from Las Vegas, expecting the signal from the noise. It's theCUBE covering InterConnect 2016, brought to you by IBM. Now your host, John Furrier and Dave Vellante. Okay, welcome back everyone. We are here live in Las Vegas for exclusive coverage of IBM InterConnect 2016. This is Silicon Angles theCUBE. This is our flagship program. We go out to the events and extract the signal from the noise. I'm John Furrier with my co-host Dave Vellante. Our next guest, we've got two guests talking mobile, Michael Gilfix, who's the VP of IBM Mobile First, and Pete Teigen, the mobile leader of IBM's Institute for Business Value. Now that sounds like, there's a lot of business value in there. Michael on stage on the keynote, Mobile First. Really a big success story. Congratulations. Great to have you guys both on theCUBE. Happy to see you. Thank you, thank you. We're Mobile First World. And you're actually Mobile First in the name. I mean, it's no brainer. I mean, love the Apple guy on stage yesterday too. Just, you know, just kind of doing the victory dance. And this game's just getting started. The iPhone's still in elementary school. It's only since in 2007, since it's launched, really a game changer. Look at the significant change. The iPhone is a computer. It's got software that makes telephone calls. Mobile's changing. Guys, what is the mobile world like right now? Besides, totally on fire and growing. What's changing about mobile? Mobile's just become everywhere. It's what we expect. It's what we experience. And mobile's bigger than smartphones and tablets. I think we were talking maybe two years ago. Three years ago, we'd be talking about that. But what we're finding is, you know, there's this digital service for every point in our lives. It's that LED that I can interact with that's running mobile technology. It's the watch. It's the new desktop, right? That is in our TVs. It's in our cars. So all these things are effectively mobile technology. They're digital technology. And mobile's driving a lot of data too as well. It's not only getting data to the mobile phone. The amount of data we're hearing, certainly in the sensors and with mobile devices, you've got GPS's on the phones. It's enabling a whole lot of creativity. A whole lot of conversation. Apple was kind of pointing at that. 100 billion downloads on the app store. Just significant engagement, success, interaction. But the data coming in from the phones is significant. You got data from machines on the other side. We've heard from the keynotes, the data, the APIs, the Apple Swift. What does it all mean to the person in an enterprise saying, I got to transform my enterprise on this digital transformation? How did that all connect? Well, I think for certainly for us as consumers, there's just a huge opportunity to get a level of convenience that we've never gotten before. It makes it easier to find things we're interested in. It makes it easier for us to get goods and get them in the moment that we need them. But I think for enterprises, the opportunity is to really help their employees be substantially more effective at their jobs because they have this incredibly powerful computer in their pocket, and that can help them to make intelligent decisions at every given moment in the day. And if we could all just make smarter decisions in our day to day, I think we'd all just be better at our jobs and therefore more productive. And I think it's that further penetration you talked about the ubiquity of mobile in our consumer lives, our personal lives, now with the accessibility of all this data moving into the enterprise. So now we expect that same level of experience in our work. Pete, talk about the business at home. Before you get started, I want to ask you, talk about what is the Institute of Business Value? The in question. Because we're actually trying to understand, we're the business value.  Exactly. So we'll talk about what you guys do and how it's evolved. The IBV Institute for Business Value is the research arm inside of IBM where we do independent research, surveying global respondents, and come out with these reports. Reports that help us understand behaviors of our clients as well as the market and really address some of those biggest challenges, some of those unanswered questions. Okay, and the latest one you did on mobile, talk about that a little, set up the discussion. Well, one of those big unanswered questions is in the mobile space, what kind of ROI am I getting? You know, I think it's easy to acknowledge that mobile is prevalent everywhere. But what we also notice is that like in iceberg, few people really see the true value that mobile can bring. You know, you think of an iceberg 10% above the surface, 90% below the surface, that's how we feel about mobile. There's still a lot of uncaptured value. That's what really drove this study. So that's interesting because you know, you don't think about ROI and mobile, you just think I need a mobile, right? But you're saying, you're putting forth the premise that people aren't getting as much as they could out of their mobile investments. If they did more, they'd get more. Is that right? So that was really the impetus for the study. That's right. So what did you find? Well, we found at the broad strokes, the biggest impactful finding was the amount of return that's expected. So we can translate that into simple math. I'm a finance orientation in the background. So we talk about revenue increases, average revenue increases of 7% achievable plus average cost decreases of 6%. Cost decreases. Decreases. So you look at that combination of return and then simply divide that into whatever your mobile spend is, easy translation for ROI. And understanding the drivers of those elements really helps understand how you maximize it. So okay, you got the surveys going on.  You get a lot of data. I wanna connect the dots on the trends and highlight two trends of Mobile World Congress that kind of highlight where we think mobile's going. We'll try to connect the dots from your survey and research. One is obviously in Barcelona, Mark Zuckerberg from Facebook went out there. They're doing the road show, virtual reality. They got Oculus Rift that's showcasing that. That's an immersive, rich, heavily compute intensive UI. Okay, so that's points to the user experience. 5G, connectivity everywhere. Could be over the top, powering IoT. So again, connectivity, experience, software, rich, media. Okay, is that where it's all going? How does this all connect? Because we still need more horsepower. We still need, but the screen's so small. What do you guys see in the data? Well, I think one of the things that we learned from the study was if you wanna unlock the value that was just described, you really need to take a holistic approach to your business. Why? Because you need to really think about each of the different touch points where people ultimately interact with different systems. It could be that you're looking at the different employee roles you have. It could be the different interface with your partners, with your customers, et cetera, and rethinking that. I think the trends that you mentioned are the opportunity to create new touch points. But what I think we saw is the people that took a holistic view of their business and really thought through each of the different angles where they could add value, those were the people that got the outsized returns. So that's sizzle then. That's just sizzle. The steak is underneath the water, if you will. So the action with the untapped value is understanding context. Is my mom getting that right? Or having contextual relevance in the moment? Well, mobile's a people problem. You need to think about, it's a human factors people problem. We need to think about how do we make people and users more productive? Whether we're acting as consumers, acting as employees, acting as partners. And really deeply understanding the needs of those roles and where you can add value. And that's really, I think what you look at these top folks that are really getting the most benefit from is they've done that analysis and they've really thought through the key moments of value and they've translated that into something that really permeates every different aspect of their business. The folks that didn't do that, the ones that maybe just did pockets of mobile or the ones that did the bare minimum to enable the mobile channel, they just didn't get the same level of return because ultimately they didn't really look at each of the different areas where they can improve people time. So you talked to a thousand people and you segmented them in some way, shape, or form. And so how did you determine the potential? You talked to the people who were actually doing it and I trust you guys know what you're doing. I'm just curious, how do you get that? Because ROI information sometimes can be fuzzy. They might not have it at their fingertips. Sometimes you got to sit down and really probe. How were you able to get that information and from whom? Well, it's a developed questionnaire that's been reviewed multiple times to really extract that kind of information and then finding the right people to interview for the survey. The interview surveyed the C-suite and directors, executives involved in their mobile initiatives. So that was one of the first qualifiers. So guys who had visibility on the financial impact. Visibility into the mobile initiatives, exactly right. All right. And so you focused on those two broad areas. Let me guess, you consolidated everything into those two broad areas, but the list of benefits must have been enormous, right? You had to categorize them into revenue generation or cost savings, right? Exactly. We have several drivers that fit into that revenue increase bucket. You think of new revenues. You think of increased revenues on your existing base. You think of expanding into new markets, creating new business models, all of those things that are very top line oriented, very growth oriented. In fact, that was one of the things that we noticed in the high performing group was that they tended to focus more on that top line for growth as opposed to just cost cutting as one of their main objectives. I mean, I think it's important to provide a rule of thumb from these kinds of studies. Yeah, of course. We get too specific. I think we'll lose people in trying to figure out how that maps to their business. I think the easier we can make it for people to just understand as they go into these efforts, where am I going to land at the end of it and how do I gauge my level of investment and involvement? That rule of thumb is just incredibly valuable for organizations at large. Basically, they don't want to bite off more than they can chew and get in this mess of twisted around and all these different objectives and metrics. And they don't want to get stuck in analysis paralysis, trying to figure out some complex matrix that they can't translate to what they experience as a business. Knock down some wins early. Agile model, kind of go down there. Yeah, absolutely. You said you found on average that people had five mobile initiatives this coming year and were spending on average 15 million per organization. Right. So these are distinct projects. They're all sort of interrelated all over the map. Can we talk about the knobs that I have to turn as an executive? One interesting point about that, as far as the number of projects in their mobile portfolio, five to six projects on average and 12 to 15 million annual spend on mobile. One thing that we thought was interesting coming from those numbers is that even with that robust pipeline, planned activity, they didn't seem to really understand the importance of the collaboration, reaching across lines of business to get that full coordination. And when you do that, you're able to really scale up all those projects and really drive that better. Yeah, so I mean, largely you learned that they were sort of independent initiatives, right? Led by an independent leader, funded by different businesses, perhaps. I think one stat on that aspect is 40% of them admit that they pursue it ad hoc. They just kind of one-off projects that aren't really coordinated. Which is understandable. They say, hey, I'm an opportunist. I'm a business leader. I'm going to go for it. I'll fund it.  You've got two researchers going at it, like, hey, how are we doing the methodology? We're like, hey, let's talk about the technology. There was a statistician that was going to be joining us. This is interesting. He's a math guy. But the point I want to get to is, okay, so how do you connect those independent initiatives? So obviously, there's a data layer. And what else? What are those other? Again, if you think about it like a people problem, a people process problem, there has to be somebody who has a good purview across the business overall to figure out the impact because all these different roles are connected. You know, if I work, let's say, in retailing, the person that does inventory management is connected to the buyer who's connected to the store associate who's on the floor. I can't just change one of these roles in isolation without impacting the other. For example, if I'm going to give a mobile application to a retail associate, well, that's a tremendous opportunity to collect information at the point of sale that helps a buyer to better pick their products. And if I can forecast based off of buyer trends, then I can stock my inventory management and do that more effectively. So someone has to take on the role of looking at the interrelationships between each of these different things and thinking about that as a way to truly optimize. Data is a huge component of that, obviously, right? That's a whole nother. We're going to have someone on the other side who's smart enough to actually understand the interrelationships from first, right? But this is the key point. The siloed isolation problem is the paralysis problem you get through because if you start to get micro on the deployment and how you're thinking about it, there's always going to be a fatal flaw. If you believe that, I mean, I do believe this integrated model works, but you have a fatal flaw if you don't go integrate it. Is that kind of where it dies? It's an initiative that you have to fund as well. You don't know what you don't know, right? So if you're not looking across other lines of business to see that full integration. Yeah, but this initiative that has to get funded, right? Somebody in the corner of the suite says to say, okay, I got to go to the CFO. I got to make a business case for actually integrating all these things. It doesn't just come for free, does it? We did discover that 62% of enterprises got payback of the project within the first year. Which is- For any mobile project, or are you talking about the integrations? With any mobile initiative. So I think the good news is, if you're worried about where to start, that's a great suffering statistic that says, what are you waiting for? It's self-funding. You might as well get started with one of those roles. And if you figure out how to link them to other roles, well, you're just going to get multiplicative benefit. Yeah, but the key is to your point, you don't have to go for the holy grail right out of the box. You can go knock down some value instantly. Absolutely. And then you have a little traction versus the big bang theory, getting it all on paper, political. That's right. That's right. One aspect you just mentioned about garnering support for the project. One of the findings that came out of the study was also those that were in the high-performing group had C-suite alignment. So in other words, they had the support of the C-suite. It was one of the most influential groups in driving mobile objectives. And it also helped guide the strategy. So it's really important to have that element. And I love the comment you made about multiplicative effects because those guys who have alignment are on the S-curve earlier and they're going to reap the returns faster, gain competitive advantage. That's right. Did you probe for that at all or are you starting to see that in the market space? Well, I think our segmentation sort of showed that that was the case. When we tried to make sure that we understood the attribute to the people who had outside success versus people that were getting minimal returns, those were some of the key attribution that we discovered as part of the study. That's just great stuff. We could do a whole cube day on this topic because it's very integrated with other aspects. But final point, guys, I want to get your comments on the show. Obviously, being on stage, mobiles in the front of everything, that is the endpoint, whether it's internet of things or human, humans are things too. What's your take on this vibe of the show? These are the people we just talked about with mobile. The blue mix integration, we saw spinning up stuff on with containers is really significant. That's a little kind of geeky point of what's going on with mobile to the data layers, the integrated value chain, the Institute of Value Management Consulting aspect of it. That's a lot there. What's the vibe of the show? Because it's a lot to get your arms around. Is there a vibe here that pulls it all together? Well, it is true that we're providing lots of options to our customers, but the fundamental message I think is really the same. I mean, we've taken a lot of steps to make it easier than ever for people to go and create applications. If you were able to listen to some of our main stage messages, the things that we've done are really about what we've been calling sort of radical simplification of end-to-end development because we want to make it substantially easier for people to build incredibly powerful business-impactful experiences, but make sure that they're leveraging their assets, leveraging the data that's locked in on-premise, leveraging algorithms built in for intelligence to their advantage, making sure they're making sense of all that data. We're making that process really easy end-to-end and I think that's going to make it even more accessible for many of those folks that want that kind of outsized return. Yeah, and it was a great keynote. I think making it easier reduces that denominator of the ROI equation, right? You're making it easier to invest. So I said that the key words were cheap computing storage, VMware, Open, Video, Apple, Developer, was kind of the summary of the first day. So you're saying easy. That's the key kind of vibe here. Trying to make it a little bit more easier for your customers to get up and running. Yeah, easier and accessible power. I think those are our two messages. You need power for IoT, that's for sure. And we're bringing the power here and remember on March 15th, Cube Madness starts. That's our March Madness Cube version where our guests get all nominated for their bracket and then they vote in and which becomes a hackathon basically. So if you're one, all the best brackets come together and Cube Madness on March 15th on SiliconANGLE.tv. War from interconnect after this short break.


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Good afternoon and thank you for joining the listen to your gut living well with IBD our lunch and learn webinar We will get started in just a few more minutes. We'll just wait for a few more people to join Good afternoon. I think we are ready to get started So thank you for joining us as I mentioned today. We are Today we have with us. Dr. Cross Dr. Raymond Cross who is a professor of medicine and the director of the IBD program At the University of Maryland Medical Center and he is the co-director of the digestive health center. Thank you for being here today, Dr. Cross Thanks for having me and Thanks for all of you for attending So if you go to the next actually we should introduce Shelley before we go to the next slide Also presenting is Shelley Neiman. She is our expert GI dietitian within the digestive health center Hi everybody. Thanks for having me All right, great Aaron. Can you go to the next slide? Absolutely So just over the next 20 minutes or so, we're gonna go over some background information about Crohn's and Colitis Who gets Crohn's and Colitis? Why did you or your family member get Crohn's or Colitis? What's the difference between the two diseases and how do you diagnose Crohn's or Colitis? It's the next slide So a little bit about these are old very old slides the Crohn's and Colitis Foundation is no longer the Crohn's and Colitis Foundation of America That's how old they are but just a little bit about anatomy So the GI tract starts from the mouth into the esophagus the esophagus is just a hollow tube that transmits food from the mouth to the stomach The stomach is a mixer a grinding area where it breaks down the food into smaller parts and then slowly releases it into The proximal small intestine where most of the work of absorption of both fluid and nutrients takes place Some other important organs in the upper GI tract the liver Which does many things but for digestion secretes bile which helps emulsify fat so that they can have they can be absorbed in the Typically the distal small intestine The gallbladder stores bile For secretion when we have a meal and the pancreas is an important organ that neutralizes acid as well as helps us to Breakdown proteins and carbohydrates next slide The lower GI tract is basically comprised of the colon So all of the work of absorbing most of the work of absorbing fluids and nutrients takes place in the small intestine Those fluids that are left over and some Unabsorbable things like think about the skins on the vegetables that you eat go into the colon Which is mostly liquid on the right side Almost all of that water is absorbed as it moves from the right to the left side of the colon and the left side of The colon and rectum is basically a storage organ So it allows you to store stool until it can be conveniently Evacuated into the toilet and then the whole process starts again next slide So when you talk about IBD inflammatory bowel diseases, they're comprised of several different diseases So we're talking today about Crohn's and colitis about 15% of the time We can't really determine whether it's all sort of colitis or Crohn's and you might hear your doctor call it indeterminate colitis or the technical term for that is IBD type unspecified if You have Crohn's disease and your doctor tells you you have colitis That just means that you have involvement of your colon and your colon is inflamed So Crohn's and Crohn's colitis and all sort of colitis are distinct There's some other disorders that we lump into IBD one is microscopic colitis, which is typically affects middle-aged and older patients and presents with severe watery diarrhea in patients that have some form of Stoma and so a bag on the outside to collect waste or those that have had prior surgery and have a Segment of the colon that's not attached to the proximal small bowel They can get inflammation in that segment called diversion colitis Some patients with diverticular disease So you may have a family member who's had diverticulitis or bleeding from diverticulosis They can develop a form of IBD in those segments And then if you've had a Collectomy removal of the colon with creation of a new rectum called an IPAA or Iliol anal pouch or J-Pouch There can also be inflammation within that pouch, which is called pouchitis Next slide So Crohn's and colitis are increasing so the first reported case goes back into the 1859 Primarily through up until 20 years ago or so This was mostly a disease of industrialized economies Western world, but in the developing world We're starting to see an increase in cases So it's now estimated that about 3.1 million Americans are about 1.3% of the population in the US has Crohn's and colitis next slide If you look within Within North America within Europe, this is Europe you see a north-south gradient So Crohn's and colitis is more common in northern climates than it is in southern climates We don't know exactly why that is It may have to do with sunlight and vitamin D deficiency It could be due to higher rates of infections and warmer climates Which shut down the autoimmune process. We just don't really know next slide If you're looking at age distribution, so this typically affects Patients in their 20s to 40s is when the onset of disease is but if you look at this graph You can see that it really can affect any age group about 15 percent of Patients affected are under the age of 18 and we're even starting to see Crohn's and colitis in very very young children, which is called very early onset IBD And you can see that even in older patients That's about 15% now of the new diagnosis new diagnoses or those that are 60 years or older Next slide So why do you get Crohn's and colitis? So if someone tells you that they know exactly why you have this They're not telling you the truth We don't really know why an individual person Develops Crohn's and colitis. This is what we know genetics are important about 15 to 20 percent of affected individuals will have a first-degree relative with the disease We'll talk a little bit about genetics in the next slide As I mentioned, this is more a problem of developed countries. So Westernized societies So it's something about the diet in those societies the environment that we live in in those societies that are important There remember we have as many bacteria in our intestines as we do cells in our body So those bacterial populations are very important And they have an impact with our immune system So some injury occurs something happens that sets off an immune response that then reacts to the microbes that we have in our intestines as a pathogen and the inflammatory response Initiates and it doesn't turn itself off. I have stress on here as well when I first started doing this I really poo pooed stress is being important, but increasingly we're recognizing that Physical and mental stress does have does play a role with some patients and either Triggering onset of the disease or triggering a relapse next slide So let's talk a little bit more about genetics. So Genetics is more important in Crohn's that it is an ulcerative colitis Typically if you have a relative with a first-degree relative with the disease You tend to inherit the same type of disease. So if my mom had Crohn's disease I tend to have Crohn's disease if my mom had Crohn's disease with blockages or strictures Then I tend to have that there's this other phenomenon. We see where It's called genetic anticipation where if your mom had the disease at age 40 I would develop the disease at age 30 and my child may develop the disease at age 20 So earlier onset of the disease It's not one specific gene. We've been looking at genetics for a long time There've been a number of genes identified, but there's clearly not one causative gene one question that comes up I'm just going to bring up quickly is if you have Crohn's or colitis The odds of your child getting it if you're the only parent that has the disease is 5% or less So it's uncommon that your child will develop the disease next slide So again, we talked about environmental triggers. So what things diet is important Shelly's going to spend a lot of time talking about diet. So I'm not going to talk too much about that antibiotics so antibiotics can trigger new onset disease or a flare and We think that that's by altering the intestinal bacteria in a negative way an acute infection can be the Precipitant of a relapse or new onset Anti-inflammatory so ibuprofen, motrin, a leaf in the in the city Goody powder, BC powder, those are powders that are basically aspirin based product can either cause relapse Trigger the disease or can cause ulcers that can be confused with Crohn's Stress we mentioned smoking is very interesting actually so Smokers are more likely to develop Crohn's more likely to have severe Crohn's and more likely to have surgery for their Crohn's Whereas smoking is actually protective for all sort of colitis. So it's one of the few illnesses that Smoking improves the symptoms that we're not suggesting that you should go out and start smoking if you have all sort of colitis But importantly if you notice that your disease started after stopping smoking we see that Association quite a bit next slide So a little bit about the bacterial environment again. We have been studying this for a long time We're still really I think it in our infancy and understanding how all this works, but simply thinking about this you can think that there's a yin and yang of Microbes in your gut. So there are good bacteria. We could call them probiotics That protect us from injury and they're back in a biot. There are microbes that are Quote bad for us and you can see this nice balance and what happens with Infections or with antibiotics is it can tip those scales to more injurious bacteria that can trigger either a relapse or Onset of disease next slide So how do you differentiate the two diseases? So all sort of colitis is simpler to think about Typically all sort of colitis presents with bloody diarrhea We mentioned smoking so if the onset of symptoms is within weeks or months of stopping smoking That's very suspicious for all sort of colitis All sort of colitis almost always starts in the rectum Which is the end of the colon and extends continuously from the rectum And it can go throughout the entire colon, but it typically does not go into the small bowel The inflammation tends to be more superficial. So it doesn't go into the walls of the colon And we don't tend to see skip areas. So it tends to be Continuous all the way around next slide now Crohn's disease is quite different. So it can affect any Segment of the intestine from the mouth all the way down to the rectum It most commonly affects the ileum, which is the end of the small bowel and the colon About 20% of patients will only have colonic involvement About a third will only have small bowel involvement and there's a subset of about maybe five percent They're going to have involvement in the middle part of the small bowel or the upper part of the intestines The duodenum or the stomach or even the esophagus Crohn's disease can have a Transmural Inflammations meaning it can go through the superficial layer of the intestine Into the muscle and the outer layer and you can develop strictures You can develop fistula so you can develop a connection between one loop of bow to another loop of bow a Loop of bow to the skin surface a loop of bow To the bladder for example The inflammation tends to be more patchy So we often see skip areas Most patients don't have bleeding with Crohn's disease. It's typically non-bloody The rectum is often spared which is different in all sort of colitis The way the lesions look is often quite different and I'm going to show you better pictures here in a different slide The area around your Anus the perianal region can be involved with fistulas and absceses as well And then on biopsies we often see these Hallmark findings called granuloma what you're present in about 40 to 50 percent of patients next slide So there's different types of Crohn's disease that you can see so in Pediatrics for example most patients present with inflammatory disease. So they don't have a blockage They don't have these internal fistulas They typically are presenting with abdominal pain non-bloody diarrhea, and then they can have extra intestinal symptoms They can have fatigue fever weight loss, etc Patients with obstructing disease can present at the time of diagnosis or after years of The disease this is can be subtle to pick up Patients in the early stages will have intermittent Abdominal cramping and pain often triggered by meals. They may have abdominal bloating loud bow sounds in later stages They can have nausea vomiting. They can wake from sleep with pain. They may have weight loss in young women in particular at the early stages this can be confused with irritable bowel syndrome because if you look at How we define irritable bowel syndrome. It's abdominal pain associated with altered bowel habits and relief of pain with bowel movements And if you have a blockage you will feel constipated for a while You have cramping and then you will have diarrhea and you'll feel better And so you could actually meet criteria for irritable bowel syndrome. So we see this fairly frequently The fish stylizing or perforating patients are usually easier to pick up. They tend to present with more severe pain Fever, they often present to the emergency room They're quite sick and then about once every two or three months We'll have a patient referred to us who the outside doctors think may have had appendicitis And it ends up being a presentation of Crohn's disease. So we see that as well next slide So I mentioned extra intestinal manifestation. So The eye can be involved. So a red painful eye is worrisome in Crohn's and colitis for Episcleritis or uveitis Our patients with both Crohn's and all sort of colitis can get mouth ulcers or canker sores Patients can get an arthritis affecting their peripheral joints. So hands and knees But it also can affect the joints in the The buttocks as well as the spine When our patients have active Crohn's and colitis, they may develop clots Either in the legs or in the lung There are a couple skin conditions erythema and adosum Piedermic angrenosome that also can be associated with the disease next slide So we're gonna move now to diagnostic testing. So why does your gastroenterologist and sometimes surgeon? Why do they order diagnostic tests? What's the logic for that? Well, initially, it's to make a diagnosis So we we rarely make a diagnosis of Crohn's disease or ulcerative colitis Without a endoscopic procedure of some type with biopsies. There are exceptions But in most cases you need to have a scope and a biopsy As either at the time of diagnosis or later in the disease We may be looking for a complication. So we may be suspicious Do you have a narrowing blockage or stricture and we're already ordering a scan of some type? If you've had chronic colitis for eight to ten years We often do these fairly regularly to look for pre-cancerous type Pre-cancerous areas or dysplasia or colon cancer, which is more common in our patients With chronic colon inflammation If your provider has you on therapy and immune suppressor or biologic We're doing this to assess the effectiveness and the safety of the drug. This can be blood work. This can be endoscopy This can be imaging can also be stool testing and when you have symptoms It's very common that your provider is going to ask you to get testing done because not every symptom that you have is Going to be a flare of your disease for example Shall we will talk to you perhaps about being lactose intolerant? Patients can have both irritable bowel syndrome and Crohn's and colitis Patients that have had surgery can have other Factors that are driving their symptoms. So when a patient's doing well and suddenly has a change We need to try to figure out why that's happening and there's some tests that can give us prognostic information We don't use the more expensive prognostic tests often, but I envision in the next 10 or 15 years We're going to be able to tell newly diagnosed patients what their risks are for a more severe form of Crohn's and colitis next slide So let's talk about endoscopic procedures. So most patients are going to have a lower endoscopic procedure A colonoscopy evaluates the entire colon and the end of the small bowel called the ilium This is a tube with a light camera and a working channel so we can pass biopsy forceps through it as Sigma doscopy is the same concept It's just a shorter scope and it's meant to evaluate the left side of the colon Sometimes we can get into the middle of the colon, but typically the end of the colon next slide What do we see? So hopefully your disease is under very good control So we're seeing the upper left panel, which is a normal colon. You see the nice glistening mucosa and the vascular pattern. You don't see any bleeding or ulcers there in The upper right corner you can start to see that we don't see the blood vessels as well. There's a little bit of redness We don't necessarily treat that degree of inflammation, but it is a difference from the left panel Now on the bottom two panels you can clearly see that that's abnormal So we've lost the vascular pattern and we see redness. You're starting to see ulcers and you're seeing bleeding So these are typical images of active ulcer of colitis next slide Now Typically, Crohn's looks much different. So this is more severe looking Crohn's disease But you can see the ulcers in Crohn's disease don't have that superficial Sandpaper you look to them If you're in Baltimore, you recognize the cobblestone street and so in the far right You can see why they call that cobblestone in so the bricks would be the heaped up mucosa and the filler between the bricks Or the ulcers so some pathologist locked up in the basement described that as cobblestone in it It still exists today. So you can see that the ulcers look much deeper and Often snake-like or linear in our patients with Crohn's next slide We use a lot of imaging as well So this is an example of a CAT scan a special type of CAT scan called a CT enterography And what you're looking at here, I don't know if my mouse does work This is an area of ilial Crohn's that is narrowed and thickened Suggesting that there's a complication as well as disease activity We also can do an MRI in the same way We typically use MRIs in younger patients because they're more likely to get multiple scans in the course of their lifetime Whereas middle-aged and older patients we often do CT's CT's are Cheaper and quicker to get But they have radiation exposure whereas MRIs are much more expensive take much longer to complete But have no radiation associated with them next slide So I didn't show you an upper endoscopy But the concept is similar except the scope is going into your mouth instead of your bottom And we can evaluate typically the esophagus stomach in the very beginning of the small bowel The colonoscopy I told you can evaluate the whole colon and the last the end of the small bowel So next click Aaron So the black box is the is the 1416 feet of small bowel in between now clearly with imaging like CT scans and MRI we can get Pictures of the intestine, but visually seeing it can be a challenge, but we do have some new techniques next slide So one of those is a video capsule endoscopy, so these are shown on the right there approximately the size of a penny They have a light source in the camera and they take Thousands and thousands of pictures from the mouth all the way down to the toilet ball And if you ever have this, please don't bring your pill camera back We don't want it because the images are transmitted to a utility belt to you well where during the course of the study So the images get transferred to this recorder and then are read by a gastroenterologist and we can See small bowel Crohn's that we can't reach with the scopes next slide So you don't get quite as clear a picture as you do with an upper endoscopy or lower endoscopy But we can see Crohn's lesions with this technology now. We have to be careful Healthy volunteers that don't have any evidence of Crohn's we can see small ulcers in their bow If you're taking those pain relievers like aspirin and motrin they can also cause small lesions So we really need to be careful But typically when we see bigger ulcers more extensive ulcers that tends to signify that we're looking at Crohn's disease next slide We also have a newer technology a single or double balloon endoscopy So it's the same concept as a as a Kalana scope But it has either one or two balloons attached to it which help us Advance the intestine over the scope so that we can go deeper into the intestine So let's say we were suspicious of Crohn's and we wanted to get to that area We could either from the bottom or from the top try to access it with this technology and the next Click will show you what that scope looks like. So this is an example of a single balloon Endoscope next slide So I went maybe a few minutes over I apologize, but to summarize Crohn's and Klaidus is very common affecting about 1% of the population Although genetics diet the environment stress and the bacteria and our intestines are important for why you develop Crohn's and Klaidus No one knows exactly why you specifically Developed this and it's unless you're a smoker with Crohn's. It's not a disease caused by bad habits. It's not your fault It's simply bad luck in most cases a good provider can differentiate between all sort of Klaidus and Crohn's as a patient you should expect regular testing including Periodic scopes to be done and this is because we've recognized that with if we go beyond symptoms We can establish tighter control of disease and patients have better outcomes and less likely to be in the hospital and need surgery And this last point is very important if you remember nothing else if you find the right provider and the right Medication you can expect to live a normal life. So our patients work Play have kids have normal lives the vast majority of them So if you find the right person in the right drug, this is what you can expect So thank you very much I think Aaron is gonna maybe give me a few questions if there are any and then we're gonna transition to Shelly for the second half Thank you, Dr. Cross if you have any questions, please type them in at this time All right, if you have questions, you can save them for the end as well and We'll we'll transition to Shelly and she's gonna teach you about diet in Crohn's and Klaidus Shelly take it away Wait, wait, we do have one question Dr. Cross that just came in The question is do we have to avoid aspirin is Tylenol better? So generally Tylenol is a much safer and better pain reliever for all of us We should start with that first but particularly for Crohn's and Klaidus If you do need those drugs, there's a couple options. For example, if you have Vascular disease heart disease you can low dose aspirin is safe to take We also know that if you take less than five doses per month of those medications For example, if you have a headache twice a month and you need to take a dose of Motrin It generally doesn't cause flares for patients that have like chronic arthritis or things like that to need more regular dosing There's drugs that are called cox two inhibitors examples of that are Celebrax and Mobic and They have been shown to be safe for our Crohn's and Klaidus patients to take they do not cause a relapse But they're more expensive and sometimes harder to get the insurance company to pay for We have a few more that just came in. Do you recommend a certain type of probiotic for Crohn's disease? Tough question generally not The the the best use of probiotics is when you're on an antibiotic because it can decrease antibiotic associated diarrhea But generally probiotics have not been shown to improve Crohn's and Klaidus So I tell people that you could save that money and go out while pre-covid you could go out to a nice dinner But they're generally safe, but not thought to improve your Crohn's and Klaidus Okay, great. Next question. Can you talk a bit about skin conditions? Yeah, so the classic skin conditions are erythema and adosem So these are bumps typically on your legs that look like black and blue marks that happen when your Klaidus or Crohn's is flaring And it typically gets better as we treat the disease Piederma can present with ulcers on the skin and that can occur even when your Klaidus or Crohn's is under good control and Often we need to intensify the either the immune suppressive therapy or the biologic therapy for that And it can be really painful and uncomfortable We have also seen that our patients with Crohn's and Klaidus have a higher risk of psoriasis So remember if you have one autoimmune condition, you're more likely to get another so we see Things like psoriasis and hydraedonitis are more common And then unfortunately about three to five percent of our patients that are on remicade eumera simsia type medications Can develop a form of psoriasis. It's actually a drug side effect and not a new diagnosis of psoriasis Thank you. What are your thoughts on turmeric? So turmeric is a spice that we find that's predominantly used in Indian food It is an anti-inflammatory It's been used in patients with arthritis to decrease pain and inflammation And there have been some studies in all sort of Klaidus in milder patients showing that it is helpful So our guidelines don't recommend it, but they don't recommend against it So in some of my patients with milder disease, you know, I I'm supportive of them using it and if it works great In patients that have had an incomplete response and need some add-on therapy I've tried that before I think it's generally harmless And so I think it's it's a reasonable thing to try for most people with milder disease Okay, great. And this is our last question before we we move on to Shelly Could you discuss the differentiate the difference between a flare and IBS? It's a tough one. So typically an ulcer of Klaidus if you're having bloody diarrhea, you're flaring If you have diarrhea alone We have to do testing to figure it out So that might include blood work that's supportive that it's from inflammation Stool testing and sometimes we need to do a scope to really figure it out About two-thirds of patients with Crohn's and Klaidus their symptoms Completely correlate with what's going on in their gut about a third of patients. There's a disconnect So some people feel have chronic symptoms, but there is little in the way of inflammation and others Don't sense their Crohn's at all until they've developed a complication So it can be a challenge to sort out at times, but we can almost always Figure it out with some thoughtful testing Okay, great Well, thank you so much dr. Cross and now we will turn over to to Shelly Neiman Great, thank you Bear with me one second. We'll get my slides up Okay, thank you everyone for joining us today and just to recap again. I'm Shelly Neiman I'm the dietitian that works in the digestive health center at the University of Maryland and today We're going to discuss eating for inflammatory bowel disease So why why even talk about diet with inflammatory bowel disease? Well, as you just heard dr. Cross explain there are potentially some roles for diet As we know in western eyes as civilizations. We seem to have a higher rate of IBD That could be due to environmental exposures and one of those may be diet Diet may play a role in prevention Excuse me or a treatment of IBD Another reason why we should be talking about diet is those that are newly diagnosed with IBD about 86% Identified knowledge about their diet is being very important to them and only Are about 69% received little or no information from their providers. So right now There's a very big interest from patients To discuss diet, but not necessarily as much good information being received by them So what happens when we have this imbalance of supply and demand it leads to us looking to alternative sources Which I would say is primarily dr. Google So when you're looking for nutrition information about IBD on the internet, what you will likely find is potentially some conflicting information and Also, what my experience too has been with patients is you find people maybe avoiding things unnecessarily, so it can definitely lead to more restrictions than maybe needed And because of those restrictions there can also be a worsening or even can be the cause of malnutrition When investigators took a look at what you'll find on the internet when you search for IBD and nutrition Some things are are okay and make sense like limiting maybe cruciferous vegetables alcohol carbonated beverages sugars so some things are You know common sense kind of things But then some websites suggest limiting any and all vegetables are all fruits and nuts and whole grains entirely forever and so maybe that isn't the best advice so overall When you search for IBD and diet you're going to find possibly some some restrictive diets and also some conflicting information What what patients have perceived as being food triggers for them are Fruits and vegetables tomatoes Beans and ice cream Also, other perceived food triggers are spicy foods fatty foods dairy products Fibrous foods particularly vegetables, so you can see that you know in general IBD There may be some intolerance of certain foods that seem to be a common theme A lot of people with IBD perceive yogurt bananas and rice to be fairly well tolerated However, this is obviously not a very diverse diet and you know may require a little more expansion in order for it to be healthy One of the things about IBD and nutrition is that you know, it can have a profound impact on your nutrition IBD may cause weight loss, which may end up leading to malnutrition It can cause a variety of different Deficiencies from iron folic acid B12 vitamin D fat soluble vitamins. It may also have an effect on Electrolites and minerals you may experience dehydration depending on the level of diarrhea that you have Or even vomiting as well And then you may also experience osteoporosis maybe from use of steroids or lack of dairy or calcium and vitamin D intake There's also been growth failure observed in children So what we know is that what you eat is important You know patients want to know about nutrition Those with IBD have noticed that their their symptoms may be worsened by food intolerances Proper nutrition may help to improve those symptoms. It may also prevent nutritional deficiencies May also help with weight loss and also even when you're not in a flare We do want to also address overall health and wellness So basically our goals for nutrition for our patients are maintaining an adequate protein carbohydrate fluid intake vitamins and minerals Minimizing the weight loss improving the GI symptoms, so You know just a few things So we really are looking at nutrition as a whole and trying to address it from all angles So now that we've talked about nutrition is important with IBD What what works do any specific diets work to help treat IBD? So what we're going to do next is just take a look a few of the the diets that are in the literature and see if any Any of them may be worth recommending The first one we'll talk about is exclusive enteral nutrition With exclusive enteral nutrition what we're looking at is providing a hundred percent of your nutrition needs with a liquid nutrition supplement You can either drink that supplement or for some patients. It may be through a feeding tube for anywhere from four to twelve weeks Excuse me the Principle of the diet is basically that by down-regulating pro-inflammatory cytokines and altering the intestinal and decreasing intestinal inflammation so by Changing what it is that you're you're drinking or eating that that will help decrease inflammation the Mechanism is not clear at this time So does IBD or does exclusive enteral nutrition work for IBD? Well, what we have found is that it is highly effective in children It can be as effective as steroids and may be able to Achieve mucosal healing However in adults the results have not been as promising It was found to be inferior to steroids except for specifically penetrating Crohn's disease The difference between children and adults may be that the tolerance and adherence is a little different Adults have more stronger feelings about foods And what they eat and how they feel about eating So really at this time we do need some further studies to be conducted in adults the other Issue with the exclusive enteral nutrition is that Typically once you go off of the diet and you start eating regular foods again You can see increases in inflammation And Completely liquid diet is probably not going to be maintainable for a lifetime. So as a result of that Investigators created a new diet. Oh, did we lose my screen? Bear with me one second Created another diet that's titled the Crohn's disease exclusion diet This diet is designed to mimic exclusive enteral nutrition. However, it is Provides food as well Hopefully thereby increasing the the tolerance and also the acceptability of the diet Again, the research is mainly published in children And it includes again a whole foods and partial about 50% of your needs are still being met through liquid nutrition Supplement and the other 50% are through foods. The diet is in three phases Which can the the first two phases are 12 weeks and then after that is kind of a maintenance phase It does include mandatory foods foods that are required to be Included or things like fresh chicken breast. You're not allowed to have frozen. It has to be fresh eggs Potatoes bananas apples There's also a variety of other foods that you can include to supplement those Mandatory foods such as fish once a week rice rice noodles Some various fruits and vegetables However, if the food is not on the allowed list, it is disallowed So it is fairly strict about what you're able to eat and as you'll notice a little bit from this list it would be very difficult to Eat out to obviously eating fast food is not an option So, you know, it requires a lot of diligence to follow the diet Again, the principle of the diet is basically that we're going to try to decrease inflammation in the GI tract So does the Crohn's disease exclusion diet work for IBD so results show that it is better tolerated than exclusive enteral nutrition and it's equally as effective and steroid-free remission Higher proportion We're able to sustain the remission and again that might be because the diet is able to be followed for a longer period of time There is a pilot study currently being Conducted on adults. So we will have to stay tuned and see how You know how the results are for adults. There are a lot of resources that are available through a dietitian Should one decide to start the diet. So there is a lot of help with this one. That's probably necessary But we'll have to you know, see how this is effective on adults Another diet is the specific carbohydrate diet if you Look up this diet, you'll find that it's Supposed to be beneficial for many conditions Including Crohn's disease and ulcerative colitis, but also IBS, autism, the list goes on There are foods to avoid Grains, lactose containing foods, sucrose containing foods The foods that are allowed are mainly meats, nuts, vegetables, fruits, yogurt, hard cheeses, some honey The principle again behind the diet is that by altering the way that you eat you're going to Have improved health of your GI tract and reduce small bowel injury and potentially yeast overgrowth. So again the Hope is that it will decrease inflammation So does the specific carbohydrate diet work for IBD? There are a very small number of studies and again many of them in pediatric patients One study in children did show mucosal healing and also clinical meaningful improvement There are also some case series that have been published where patients were able to maintain To stop and stay off of their medications. The diet did have a high adherence rate, which is important when you're looking at A diet for IBD is what is one that you can actually follow long term So it did have a high adherence rate again not a lot of studies have been conducted yet and We still need a little more information. I think on adults Dr. Cross had spent a little bit of time talking about functional GI symptoms Such as those with IBS such as gas, bloating, abdominal pain, maybe diarrhea Sometimes our IBD patients may exhibit signs of functional GI symptoms When they're in remission and they're not flaring This particular diet again has three phases in elimination, a reintroduction and a maintenance phase Foods to avoid and foods to include I think you can see for yourself when you look at the list It's a little confusing It's certain fruits certain vegetables certain beans and nuts Definitely though lactose containing dairy is not allowed Gluten is not allowed Neither honey or high fructose corn syrup, but some other sweeteners are allowed So there are again tools that are available to help patients sort through the diet and to make it work for them The principle of this diet is not so much having to do with information and healing of the gastrointestinal tract but has more to do with the tolerance of carbohydrates So these particular carbohydrates can be poorly tolerated Leading defermentation and fluid load within the GI tract which can then cause symptoms such as the IBS symptoms we talked about Bloating abdominal pain and gas So does this particular low FODMAP diet and FODMAP is just an acronym for the for the carbohydrates So does it work for IBD? There have been several published studies on the low FODMAP diet What we have found is that for IBD patients that are having symptoms similar to to those of IBS or functional GI symptoms That those symptoms do improve if you're adhering to the diet With ulcerative colitis with a colectomy it can help to decrease the daily stool of frequency from 8 to 4 in one study So the results definitely suggest that if you have a functional Component to your GI symptoms that or maybe even non-celiac gluten sensitivity That this diet can help to improve symptoms again This is not necessarily addressing a flare or the overall recovery from inflammatory bowel disease Another diet that is in the literature is the Mediterranean diet This diet is high in fruits and vegetables whole grains nuts and Also lean proteins you will limit red meat processed foods and sugar The principle of the diet is that by including Things like fish things that are high in omega-3 fatty acids Which are the good kind of fat and limiting the omega-6 fatty acids Which are the bad kinds of fat that may help reduce inflammation This diet has been promoted or recognized by the dietary guidelines of americans and also the world health organization as promoting health and maybe also helping to prevent chronic disease So You know regardless of IBD it is also recommended for general health There has been a study Called the dine cd study which took a look at the specific carbohydrate diet versus the Mediterranean diet It was a good study randomized study over a 12-week period of time where patients were delivered six weeks of meals You randomized either to specific carbohydrate or Mediterranean and then for six weeks you're to follow the diet for yourself The primary outcomes that are being looked at are again dealing with inflammatory markers This study we should hopefully I believe have the results maybe by next summer So that will be something we can really take a look at and See if it gives us any good information about these two particular diets But the bottom line is that diet has not been definitively shown to cause or to prevent or to treat IBD at this time We do know for sure that we can help with GI symptoms and helping patients to feel better Currently there's just lacking Data to say any specific diet is better than another Or to say yes, this is the one you should follow and this is going to help or to cure your IBD We are definitely not anywhere near that yet But that doesn't mean that you should just eat whatever you want either People with IBD should also maintain a diverse and nutrient rich diet You can take a look at choosemyplate.gov. They have lots of great information on healthy eating You can also consider Taking a look at the Mediterranean diet again It's a diet that has been recommended for overall health and wellness prevention of chronic disease And it's also important that you also track your own experience with food and keep track of what foods may be triggers for you During a flare you may need to alter what it is that you're eating You know smaller more frequent meals are generally tolerated better You want to avoid high fat or greasy foods? Limit spicy or highly seasoned foods certainly avoid what you know are your own sugar foods You want to limit? Probably high fiber foods during that time To try to decrease stool bulk You may need nutritional supplements. There's a wide variety of them available It's not just your boost and your unsure anymore So there are a lot of different options if you're losing weight. That may be something you want to consider You also want to make sure you're maintaining your fluid intake and making sure you're not dehydrated Or maybe even including some oral rehydration beverages But what's really important is that you stay flexible and focus on what you can eat Versus on what you're not able to eat at that time Um and and also keep in mind that during a flare That's a hopefully a period of time and you're as you heal and you're Your symptoms improve you should again try to get your diet back to as healthy of a diet as you can So um in conclusion, you know many maintaining a healthy diet is definitely important for iBD Everyone is different and may require different strategies This is where some of the frustration may come in because what works for one person may not work for another Unfortunately, we we don't have a lot of studies right now to say one thing is better than the other But all of this information is definitely emerging and we should have More information as time goes on that doesn't mean that any of those diets may not be appropriate for you to try But you want to keep in mind and here's my cheesy comment for the day that nutrition is a journey Where you're at now may not be where you're at six months from now or a year from now So things that you may not tolerate during a flare does not mean you will not tolerate them when you're not in a flare You know, so you may want to consider partnering with a dietitian To discuss your own personal food intolerances and how to maintain as healthy of a diet as you can and trying to reduce inflammation overall Which can also in the long run help with your iBD Thank you very much for listening and at this time. I believe we'll go back to questions Okay, great. Thank you. Shelly all right, so first um This person has a question about I have I am a vegetarian and take vegetables lentils and of course Let's see spicy Indian food and I have crones disease. How does that affect how will that probably affect him? Um, well, it depends if you are currently experiencing gi symptoms Um, you know, you may need and having a flare you may need to rely more on cooked foods Um, you may need to dial down the spices a little bit if you feel like that's contributing to your discomfort Um, there are lots of patients that are on vegetarian diets and that is not an issue Um, you just need to maybe be more careful about the form in which you're eating them how they're cooked Um, thank you Can drinking large amounts of diet soda cause Induce a uc flare Um, well, I at first my mantra is always everything in moderation So I wouldn't recommend that anybody probably drink large quantities of diet soda just for overall health Um, we don't know Excuse me that any particular food itself can cause a flare of IBD So it's hard to say whether that can necessarily cause a flare If it's caffeinated that might make diarrhea worse There's information That maybe some of the alternative sugar You know may play a role in diarrhea and the Keeping the health of your microbiome Good Some of those sugar alternatives may not be good for that But whether or not it actually caused a flare is probably up for debate What are the pros and cons of caffeine and IBD slash uc? Well, in general what we tend to recommend is one to maybe three servings of caffeine a day, which is In line with general health recommendations If you're if you are flaring it's hard because when you have fatigue you You know a lot of times patients will go to caffeine Just to try to get through their day, which is completely understandable But depending on where you're at with your GI symptoms caffeine is definitely in gastric irritant It can definitely speed up and make diarrhea worse So, you know, you have to weigh the benefits and you know the risks of drinking too much Okay, great Next question is I was under the impression that a food map food map diet was not for the long term. Can you please explain? Yeah, so the low FOD map diet is an elimination diet So you follow the diet for a period of time Generally now it's recommended about four weeks And then it requires that reintroduction phase So for four weeks you completely avoid all high FOD map foods Then during the reintroduction phase you're going to reintroduce one new food at a time A serving of that food each day for about three days and see how your GI symptoms are So journaling food journaling is very important during this time I can't get a little bit tedious. This is the step where I start to lose everyone Is they want to go back to regular eating and including foods they enjoy I mean, it's really important to try you went through all those that work for those four weeks So it's really important to try to do it systematically So that you can figure out which FOD maps bother you because not all FOD maps are going to bother you as an individual So that reintroduction phase you're really diving into it and trying to figure out which foods are the ones that are your triggers How do you choose a diet if you also have type two diabetes? I'm well if I hate to keep Touting dietitians, but if you have a dietitian they can do both so Having diabetes is not a barrier to having a healthy diet You should be including Foods and eating a healthy diet just like everyone else should be Um, and if you have specific needs in terms of you know insulin requirements or timing of your meals Definitely partnering with a dietitian would be You know a good thing to do Great. Thank you. Those are all of our questions for now. Um, we want to thank dr. Cross and shelly Neiman to for here being here today If you have any other questions or would like to make an appointment Please feel free to call the number on the screen at<PHONE_NUMBER> Great. Thank you so much