), she mentioned how I have gone full-circle and am now Associate Editor for the NEJM. I stayed on at the Instituto Nacional de la Nutrición for residency and fellowship, at the end of

44 | GI.ORG/ACGMAGAZINE

“In a way, my focus has always been to do what I love and to never give up. It would have probably been easier if, early on, I had been more assertive. But assertiveness comes with knowledge and with being more comfortable in your skin.”

which David Kershenobich wrote letters to every hepatologist he knew across the U.S. to see if I could perform research at their institution. Most of them said, “Of course, if she comes with funding, we will be happy to take her.” But there was no money. So, the only two places that would accept me and provide a salary were Northwestern University and Harold Conn at the West Haven VA. Harold was the very first one to respond and said, “Yes, we have a research position for her.” I had met Harold in Mexico when he came to lecture and I liked him a lot. Also, I looked at a U.S. map and thought, “Oh wow! Connecticut is right on the water.” I was thinking it was going to look like the Mexican beaches.

JG: Right! Not quite.

GGT: Not quite. But, I came for a visit, met with Harold at the West Haven VA and chose his research fellowship position. It turns out that two weeks before coming to the U.S., Harold calls me and says, “I have some news for you. I am starting a one-year sabbatical in California.” And I’m thinking, “What the hell! Now my mentor is leaving.”

And he said, “And you will lead my lab.” So, I come here but my mentor is away. He had started some studies on lactulose and he also had ongoing randomized controlled trials, so I decided to just continue those projects. However, Roberto Groszmann had just returned from his sabbatical in the U.K. so I started working with him as well. That is why I have experience in two different fields; one is portal hypertension with Roberto and the other is ascites and other complications of cirrhosis such as SBP with Harold. So, I was lucky in that way that in my fellowship I had two mentors studying different areas of cirrhosis. As part of the fellowship, I also had to review many charts (in that time, all paper charts) and I learned so much clinical hepatology from doing so, particularly reading the notes from Colin Atterbury who was a brilliant clinician and hepatologist at the VA. After completing my research fellowship, I returned to Mexico to apply what I had learned in the U.S. and continue the lines of research. I returned to the Instituto Nacional de la Nutrición (my alma mater) but it was rough because the salary was very meager and I had to supplement it by doing private practice, which mostly consisted of general GI, which I definitely do not enjoy. Then, as time progressed, I started getting grants including national investigator awards and teaching at private

universities that supplemented my salary so I could dedicate a bit more time to my academic position, rather than to private practice. Then, maybe about a year into this, Harold Conn calls and says, “I want you back.” And I said, “Will I have a faculty position?” And he said, “Come as a fellow and while you are here, we will work on it.” I said no to this. Roberto had another approach and he had discussed with Jim (James Boyer) the possibility of me returning in a junior faculty position. Three years into me being in Mexico, Jim said, “I want you as a faculty member.” I was already quite established in Mexico, so I thought, “Let me give it a try. I’ll give it a year.” That was 30 years ago. (laughs) JG: In reading your bio (available at medicine.yale.edu/profile/guadalupe_ garcia-tsao), you were interested in hepatology starting in medical school.

GGT: Exactly! During our GI course as a medical student, they provided a little book entitled “The Jaundiced Patient” by a Mexican gastroenterologist (Dr. Horacio Jinich) and it was so didactic and explained the bilirubin pathways and all the entities that could lead to jaundice so simply that I thought I could easily make the diagnosis. And all of my fellow students knew that if a jaundiced patient was admitted, call Lupe (in Mexico, they actually call me Lupita) because she will know, she can figure it out. This led to me discussing cases and interacting with the hepatology attendings and this, together with my medical student experience, led me to a career in hepatology. I loved the liver from very early on.

JG: What got you into medicine?

GGT: That is an interesting question which no one has ever asked me.

There are no doctors in my family.

My father thought he wanted to be a doctor but he quit after only one semester in medical school. He ended up in advertising. So, entirely different, right?

JG: Yes, right!

GGT: In “preparatoria“ (or preparatory school, which is sort of a combination of high school/college in Mexico), I had an awesome female biology teacher who made me consider biology as a career that I would like

to pursue. But when I looked at the course work for biology, it was all lab work. I thought, “What am I going to do as a biologist?” It wasn’t clear to me what my path would be. I couldn’t see myself just being in a lab because I like people. So, then I said, “So, let me do medicine.” I went to my parents saying, “I think I’m going to do medicine.” And my father was grumbling because he wanted me to do something in advertising. So, that is how I decided to do medicine, because of my love of biology and people.

JG: When you started on this pathway, did you have specific aspirations? For example, did you plan to be the Chief of a GI Section or the president of a national society?

GGT: No, not in the least. Zero. That’s the whole thing, Jill. When I was a medical student, all I wanted to do was complete medical school with the best scores.

JG: Exactly! Just let me finish that first.

GGT: Let me just finish this successfully and see then what life brings me and perhaps follow the steps of my mentors who had pursued further training abroad after which they had returned to Mexico and would be in academics in the morning and in their private practice in the afternoons. However, when I came to the U.S. as a fellow, I realized that one could dedicate their whole life to academics and have a practice at the same institution composed of patients that are the subjects of one’s research and I thought this was the ideal world. In fact, before going back to Mexico I remember thinking, “If someone would offer me a position here now, I think I would take it.” But nobody offered me a position, so I went back to Mexico until years later, when Jim Boyer offered me the position. However, let me tell you, Jill, that coming back was brutal. I thought it would be easy. I knew the place and many of the players, I had a bank account, a credit card - I thought I was all set! But it was totally different from being a fellow. A fellow from another country that works hard and does well is very liked and is not threatening. I found out that, in returning as a junior faculty member and an attending,

people who had been nice to me were no longer as nice. Perhaps because I became a threat, a competitor.

JG: Oh, no... Really?

GGT: The fellows were definitely not nice to me, but they didn’t know me, right?

Here I am, a young female attending from Mexico. So, they had no respect for me.

At that time, we had mostly male fellows.

I remember rounding and they were just looking at their watches like, “when is this going to be over?” But it was also bad with other attendings. I remember when I was on a clinical rotation and a male colleague was asked to see a patient because they did not have confidence in my opinion.

But this was not the worst part, the worst part is that my colleague consulted on the patient instead of saying, “You know, Dr. Garcia-Tsao is actually the liver attending.”

Another attending (a surgeon) also wrote a comment in the chart on how unhelpful my note had been regarding a patient with jaundice (I had recommended supportive care for a very complicated post-op course). I also remember being at a Friday conference with Dr. Howard Spiro sitting in his usual seat in the front row and at one point I am sitting there suffering because I wanted to make a comment but didn’t feel comfortable. I finally raised my hand and made the comment and Dr. Spiro turns to me and says, “And whom may I ask is this young lady?” I suspect he must have known who I was (because he had seen me when I was a fellow) but since no one had introduced me to other faculty, and there was animosity with the liver people, he seized the opportunity. It was very uncomfortable.

JG: How did you break through that lack of respect?

GGT: I just went along and considered that, little by little, I would be able to overcome these challenges by doing a good job, asserting myself by acquiring and demonstrating clinical and research knowledge that would support my opinions and decisions. I always thought that all these microaggressions had to do with me being Mexican; I never thought it was because I was female. Now, I think that it was probably both.

ACG Perspectives | 45

// PERSPECTIVES

JG: With these experiences, how do you talk to women or foreign medical graduates about microaggressions and handling these kinds of situations?

GGT: I have learned that one has to stand up and not be timid (like I had been). If one feels that something is not correct, one has to speak up even though it may be very difficult. I did speak up to that surgeon who had written in the chart about my consult being unhelpful. But I remember sitting in my office for a long time with the phone in my hand until I finally called him and told him how inappropriate he had been. He apologized. Never got to meet him because he left Yale shortly after. This was one thing I could not let pass and I had to get out of me. I felt like a really little person and I had to grow into this body and then say when things I think are not right and just say it. In a way, this reluctance to speak up, in my case, is cultural. But progressively, people recognized that I was a good clinician, making accurate diagnoses and providing good advice, that I was doing my research and I was publishing important papers. By the nature of my work is how I overcame everything, but not so much by speaking up, which I should have.

JG: For people who know you, timid is not the first characteristic that comes to mind (laughing). I think it’s hard to speak up, though, when you are so outnumbered.

GGT: Outnumbered, and probably me feeling that they were doing me a favor by taking me as faculty, like maybe I was not deserving of it. The beginning was hard.

JG: Do you now see yourself as a role model?

GGT: Now I do. Back then, no; but now, yes.

JG: With your amazing career and with your background, do women come to you for mentoring and career advice?

Or, foreign medical graduates as well because, as you said, there is still a stigma associated with being a foreign medical graduate.

GGT: Totally. I feel very connected to female trainees and I have mentored more women, in proportion to males, in our GI program. As a trainee,

46 | GI.ORG/ACGMAGAZINE

attending the Liver Meeting (and realizing that there were incredible women in the field, such as Dame Sheila Sherlock) was instrumental in me continuing to pursue a career in hepatology. When I was President of the AASLD, I started the Emerging Liver Scholar program that selects residents who may be interested in hepatology to attend the Liver Meeting. They get a guided tour of the meeting. And one of the slots is for someone from Latin America. I am very proud of this program. I still find that foreign medical graduates are more timid than American fellows. Although it may be a language issue, I speak Spanish to those from Latin America and they are still not as open and outspoken. They are like I was when I came to the U.S. JG: As part of our GI LEADER program at Yale, we have had some discussions about microaggressions and inequality in medicine, particularly in GI, which is still male-dominated, and in some of those discussions your perspective on gender issues and microaggressions was sometimes more of a “get over it” and “just push through” kind of attitude.

GGT: (Laughs) Yes, yes it was. I hate to say this but that’s what it was. In a way, my focus has always been to do what I love and to never give up. It would have probably been easier if, early on, I had been more assertive. But assertiveness comes with knowledge and with being more comfortable in your skin.

JG: Do you think your “get over it” attitude is from the male-dominated training or from growing up in Mexico?

GGT: When I was in medical school in Mexico it was actually 90 percent male.

I was the only woman in my class for internship, residency, and fellowship. All my buddies were male. I met my very first female medical friend at the end of my internal medicine residency. Unlike me, she is very tall and outspoken and she became a surgeon in Mexico. As such, and as you can imagine, she has had a very difficult time and she has somehow overcome all these difficulties. She is an outstanding physician and surgeon, despite which she has, to this day, been unable to gain the respect of many of her male peers. I cannot compare my environment to hers but, while I have tried to navigate my way, she just says what she feels without any thought of the consequences, which I think generates even more animosity. So,

I am not sure but I think it may be a bit of both. It is the “macho” attitude.

I have to say, I have clearly had very good mentors and they have all been men. I have learned good things and bad things from these mentors. I have learned that when something is truly unfair, one has to speak up. I have also learned that seeking advice from other people (men or women) is very important in determining actions to take when one considers they are being treated unfairly. When I was a fellow, there were none of these mentoring committees that exist now where one can discuss these issues without fear of retaliation.

Hearing someone’s story, as in this interview, is important for young people to understand that we all have confronted obstacles and that it is on us to decide how to overcome them and move forward. At the end, it is the love and passion of what one does that drives everything.

JG: It’s definitely helpful to hear other people’s stories to recognize that others have had similar struggles, but equally as important to have people to discuss these situations with.

GGT: Yes, and I did. At important points in my career, I have asked for help. I don’t think it has anything to do with being a man or woman.

It has to do with being a professor and a mentor. As a professor now, I know that the success of a mentee is my success and, therefore, it is not a competition; it is in my best interest to ensure that my mentees succeed.

JG: Exactly! That is what makes you such a great mentor.

Jill K. J. Gaidos, MD, FACG, is Associate Professor at Yale School of Medicine Section of Digestive Diseases and Director of Clinical Research for the Yale IBD Program.

Guadalupe Garcia-Tsao, MD, FACG, is Chief of Digestive Diseases at the VA-Connecticut Healthcare System and Professor of Medicine at Yale University School of Medicine.

EDUCATION ACG Institute Edgar Achkar Visiting Professorship

Noteworthy for Training in Speakers Your Communities

Providing

EAVP Visit photo from 2017 when Carol A. Burke, MD, FACG visited Houston Methodist Hospital

THE EDGAR ACHKAR VISITING PROFESSORSHIP PROGRAM (EAVP) HAS FLOURISHED SINCE 2014 in its mission to address an unmet need in GI training programs for clinical education from leading experts, to offer trainees an opportunity for inspiring interactions with nationally recognized speakers, and to cultivate opportunities for ACG members in the community to participate in grand rounds and other gatherings. To date, 81 institutions have hosted 57 speakers from coast to coast in the United States, as well as in Canada.

During the pandemic, EAVP provided an invaluable resource to GI fellowship programs which were able to supplement their curricula with virtual visits and connect their fellows with distinguished

visiting professors. During a time of remote learning, these EAVP visits created meaningful ways for GI fellows and faculty to benefit from lectures, small group discussions, mentoring, and one-on-one discussions.

To extend the impact of EAVP, the ACG Institute, in 2021, enhanced the program to include a new “Visiting Scholar in Equity, Diversity, and Ethical Care” initiative that provides training programs with focused talks on the issues and challenges of delivering equitable care, respecting diversity, and instilling ethical decision-making.

The ACG Institute makes it a priority to match EAVP speakers with those GI training programs that are also able to offer a broader opportunity for

community involvement through gut club discussions or participation by local ACG members during medical grand rounds.

As the program returns to in-person visits, EAVP remains truly mutually beneficial – the feedback from both speakers and GI fellowship programs remains resoundingly positive. GI fellows, program faculty, and visiting professors continue to report on how engaging and informative these visits are. The ACG Institute is proud to support a thriving program for visiting professors to share their career path and expertise and help to develop the next generation of leaders in gastroenterology.

Education | 47

// EDUCATION

David T. Rubin, MD, FACG, Visit to The University of Texas Health Science Center at Houston – April 14, 2022. Dr. Rubin of The University of Chicago presented on the Medical Management of IBD.

Tyler Berzin, MD, Visit to Cleveland Clinic – April 27, 2022. Dr. Berzin of Beth Israel Deaconess Medical Center presented on Artificial Intelligence in Endoscopy.

Marcelo F. Vela, MD, MSCR, FACG, Visit to Tufts Medical Center – May 12-13, 2022.

Dr. Vela of Mayo Clinic Arizona presented on Motility and Esophageal Diseases.

48 | GI.ORG/ACGMAGAZINE

2022

ACG EDGAR ACHKAR VISITING PROFESSORSHIPS *Visiting Scholar in Equity, Diversity, and Ethical Care

FOLASADE P. MAY, MD, PHD, MPHIL* Geisinger Medical Center MARCH 11 MARK B. POCHAPIN, MD, FACG* University of Virginia MARCH 18 RACHEL ISSAKA, MD, MAS* Mount Sinai Hospital MARCH 25

Satish S.C. Rao, MD, PhD, FACG, Visit to The Wright Center for GME – May 31, 2022.

Dr. Rao of Augusta University presented on GI Motility.

DAVID T. RUBIN, MD, FACG The University of Texas Health Science Center at Houston APRIL 14 NICOLE E. RICH, MD* University of Miami APRIL 21 TYLER BERZIN, MD Cleveland Clinic APRIL 27 MARCELO F. VELA, MD, MSCR, FACG Tufts Medical Center MAY 12-13 SATISH S.C. RAO, MD, PHD, FACG The Wright Center for GME MAY 31 SOPHIE M. BALZORA, MD, FACG* Mayo Clinic Arizona JUNE 9 RENEE L. WILLIAMS, MD, MHPE, FACG* Loma Linda University Medical Center JUNE 22

Sophie Balzora, MD, FACG, Visit to Mayo Clinic Arizona – June 9, 2022. Dr. Balzora of NYU Langone presented on Healthcare Outcomes and Healthcare Disparities.

ALLISON R. SCHULMAN, MD, MPH University of Pittsburgh School of Medicine SEPTEMBER 14-15 BRIAN E. LACY, MD, PHD, FACG University of South Alabama SEPTEMBER 21-22 EDWARD V. LOFTUS, JR., MD, FACG UC Riverside SEPTEMBER 22-23

The Edgar Achkar Visiting Professorship program is a project of the ACG Institute and is supported by charitable contributions to the G.U.T. Fund.

Education | 49

EVIDENCE-BASED GI JOURNAL REVIEW Clinical take-aways and evidence-based summaries of articles in GI, Hepatology & Endoscopy.

ACG PUBLICATION EVIDENCE--BASED GI (EBGI) evaluates new research articles published across GI and Hepatology journals using evidence-based criteria.

ACG Editors identify the highest quality studies published on important topics and create structured abstracts summarizing the study for quick reference and provide commentary on how the data is applicable to clinical practice.

Editors record audio summaries for easy listening on the go.

Listen to individual article summaries or stream the entire issue all at once.

Member benefit!

Watch for the eTOC delivered in your inbox monthly!



Full issue download available as PDF: gi.org/ebgi

50 | GI.ORG/ACGMAGAZINE

Inside the

JOURNALS

G

AC RTS EPO CASE RO J URN L

an of the Americ Official Journal enterology College of Gastro

Volume 117

| Number 6

G OM I.OR TS.C TS.G POR POR ERE ERE CAS CAS ACG ACG

VOLUME 6

| June 2022

FOOD as E MEDICIN ed by orts edit e Rep ed by nal of CasRep orts edit ne Jour ows An Onli nal of Case atology Fell ne Jour ows An Onli ology & Hep atology Fell Gastroenter ology & Hep Gastroenter

EDITORS: Brian

E. Lacy, MD, PhD,

n Spiegel, MD,

FACG and Brenna

MSHS, FACG

IN KEEPING WITH THE ACG MAGAZINE cover “GI at the Table,” we wanted to bring attention to the Red Journal special issue on “Food as Medicine” from June 2022 and highlight noteworthy work by Dr. Elliot Tapper and colleagues on pickle juice for muscle cramps in cirrhosis.

In CTG, Hussan, et al., report on changes in the microbiome and lipidomics with placement of an intragastric balloon, suggesting possible mechanisms for weight loss.

The start of the academic year in July welcomed the new editorial board for ACG Case Reports Journal, a fellow-edited journal of interesting and thought-provoking cases (acgcasereports.com).

Inside the Journals | 51

// INSIDE THE JOURNALS

[THE AMERICAN JOURNAL OF GASTROENTEROLOGY]

[CLINICAL & TRANSLATIONAL GASTROENTEROLOGY]

AJG SPECIAL ISSUE: FOOD AS MEDICINE

Adjustable Intragastric Balloon Leads to Significant Improvement in Obesity-Related Lipidome and Fecal Microbiome Profiles: A Proof of Concept Study

 "The theme of our 'Food as Medicine' special issue is multidisciplinary, representing a true intersection between health care disciplines such as gastroenterology, nutrition, and complementary medicine, while avoiding the pitfalls of 'pseudoscience' that often plague this field."

–Dr. Jasmohan Bajaj and Dr. Millie Long, Co-EICs

Official Journal of the College of GastroenAmerican terology

Volume 117

FOOD as MEDICINE

EDITORS: Brian

E. Lacy, MD, PhD,

FACG and Brennan

Hussan, et al., Clinical and Translational Gastroenterology: July 2022 | Number 6 |

Spiegel, MD, MSHS,

 READ the issue: bit.ly/ajg-june2022

Pickle Juice Intervention for Cirrhotic Cramps Reduction: The PICCLES Randomized Controlled Trial Elliot B. Tapper, MD; Najat Salim, BA; Jad Baki, BA; Zhe Zhao, MS; Vinay Sundaram, MD; Vilas Patwardhan, MD; Samantha J. Nikirk, MPH, The American Journal of Gastroenterology: June 2022 - Volume 117 - Issue 6 - p 895-901 doi: 10.14309/ ajg.0000000000001781

June 2022

 ACCORDING TO THE AUTHORS, THIS STUDY SHOWS A CHANGE IN MICROBIOME AND LIPIDOMICS WITH IGB PLACEMENT,

FACG

suggesting possible mechanisms for weight loss and the beneficial impact of IGBs on obesity-related comorbidities. In parallel, pilot data explore the utility of the microbiome and lipids in treatment stratification by facilitating identification of patients most likely to tolerate intragastric balloons placement, thus avoiding an expensive procedure in those likely to fail.

“To our knowledge, this study is the first to demonstrate a lasting impact on the fecal microbiome, including a potential trend towards increased Bacteroidetes and decreased Firmicutes levels after intragastric balloons and associated weight loss. IGB patients who tolerated the treatment had a total weight loss percentage of 15.5% after IGB placement compared to less than 3% in controls. IGB patients maintained a 10.5% TWL after 24 weeks from IGB removal. With this profound weight loss, IGB placement was associated with microbiome changes that are inconclusively different from non-surgical weight loss seen in our controls and prior studies.”

What is Known:  Improvements in the obesity-related lipidome mediate the beneficial effect of weight loss  The impact of intragastric balloon placement on serum lipid profiles is unknown  Also, limited data exist on microbiome changes with balloon placement

Muscle cramps are common for patients with cirrhosis, and conventional therapies are often unsatisfactory. The PICCLES trial is one of the largest randomized controlled trials aimed at muscle cramps for patients with cirrhosis, and its results establish a novel tool to address this symptom. In this shortterm trial, sips of pickle juice safely reduce the severity of muscle cramps.  READ bit.ly/ajg-pickle-juice  LISTEN bit.ly/ajg-podcast-tapper

52 | GI.ORG/ACGMAGAZINE

What is New Here:  Intragastric balloons are associated with improvement in the obesity-related lipidome, mainly decreased saturated mono and omega-6 free fatty acids  The improvement in the obesity-related lipidome with intragastric balloons and lifestyle counseling is more impactful than counseling alone  Despite a more pronounced weight loss, the fecal microbiome after intragastric balloons and counseling is not conclusively different from counseling alone  READ bit.ly/ctg-hussan-balloon

Meet the 2022–2023

ACGCRJ EDITORIAL BOARD A



ACGCRJ IS A FULLY OPEN ACCESS JOURNAL. VIEW ALL PUBLISHED CASE REPORTS FOR FREE. ACGCASEREPORTS.COM

CG CASE RE PO S J O U RRT N ACGCASEREP ORTS.COM

L

VOLUME 6

An Online Journal of Case Gastroentero logy & Hepat Reports edited by ology Fellow s

Thanks to outgoing ACGCRJ Editorial Board members!

We thank the outgoing members of the Editorial Board for their outstanding service to the Journal and wish them continued success in their careers.

Nicholas McDonald, MD Editor-in-Chief University of Minnesota Minneapolis, MN

Tomoki Sempokuya, MD Editor-in-Chief Nebraska Medical Center Omaha, NE

Yvette Achuo-Egbe MD, MPH, MS Associate Editor New York Medical College Metropolitan Hospital, New York, NY

GI D E S BA W E REVI

Michael Beattie, DO Associate Editor Ascension Genesys Hospital Grand Blanc, MI

Khushboo Gala, MBBS Associate Editor Mayo Clinic Rochester, MN

Judy Trieu, MD, MPH Katherine Falloon, MD Abhishek Agnihotri, MBBS, MD Amber Charoen, MD Anthony Horton, MD

Divya Chalikonda, MD Associate Editor Thomas Jefferson University Hospital, Philadelphia, PA

Fredy Nehme, MD, MS Hirsh Trivedi, MD Malav Parikh, MD Mike Wei, MD Phillip Gu, MD

Vibhu Chittajallu, MD Associate Editor University Hospitals, Cleveland Medical Center, Cleveland, OH

Erik Holzwanger, MD Associate Editor Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

Anand Kumar, MBBS, MD Associate Editor Northwell Health - Lenox Hill Hospital New York, NY

Shazia Rashid, MD Associate Editor Louisiana State University Health Sciences Center, Shreveport, LA

Eric Swei, MD Associate Editor University of Colorado Hospitals Aurora, CO

ies of mmar sed su a -b e enc copy. s new Endos

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s topic rtant impo Onwochei MD, MPH, MS d d on Jennifer ce an e n h s re li k refe s pub Associate Editor tudie r quic s fo ty y . li e stud qua ractic g the ical p University of Connecticut Health arizin to clin summ licable p p a is Farmington, CT go. e data once. n the all at ing o issue listen ntire easy e r e fo es am th r stre ries o mma

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EBGI ACG’s Evidence-Based GI evaluates new research articles published across GI and hepatology journals by using evidence-based criteria to identify the highest quality studies, write structured abstracts, and provide expert commentary on the article. A free member benefit!

Inside the Journals | 53

About ACID REFLUX & GERD

Information from the American College of Gastroenterology

GASTROESOPHAGEAL REFLUX DISEASE (GERD) is one of the most common gastrointestinal diseases. GERD is caused by the flow of contents from the stomach upwards into the esophagus resulting in both symptoms and complications. The most common GERD symptoms are heartburn and regurgitation. HEARTBURN is a burning sensation in the chest behind the breastbone. REGURGITATION is a feeling of fluid or food coming up into the chest. Many people experience both symptoms; however, some patients can have one without the other.

UP TO 20% OF THE U.S. POPULATION MAY HAVE GERD Heartburn is COMMON but NOT TRIVIAL

These may be

GERD TIPS

 Symptoms are often experienced after meals  Heartburn or symptoms happening two or more times per week can be troublesome  Antacids can provide temporary symptom relief

2 TO 3 HOURS

$15 TO 20 BILLION ANNUALLY

 Asthma-like symptoms  Bitter taste in mouth

GERD-related symptoms

GERD FACTS

U.S. Economic Burden

 Chronic cough  Dental erosions

 Over-the-counter or prescription medications may be needed  Persistent symptoms may require further investigation such as endoscopy  Surgery can be considered if you cannot tolerate medications or have persistent symptoms

LOSE WEIGHT

Avoid meals within 2–3 hours of bedtime

MORE TIPS:

If you are overweight and can lose weight GERD symptoms can improve

 

 STOP SMOKING

 

HEADS UP

LEFT SIDE

Raise the head of your bed 6–8 inches

 Hoarseness

Sleep on your left side to ease nighttime heartburn

Wear loose fitting clothes Eliminate food triggers Take your medications as directed Ask your doctor which treatment option is right for you

If left UNTREATED COMPLICATIONS may include: 

Esophageal stricture



Bleeding



Barrett’s esophagus



Esophageal cancer

FOOD Triggers to AVOID Carbonated beverages  Chocolate 

Citrus drinks  Coffee 

Fatty or spicy foods  Peppermint 

 Learn More: Scan QR code or visit: bit.ly/acg-gerd-info



Tomato products

 Find a gastroenterologist near you: gi.org/FindaGI

READ The American College of Gastroenterology 2022 GERD Guidelines: bit.ly/ACG-GERD-Guidelines-2022

54 | GI.ORG/ACGMAGAZINE

BRIEF SUMMARY: Before prescribing, please see Full Prescribing Information and Medication Guide for SUTAB® (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use.

INDICATIONS AND USAGE: An osmotic laxative indicated for cleansing of the colon in preparation for colonoscopy in adults.

DOSAGE AND ADMINSTRATION: Split Dose (2-Day) Regimen: Dose 1 – On the day prior to colonoscopy: A low residue breakfast may be Packaging and consumed. After breakfast, only clear liquids may be consumed until after the tablets not shown colonoscopy. Early in the evening prior to colonoscopy, open one bottle of actual size.

12 tablets. Fill the provided container with 16 ounces of water (up to the fill line).

Swallow each tablet with a sip of water and drink the entire amount over 15 to 20 minutes. Approximately one hour after the last tablet is ingested, fill the provided container a second time with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Approximately 30 minutes after finishing the second container of water, fill the provided container with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Dose 2 - Day of colonoscopy: Continue to consume only clear liquids until after the colonoscopy. The morning of colonoscopy (5 to 8 hours prior to the colonoscopy and no sooner than 4 hours from starting Dose 1), open the second bottle of 12 tablets. Fill the provided container with 16 ounces of water (up to the fill line). Swallow each tablet with a sip of water and drink the entire amount over 15 to 20 minutes. Approximately one hour after the last tablet is ingested, fill the provided container a second time with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes.

Approximately 30 minutes after finishing the second container of water, fill the provided container with 16 ounces of water (up to the fill line) and drink the entire amount over 30 minutes. Complete all SUTAB tablets and required water at least 2 hours before colonoscopy.

CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Serious Fluid and Electrolyte Abnormalities: Advise all patients to hydrate adequately before, during, and after the use of SUTAB. If a patient develops significant vomiting or signs of dehydration after taking SUTAB, consider performing post-colonoscopy lab tests (electrolytes, creatinine, and BUN). Fluid and electrolyte disturbances can lead to serious adverse events including cardiac arrhythmias, seizures and renal impairment. Correct fluid and electrolyte abnormalities before treatment with SUTAB. Use SUTAB with caution in patients with conditions, or who are using medications, that increase the risk for fluid and electrolyte disturbances or may increase the risk of adverse events of seizure, arrhythmias, and renal impairment; Cardiac arrhythmias: Use caution when prescribing SUTAB for patients at increased risk of arrhythmias (e.g., patients with a history of prolonged QT, uncontrolled arrhythmias, recent myocardial infarction, unstable angina, congestive heart failure, or cardiomyopathy). Consider pre-dose and post-colonoscopy ECGs in patients at increased risk of serious cardiac arrhythmias; Seizures: Use caution when prescribing SUTAB for patients with a history of seizures and in patients at increased risk of seizure, such as patients taking medications that lower the seizure threshold (e.g., tricyclic antidepressants), patients withdrawing from alcohol or benzodiazepines, or patients with known or suspected hyponatremia; Use in Patients with Risk of Renal Injury: Use SUTAB with caution in patients with impaired renal function or patients taking concomitant medications that may affect renal function (such as diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or non-steroidal anti-inflammatory drugs). These patients may be at risk for renal injury.

Advise these patients of the importance of adequate hydration with SUTAB and consider performing baseline and post-colonoscopy laboratory tests (electrolytes, creatinine, and BUN) in these patients; Colonic Mucosal Ulcerations and Ischemic Colitis: Osmotic laxative products may produce colonic mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Concurrent use of stimulant laxatives and SUTAB may increase these risks. Consider the potential for mucosal ulcerations resulting from the bowel preparation when interpreting colonoscopy findings in patients with known or suspect inflammatory bowel disease (IBD); Use in Patients with Significant Gastrointestinal Disease: If gastrointestinal obstruction or perforation is suspected, perform appropriate diagnostic studies to rule out these conditions before administering SUTAB. Use with caution in patients with severe active ulcerative colitis. ADVERSE REACTIONS: Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. POTENTIAL FOR DRUG ABSORPTION: SUTAB can reduce the absorption of other co-administered drugs. Administer oral medications at least one hour before starting each dose of SUTAB. Administer tetracycline and fluoroquinolone antibiotics, iron, digoxin, chlorpromazine, and penicillamine at least 2 hours before and not less than 6 hours after administration of each dose of SUTAB to avoid chelation with magnesium. Pregnancy: There are no available data on SUTAB use in pregnant women to evaluate for a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes. No reproduction or developmental studies in animals have been conducted with sodium sulfate, magnesium sulfate, and potassium chloride (SUTAB). Lactation: There are no available data on the presence of SUTAB in human or animal milk, the effects on the breastfed child, or the effects on milk production.

Pediatric Use: Safety and effectiveness in pediatric patients has not been established. Geriatric Use: Of the 471 patients who received SUTAB in pivotal clinical trials, 150 (32%) were 65 years of age or older, and 25 (5%) were 75 years of age or older. No differences in safety or effectiveness of SUTAB were observed between geriatric patients and younger patients. Elderly patients are more likely to have decreased hepatic, renal or cardiac function and may be more susceptible to adverse reactions resulting from fluid and electrolyte abnormalities. STORAGE: Store at 20º to 25°C (68º to 77°F). Excursions permitted between 15º to 30°C (59º to 86°F). See USP controlled room temperature. Rx only. Manufactured by Braintree Laboratories, Inc. Braintree, MA 02185 See Full Prescribing Information and Medication Guide at SUTAB.com.

References: 1. SUTAB® [package insert]. Braintree, MA; 2020. 2. Di Palma JA, Bhandari R, Cleveland M, et al. A safety and efficacy comparison of a new sulfate-based tablet bowel preparation versus a PEG and ascorbate comparator in adult subjects undergoing colonoscopy. Am J Gastroenterol. Published online November 6, 2020. doi: 10.14309/ajg.0000000000001020 3. Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM; ACG. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol. 2009;104(3):739-750. 4. IQVIA. National Prescription Audit Report. November 2020.

For additional information, please call 1-800-874-6756 ©2021 Braintree Laboratories, Inc.

All rights reserved.

201-133-v1-A January 2021

!

W! E NEW N

A NEW TABLET CHOICE A BOWEL NEW TABLET CHOICE IN PREPARATION IN BOWEL PREPARATION

• NO SODIUM PHOSPHATE1

• SAFE AND EFFECTIVE1,2 1 • NO SODIUM PHOSPHATE • ACG-RECOMMENDED1,2 SPLIT-DOSE REGIMEN3 • SAFE AND EFFECTIVE 1 – Two SUTAB doses are required for a complete preparation

Dose 1 consists of 12 tablets and 16 oz of water REGIMEN3 • ACG-RECOMMENDED SPLIT-DOSE Dose 2 consists of 12 tablets and 16 oz of water 1 – Two are required for a complete preparation EachSUTAB dose isdoses followed by two additional 16 oz of water Dose 1 consists of 12 tablets and 16 oz of water Dose 2 consists of 12 tablets and 16 oz of water Packaging and tablets not shown size.

Each dose is followed by actual two additional 16 oz of water

92% OF PATIENTS IN TWO PIVOTAL TRIALS ACHIEVED SUCCESSFUL BOWEL CLEANSING WITH SUTAB1,2* 91% OF PATIENTS IN ONE PIVOTAL TRIAL RATED SUTAB AS TOLERABLE TO VERY EASY TO CONSUME2† 1,2 ® 1,2‡ 92% OF PATIENTS IN TWO PIVOTAL TRIALSreported ACHIEVED SUCCESSFUL CLEANSING SUTAB * • 52% of all SUTAB and MoviPrep patients at least one selectedBOWEL gastrointestinal adverseWITH reaction • More SUTAB patients reported experiencing nausea and vomiting than competitor, with ≤1%TO of these reports2† 91% OF PATIENTS IN ONE PIVOTAL TRIAL RATED SUTAB AS TOLERABLE TO VERY EASY CONSUME 2‡ Packaging and tablets not shown actual size.

considered severeand MoviPrep® patients reported at least one selected gastrointestinal adverse reaction1,2‡ • 52% of all SUTAB

2† 78% OF PATIENTS ONE reported PIVOTALexperiencing TRIAL WOULD REQUEST SUTAB AGAIN FOR A FUTURE • More SUTAB IN patients nausea and vomiting than competitor, with ≤1% ofCOLONOSCOPY these reports

considered severe * Success was primary endpoint and was defined in noninferiority trials as an overall cleaning assessment of 3 (good) or 4 (excellent) by the blinded endoscopist; scores were assigned on withdrawal of colonoscope.

OF PATIENTS IN ONE PIVOTAL TRIAL WOULD REQUEST SUTAB AGAIN FOR A FUTURE COLONOSCOPY2† † Patients completed preference questionnaire following completion of study drug to capture the subject’s perceptions of the preparation experience. This * questionnaire has not undergone formal validation.

Success was primary endpoint and was defined in noninferiority trials as an overall cleaning assessment of 3 (good) or 4 (excellent) by the blinded endoscopist; ‡ scores were assigned on withdrawal of colonoscope.

Patients were queried for selected gastrointestinal adverse reactions of upper abdominal pain, abdominal distension, nausea, and vomiting following completion †of study drug, rating the intensity as mild, moderate, or severe.

Patients completed preference questionnaire following completion of study drug to capture the subject’s perceptions of the preparation experience. This questionnaire has not undergone formal validation.

ACG=American College of Gastroenterology ‡ ® Patients were queried for selected gastrointestinal adverse reactions of upper abdominal pain, abdominal distension, nausea, and vomiting following completion is a registered trademark of Velinor AG. MoviPrep of study drug, rating the intensity as mild, moderate, or severe.

ACG=American College of Gastroenterology MoviPrep® is a registered trademark of Velinor AG. IMPORTANT SAFETY INFORMATION 2‡

78%

SUTAB® (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use is an osmotic laxative indicated for cleansing of the colon in preparation for colonoscopy in adults. DOSAGE AND ADMINSTRATION: A low residue breakfast may be consumed. After IMPORTANT SAFETY INFORMATION breakfast, only clear liquids may be consumed until after the colonoscopy. Administration of two doses of SUTAB (24 tablets) are required ® SUTAB (sodium sulfate, magnesium sulfate, potassium chloride) tablets for oral use is an osmotic laxative indicated for cleansing of the for a complete preparation for colonoscopy. Twelve (12) tablets are equivalent to one dose. Water must be consumed with each dose colon in preparation for colonoscopy in adults. DOSAGE AND ADMINSTRATION: A low residue breakfast may be consumed. After of SUTAB and additional water must be consumed after each dose. Complete all SUTAB tablets and required water at least 2 hours breakfast, only clear liquids may be consumed until after the colonoscopy. Administration of two doses of SUTAB (24 tablets) are required before colonoscopy. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, for a complete preparation for colonoscopy. Twelve (12) tablets are equivalent to one dose. Water must be consumed with each dose bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Risk of fluid and electrolyte of SUTAB and additional water must be consumed after each dose. Complete all SUTAB tablets and required water at least 2 hours abnormalities: Encourage adequate hydration, assess concurrent medications and consider laboratory assessments prior to and after each before colonoscopy. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal obstruction or ileus, use; Cardiac arrhythmias: Consider pre-dose and post-colonoscopy ECGs in patients at increased risk; Seizures: Use caution in patients bowel perforation, toxic colitis or toxic megacolon, gastric retention. WARNINGS AND PRECAUTIONS: Risk of fluid and electrolyte with a history of seizures and patients at increased risk of seizures, including medications that lower the seizure threshold; Patients with abnormalities: Encourage adequate hydration, assess concurrent medications and consider laboratory assessments prior to and after each renal impairment or taking concomitant medications that affect renal function: Use caution, ensure adequate hydration and consider use; Cardiac arrhythmias: Consider pre-dose and post-colonoscopy ECGs in patients at increased risk; Seizures: Use caution in patients laboratory testing; Suspected GI obstruction or perforation: Rule out the diagnosis before administration. ADVERSE REACTIONS: with a history of seizures and patients at increased risk of seizures, including medications that lower the seizure threshold; Patients with Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. DRUG renal impairment or taking concomitant medications that affect renal function: Use caution, ensure adequate hydration and consider INTERACTIONS: Drugs that increase risk of fluid and electrolyte imbalance. laboratory testing; Suspected GI obstruction or perforation: Rule out the diagnosis before administration. ADVERSE REACTIONS: Please see Brief Summary of Prescribing Information on reverse side. See Full Prescribing Information and Medication Guide at Most common gastrointestinal adverse reactions are: nausea, abdominal distension, vomiting and upper abdominal pain. DRUG SUTAB.com.

INTERACTIONS: Drugs that increase risk of fluid and electrolyte imbalance.

Please see Brief Summary of Prescribing Information on reverse side. See Full Prescribing Information and Medication Guide at SUTAB.com.

From the makers of SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution for adults—

THE #1 MOST PRESCRIBED, BRANDED BOWEL PREP KIT4

From the makers of SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution for adults—

THE #1 MOST PRESCRIBED, BRANDED BOWEL PREP KIT4