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WHAT ARE ANTI-OXIDANTS?

Anti-oxidants are substances which are found naturally in our diets -

usually vitamins or minerals. They include: Selenium Methionine Vitamin A

Vitamin C Vitamin E You may be taking anti-oxidants in tablet form e.g.

Antox or Selenium ACE

WHY ARE ANTI-OXIDANTS IMPORTANT?

Anti-oxidants are important because they neutralise or " mop up " FREE

RADICALS. This protects your body, especially the pancreas, from damage

which may be caused by free radicals.

WHAT ARE FREE RADICALS?

Free radicals are molecules (small substances). They are able to cause

damage because they react with your body tissues.

WHERE DO FREE RADICALS

COME FROM?

Free radicals are produced by our bodies during the normal course of life,

and our bodies have ways of getting rid of them. Sometimes, however, we make

too many free radicals for our body's protective mechanism to deal with.

Environmental pollution and smoking are two contributory factors.

HOW CAN WE PROTECT OURSELVES?

By eating a diet rich in anti-oxidants we can help protect ourselves.

ANTI-OXIDANTS

AND DIET DIETARY RECOMMENDATIONS FOR AN ANTI-OXIDANT RICH DIET

.. You should include fruit, or fruit juice and vegetables in your mid-day

and evening meals everyday. Try particularly to include the fruits and

vegetables listed in this diet sheet. Have fresh grapefruit/grapefruit juice

or orange/orange juice with your breakfast.

.. Don't overcook vegetables - this destroys the vitamin content. Try to eat

more raw vegetables, especially as salads. Fresh and frozen vegetables are a

good source of vitamins so both can be used. Avoid tinned vegetables as they

are not a good source of vitamins. Do not use bicarbonate of soda when

cooking vegetables.

Cook vegetables in a minimum of water, steam or microwave them.

If using fresh fruit and vegetables, make sure they are fresh. Fruit and

vegetables that have been sitting around for days will have lost much of

their vitamin content.

.. Chopping and peeling fruit and vegetables also destroys some of the

vitamins as they are exposed to the air. If you need to chop them do so just

before cooking and leave the pieces as large as possible.

.. Try to use more wholegrain or wholemeal products, e.g. wholegrain

breakfast cereals such as Weetabix, Shredded Wheat, All Bran Flakes. Use

wholemeal bread, biscuits and crackers. When baking use wholemeal flour.

Include protein rich foods in your diet at least 2-3 times a day, e.g.

meat, eggs, milk, yoghurt, cheese and fish.

.. A good type of fat to include in your diet is mono-unsaturated fat which

is found in rapeseed oil and olive oil. Olive oil is very expensive, however

rapeseed oil can be used as a cooking fat. An olive oil based spread, e.g.

Olive Gold or Olivio can be used instead of margarine.and Bran

.. INCLUDE A WIDE VARIETY OF FOODS IN YOUR DIET.

VITAMINS

BETA CAROTENE (VITAMIN A) is found in fruit and vegetables

FRUIT

Mangoes

Melon

Apricots

Peaches

VEGETABLES

Spinach

Carrots

Broccoli

Green Beans

Brussels Sprouts

Cabbage

SALAD

Lettuce

Tomatoes

Parsley

Endive

VITAMIN C is sometimes called the sunshine vitamin because rich sources are

found in brightly coloured fruit such as oranges, blackcurrants,

strawberries

FRUIT

Blackcurrants

Kiwi Fruit

Oranges

Lemons

Grapefruit

Melon

Strawberries

Pineapple

Bananas

Cherries

Gooseberries

Guava

VEGETABLES

Brussels Sprouts

Broccoli

Peppers

Cabbage

Spinach

Potatoes

Cauliflower

Parsnips

Swede

Turnip

SALAD

Tomatoes

Lettuce

Parsley

Watercress

Radishes

Mustard & Cress

NB Overcooking vegetables destroys their vitamin C content

VITAMIN E is found in a wide variety of foods, especially vegetable

oils (rapeseed oil, sunflower oil) margarine and nuts

FRUIT

Apples

Bananas

Damsons

Blackberries

VEGETABLES

Asparagus

Spinach

Carrots

Broccoli

Peas

SALAD

Lettuce

Parsley

Watercress

Tomatoes

SELENIUM Rich sources are :

Fish and shellfish Meat - especially liver and kidney Wholemeal

bread, wholemeal pitta bread and high fibre chapatti

Wholemeal products e.g. high fibre breakfast cereal

METHIONINE is found in protein rich foods

Milk

Yoghurt

Cheese

Meat e.g. Beef, lamb, pork, chicken

Fish and shellfish

QUESTIONS & ANSWERS

SELECTED FROM THE LAST TWO ANNUAL GENERAL MEETINGS OF THE PPSG.

The biggest paracetamol makers are against a combination of

paracetamol with methionine say that too much methionine can increase

chemicals in the body linked with heart disease. What is the latest on this?

Megadoses of methionine in excess of 8g per day may occasionally precipitate

symptoms of depression; our PB Service does not prescribe anything like this

dose and the prescription is always accompanied by other antioxidants, for

example, vitamin C, that facilitate the metabolism of methionine. Great care

is taken to monitor clinical effects, treatment and blood levels of

glutathione; in observations on some 500 patients, there have been two

instances of depression in patients with a very strong family history of

this condition.

I am not diabetic my blood sugar is low- Why? Will I become diabetic

eventually? Will all CIP sufferers become diabetic? Why are some and not

others? (It is not a worry at all, I would just like to know - thank you).

The development of diabetes largely depends upon genetic factors, that is

whether there is a family member who has the disease. Of course, if the

pancreas is removed for treatment of chronic pancreatitis - not done at the

MRI - diabetes will follow.

Can HRT be taken with the antioxidant or can you suggest an

alternative? In general we prefer to prescribe low oestrogen preparations;

it is prudent to mention HRT treatment at the PB Clinic so that details of

the preparation can be obtained and appropriate advice given.

Is any research being carried out with regard to stress and acute

pancreatitis? Yes, there is clear evidence now that stress can activate

certain proteins in the pancreas that are linked with the production of free

radicals.

Why can't the blood tests be done quicker, why do I have to wait 30

minutes sometimes for a blood test? The processing of glutathione has to be

done immediately and under very special conditions; hence the delay.

With high dosages of vitamins and methionine being taken constantly,

is there a danger when increasing the dosage for holidays, etc. - that

dropping back to pre-emergency levels that the pancreas has become used to

the higher dosage, causing the possibility of a flare-up? We do not have a

clear answer but we generally advise that the reduction to baseline doses of

antioxidants after they have been stepped up to cover holidays, etc., is

done gradually, precisely so that the pancreas can re-acclimatise

Why do we not become diabetic when we have a diseased pancreas? See

earlier reply.

What is the difference between chronic and acute pancreatitis? The

word pancreatitis simply means inflammation of the food digesting part of

the pancreas and the problem usually shows itself as an 'attack'. Terrific

abdominal pain accompanied by a sharp rise in the blood level of pancreatic

enzymes of which amylase is the one that is most commonly measured. This

attack could be a " one-off " , or it may be indicative of smouldering

inflammation in the pancreas which will lead to scarring and possibly

formation of calcium stones. In the first of these situations we would call

the disease acute pancreatitis, in the second we would call it chronic

pancreatitis and the distinction is made by specialised tests.

Are sufferers more inclined to pancreatic cancer and if so how much

protection does bio-antox or methionine give us in this respect? The answer

is probably Yes, but the risk is extremely small. There is experimental

evidence that antioxidants of the type we are prescribing helps to prevent

this transformation when it is given prophylactically; we are optimistic

that some protection is afforded if treatment is given early enough into the

development of chronic pancreatitis.

Why is it that you do not always take blood on each visit to measure

antioxidants? When the blood levels of antioxidants have been stable for

some time, it is probably safe to assume that the body has adjusted to doses

and blood tests need not be undertaken as frequently as at the start of

antioxidant treatment

Should I be on a fat free diet? I have had my gallbladder removed -

does this make the above question necessary?

No, a fat free diet is not necessary but some patients feel more

comfortable when they restrict fat, particularly if they have done this

before the gallbladder was removed.

Why do some of us need an angiogram? Whenever pancreatic surgery is

being considered, whether to complete the clinical evaluation or for

treatment of, say, suspected cancer, then it is necessary to have a map of

the blood vessels in the gland. An angiogram is also needed if a Patient

with chronic pancreatitis is anaemic or loses blood into the

gastrointestinal tract because it is necessary then to be sure that the

bleeding is not from a blood vessel in the pancreas that is caught up in the

inflammatory process

Is pancreatitis hereditary? It is probably correct to say that all

disease represents a combination of environmental and genetic factors;

sometimes one or other is predominant. There is a type of hereditary

pancreatitis but it is extremely rare - we have perhaps one documented

family attending the PB Service here. Cystic fibrosis is another example of

disease that is transferable and always affects the pancreas.

What is the average age people begin to suffer from pancreatitis?

When chronic pancreatitis is due solely to excess alcohol consumption,

it usually takes about 15 years before the first symptom, so patients

usually present around the age of 40 years. Non-alcoholic chronic

pancreatitis declares itself younger - in the early 20s or sometimes in

childhood. Gallstone pancreatitis tends to come later, after the age of 50

years

What damage does one pint of beer do to chronic pancreatitis patients?

One pint can be one pint too many when all defences in the gland have been

stripped by huge intakes of alcohol in the years building up to the disease

I was recently told that I would have to have an MRCP scan, what is

this? MRCP stands for magnetic resonance imaging called

Angiopancreatography; it is basically highly specialised technique to allow

pictures of the pancreatic and bile duct systems without the need for a

camera endoscope.

What symptoms can I expect in later life - diabetes, cancer, etc., and

what effect does pancreatitis have on my other organs, i.e., liver, kidneys,

gallbladder, etc.

For diabetes and cancer see previous replies. An attack of pancreatitis

can lead to sudden damage of the liver, lung and kidney which can

occasionally be so severe that a patient requires management in the Critical

Care Unit. Most attacks of pancreatitis do not have major effects on these

organs, however.As time goes by patients with chronic pancreatitis may

develop obstruction to bile flow. This is easily dealt with by surgery.

Kidneys do not usually suffer in chronic pancreatitis, except in a patient

who has long standing diabetes.Once the gallbladder containing stones is

removed in a patient who had an attack of pancreatitis, further attacks are

not expected unless there is another cause for pancreatitis, for example,

alcoholism.

Is it possible to travel with pancreatitis - if so, how do I go about

getting my treatment? Also, will it be possible to emigrate to foreign

countries, e.g., Australia? Of course it is possible to travel with

pancreatitis and hundreds of patients do. We suggest that you increase your

dose of antioxidant supplement as indicated in a previous issue of this

magazine. it,is best that you write to Staff Nurse Sue Postill, who carries

a pager, and she will ensure that a letter is sent 'to whom it may concern'.

Should you emigrate, you should register with a General Practitioner and

tell him about your treatment, something that the PPSG circulars will help

you with. The best way would be for the new doctor to write to a

Pancreatobiliary Consultant at the MRI, so that appropriate scientific

documents can be made available.

Are other salts apart from calcium deposited to form stones in the

pancreas? No, it is always calcite because the strong alkalinity of

pancreatic juice is due to the high content of bicarbonate

Is rapeseed oil safe? This oil has highly unsaturated fatty acids;

olive oil is the healthy but expensive. A mixed vegetable oil is better than

pure corn oil

How strong is the evidence for pancreatitis from chemical fumes An

independent study of 103 patients and 3 controls per patient has been

published and especially incriminated diesel exhaust However, compensation

from chemical industries will not be forthcoming until other centres confirm

the findings.

Is antioxidant treatment available elsewhere? Answer drowned out by

other questions, but the new treatment has been recommended by the Oxford

Health Authority and independent trials are ongoing at Belfast.

Why don't you simply give the patient a new pancreas? Pancreas

transplantation is used for diabetes complicated by kidney failure; it is a

major operation and not entirely efficient. It is a not a treatment of

chronic pancreatitis.

Is cholesterol bad? Everything is safe for pancreatitis taken in

sensible amounts. (Patients with in-born errors of fat metabolism are a

special group )

Any medication with an adverse reaction to antioxidant therapy?

Certain drugs could increase pressure on the pancreatic engine by generating

more free radicals which are the automatic spark in cells. He volunteered to

help by answering telephoned queries directly

Are there any side effects of the Manchester treatment? Not aware of

any, offered to advise via telephone queries

Why do I only get pancreatic pain at night? Most unlikely the pain is

pancreatic; much more chance that it is due to a disease such as peptic

ulcer that is troublesome at night-time.

Why is it that only certain people get this disorder? There is of

course a genetic element and the Manchester group have recently identified

one of the genes involved. The total load of environmental oxidants is

another factor which is why so many questions are asked about lifestyle when

patients attend the clinic.

Are patients with pancreatitis likely to develop diabetes and need

insulin? When all of the pancreas is destroyed, diabetes is expected, but in

general it is the patient's genetic inheritance that determines the ease

with which the insulin-secreting cells are injured after pancreatitis.

What effect does stress have? There is a proven link between stress

and the production of free radicals and in this sense stress could aggravate

oxidant load from environmental pollutants.

Is pancreatitis hereditary? Yes, in exceptional circumstances, but in

general the disease is not passed on to children

What can be done to convince other doctors that having pancreatitis

doesn't mean we are alcoholics? One of the functions of a self-help group

would be to raise awareness of the new developments.

Every time I go to hospital for whatever pain my amylase level is

raised, but I am told it is not pancreatitis, why? In pancreatitis, amylase

leaks out of the gland into the bloodstream instead of being channelled into

the digestive system, Dr Braganza: there are two forms of amylase, the

second form is called salivary amylase and can actually be produced by many

cells in the body. In certain patients this form of amylase is produced in

excessive amounts and does not indicate pancreatitis.

I have heard that antioxidants in the wrong levels can be harmful; how

do you know that this is not happening. ? That is the function of the

Pancreatic Laboratory. The prescription has been worked out by over 10 years

of testing and the doses are intended to counteract the effects of toxins

from the diet, environment etc.

What reaction would there be to taking too many of these tablets ?

There are no side effects from the correct doses of the tablets prescribed

at the MRI. We do not recommend over - the- counter preparations.

Extract from an article published in Centre point, the Information Sheet of

the Centre of Manchester Hospital Trust, in 1990 to mark the end of Dr. Joan

Braganza's tenure as President of the Pancreatic Society of Great Britain

and Ireland.

A DECADE OF RESEARCH YIELDS TREATMENT FOR PANCREATIC DISEASE

I nvestigative work over 10 years at the Manchester Royal Infirmary has led

to the control for a disease that hitherto was almost untreatable. And the

new treatment is not only effective - it is simple and cheap. The therapy

was discussed by Dr Joan Braganza and leading specialists at a conference

held at the University of Manchester on November 15th of The British

Pancreatic Society. Acute and chronic pancreatitis and cancer of the

pancreas are on the increase in developing countries in the world; and in

certain tropical countries, one in 20 of the population suffers from

pancreatic disease. Despite easier diagnosis by modern radiological methods,

one in five patients admitted with acute pancreatitis may still die.

Pancreatic cancer is almost always fatal, and it is now the fifth highest

cause of death from cancer in the USA and was the seventh highest cause of

deaths in the North West Region in 1989. Similarly, there has been little

effective treatment for chronic pancreatitis. This disease causes severe

pain that can only be controlled by narcotic analgesics - morphine and

pethidine; these are addictive drugs and cause personality and behaviour

changes such that patients are unable to hold on to their jobs, they become

demoralised, family life is broken up and there is all the cost of social

security payments to maintain them. Radical surgery to remove all or almost

all or almost all of the pancreas was the only alternative, but it was not

really a long-term solution. The pancreas is the body's main factory for

producing digestive enzymes, with five per cent - the Islets of Langerhans -

producing insulin; so the result would be a patient who might not be

suffering from the pain of pancreatitis any more, but has severe and

unstable diabetes, and gross mal-digestion, and is already addicted to the

narcotic painkillers. Pancreatic disease has for years been linked with

excessive alcohol consumption. Increasingly, however, cases are occurring

among teenagers here and even younger children in tropical countries, where

alcohol is not a relevant factor. A detailed survey of the lifestyles of

Manchester patients showed that many of the adults had never drunk in

excess.

INHALED FUMES

However, a pattern of exposure was noted to substances that chemically act

within the body in the same way as alcohol. Even more significantly, in many

cases this exposure was via inhalation of fumes from substances such as

diesel, petrol, acetone and trichloroethylene. Often it was linked to the

work environment, but there were instances where children had played every

day in a diesel loco shed, or cycled on a long journey to school each day on

busy roads, exposed to car exhaust fumes " . The effect of such exposure is to

change the level and type of activity of the pancreas. At birth, the

pancreas fulfils a wide range of functions, but

gradually specialises in the production of digestive enzymes and insulin,

while the liver takes over the role of filtering out wastes. Inhaling

harmful substances means that they bypass the liver, and strike the pancreas

directly. It then reverts to the task of rendering these alcohol

equivalents, which are fat-soluble. Besides, if a patient also smokes, then

the pancreatic engine is excessively fired, rather like a choke achieves for

a motor car engine. Processing the alcohol equivalents produces oxygen-free

radicals and other potentially toxic products in the pancreas, and the

Manchester Scientists suspected that these were the real cause of the

trouble. All cells produce oxygen-free radicals because they serve vital

roles: nevertheless an excess is dangerous. The puzzle was that far more

people are exposed to this identified combination of lifestyle events than

develop pancreatic disease. Why does a small percentage suffer when the

majority does not? In what way is the minority different? Investigation

turned to the diet, to seek out whether the patients had developed the

disease because their diet happened to include lower amounts of protective

foods. The agents that protect against oxygen-free radicals are called

antioxidants. Among these perhaps the best known are Vitamins C and E,

methionine, selenium and beta-carotene. The habitual diets of patients who

did not have a history of alcoholic excess were compered - at a time they

did not have pancreatic pain - with the diets, age and sex-matched healthy

individuals.

TABLET STRATEGY

The two key factors that turned out to be lacking in the patients' diets

were Vitamin C and methionine: selenium was also important. It seems too

simple that this could the answer but subsequent blood tests confirmed the

results. The logical solution was to prescribe extra amounts of these items

as tablets. A long-term study followed by a controlled trial confirmed that

the strategy worked! So now there was a new medical treatment for chronic

pancreatitis: antioxidant tablets for several months to get the blood levels

of the different factors into the high normal range,. while the dietician

advises on antioxidant - rich foods. These include raw vegetables and fruit

for vitamin C; meat and eggs for methionine; liver, kidney and shrimps, and

to a lesser extent, whole wheat products, for selenium. Blood levels must be

checked regularly because even vitamins and trace elements - so important

for normal body function - can be toxic if too much is taken for too long.

About 1 in 10 patients still needs surgery for complications of chronic

pancreatitis - for example, obstruction to drainage of bile from the liver.

Other patients with pancreatitis may have gallstones which must be removed.

This can be done by lithotripsy (sonic vibrations which break up the stones

and allow them to be flushed away naturally) or even more modern development

of " keyhole " gallbladder surgery. Special X-rays and ultrasound tests are

needed to decide which form of treatment is best for each patient . In 1988

Dr Braganza took a four-week sabbatical to work in Southern India, where

this disease of the pancreas is rife. Traditionally, high consumption of a

local crop, cassava (known elsewhere as manioc or tapioca) has

been blamed because the food releases a cyanide derivative as it is broken

down in the body. But laboratory tests on rats had shown that although

feeding them cyanide produced diabetes, it did not produce other chronic

pancreatitis. In Madras, at the Diabetes Research Centre founded by

Professor Viswanathan, Dr Braganza met a family of eight with pancreatic

disease. She went through the history, including the father's job - a clerk

in the Town Hall - and said aloud in despair " There's just no exposure here

to fumes. " The youngest family member, a boy of 8 years, said " Yes there is.

We all sit round a kerosene stove every morning while mother makes our

chapattis, and there's no window in the kitchen. " The other 80 patients

surveyed were recalled and almost all turned out to be regularly exposed. to

kerosene stoves or lamps. A possible new link had been found - not cassava,

but kerosene, still widely used in Southern India. Even in areas where

electrification has been installed, the supply may be turned off for hours

and many families cannot afford to rely on expensive electricity. So that

many children do their homework by the light of kerosene lamps. Furthermore

the diet makes little use of raw food stuffs: vegetable tend to be fried,

destroying almost all the Vitamin C. This had now been proved by blood tests

done in the pancreatic laboratory at the MRI. The goal of the Manchester

workers is to prevent pancreatic disease in groups who are at risk - simply

by prescribing a tablet each day of Vitamin C along with methionine and

selenium. People who are regularly exposed to industrial fumes and those for

economical reasons use kerosene in lamps and cookers should gain most from

this strategy.

FUTURE STUDIES

But these links clearly have to be proved in properly conducted case-

control studies. Senior Professors in the Departments of Occupational Health

and Epidemiology in the Manchester Medical School are advised in

collaborative research that was generously funded by the North West Regional

Health Authority.

THE MRI PANCREATIC-BILIARY SERVICE

All these developments and especially the wide referred base of patients

necessitate a one-stop clinic that could draw on the combined expertise of a

physician

( Dr. Braganza), pancreato-biliary surgeon who has already introduced '

keyhole' gallbladder operations at the MRI (Mr. McCloy) and a highly

experienced radiologist (Dr. ). A clinic administrator, dietician and

nurse-counsellor complete the team, which is backed up by a well equipped

pancreatic laboratory where blood samples are analysed without delay.

ADDENDUM: Now in 1997, the PB service is thriving because other health

authorities have perceived the strength of a multi disciplinary

consultant-led team to optimise management of patients, and of the new

medical treatment using antioxidant tablets but under a safety net provided

by a sophisticated biochemical laboratory and dedicated team of laboratory

chemists.

Three very useful booklets, entitled " What's wrong with my pancreas "

covering acute pancreatitis, chronic pancreatitis and cancer of the pancreas

have been compiled by Solvay Healthcare, the manufacturers of Creon. They

will send copies of these if you contact them at

Solvay Healthcare

Mansbridge Road

West End

Southampton

Hants

SO18 3JD

Tel: 02380 467 009

Another useful address is:

(send a sae)

Digestive Disorders Foundation

PO Box 251,

Edgeware

Middlesex

HA8 6HG

www.digestivedisorders.org.uk

EUROPAC

European Register for Familial Pancreas Cancer and Hereditary Pancreatitis.

The principal register in Europe providing advice and research in inherited

pancreatic disorders.

EUROPAC Co-ordinator

Department of Clinical Services

Alder Hey ChildrenÕs Hospital

Eaton Road

Liverpool

L12 2AP

Europac@...

This and other info can be found at

http://www.pancreaticdisease.com/default.htm

I hope this finds you and yours well

Mark