Colorectal cancer (cancers of the colon and rectum) is rising globally among people under 50 years old, prompting the American Cancer Society in 2018 to change their screening recommendation from age 50 to 45. While rates are also rising among those in their 20s and 30s, colorectal cancer is still less common among this age group.

Pascale White, MD, MBA, MS, FACG

Experts don’t know why more younger people are getting colorectal cancer, but it’s clear that early-onset colorectal cancer (affecting those under 50 years old) is becoming an important public health issue. In this Q&A, Pascale White, MD, MBA, MS, FACG, Director of the Gastroenterology Clinic, and Associate Professor of Medicine (Gastroenterology), Icahn School of Medicine at Mount Sinai, discusses warning signs younger people should look out for and when to see a doctor.

Why are many people in their 20s and 30s going undiagnosed with colorectal cancer?

Many young people don’t have primary care doctors or are ignoring their symptoms until they already have late-stage colorectal cancer. They may go to an urgent care center for strep throat or the flu, but they are ignoring important symptoms like rectal bleeding. They think they are too young to have cancer or are embarrassed. Regardless of how old you are, you should have a relationship with a primary care doctor who knows you and your patterns, who will be able to tell if something is wrong.

What increases my risks as a younger person?

Some of the risk factors for younger people are the same as those who are older. These include having a family history of colorectal cancer or having a hereditary condition like Lynch syndrome; being obese; not getting enough physical activity; using alcohol and tobacco, which have both been shown to be independent risk factors for colorectal cancer; and eating a low-fiber diet high in processed meat.

Are certain groups more at risk than others?

Early-onset colorectal cancer is increasing in both men and women; the most significant increase is occurring among non-Hispanic white patients. However, there are racial disparities that exist in early-onset colorectal cancer. Studies have shown that young Black patients have overall worse survival rates.

What type of family history puts me at risk?

The majority of young people who are getting early-onset colorectal cancer don’t have a family history of cancer. That said, any family history of colorectal cancer could be relevant. Knowing first-degree family history (mom/dad/brother/sister) helps your doctor determine if there is a higher risk. However, second-degree family history (aunts/uncles/grandparents/grandchildren/half siblings/nieces and nephews) can help spot potential patterns that might put you at risk. Mount Sinai has genetic counselors that can help identify these patterns.

What symptoms indicate that younger people should see a doctor?

A majority of people who are coming to see the doctor with early-onset colorectal cancer are symptomatic, and a majority of symptoms are blood in stool and abdominal or rectal pain. Other symptoms include unintentional weight loss, changes in bowel habits, diarrhea, and iron deficiency anemia. Young people need to understand seeing blood in the stool (whether it is bright red blood or black stool) should not be ignored. Bleeding could be caused by something benign like hemorrhoids or something malignant like colorectal cancer. If you experience these symptoms, see a doctor as soon as possible. If colorectal cancer is caught early, your chances of survival are higher.

How can I reduce my risk?

Some things may not be in your complete control. For example, we are investigating whether there are certain environmental exposures that put younger people at risk. That said, there are actions you can take regardless of age that reduce overall risk for colorectal cancer. These include eating a well-balanced diet of high-fiber foods (fruits, vegetables, nuts, legumes, and whole grains); reducing your intake of processed foods, especially processed meat; getting regular exercise; and monitoring any health conditions you have, such as diabetes and obesity.

What is a colonoscopy?

A colonoscopy is a safe and effective procedure where a doctor uses a camera to examine the lining of the colon and rectum for growths called polyps and/or other abnormalities including colorectal cancer. During the examination, you are given some sedation to keep you comfortable. If polyps are found they are removed and sent to the pathologist for evaluation. Some polyps are benign while others could be precancerous. The type of polyps removed will determine when the colonoscopy should be repeated in the future.

Will my insurance cover it?

Insurance companies cover colonoscopies for people who are 45 years and older for screening colonoscopies. A screening colonoscopy is what the procedure is called when it is being done on a patient who has no symptoms. If you are under age 45 but are experiencing symptoms, you would be sent for a diagnostic colonoscopy because the procedure is being done to find the diagnosis that would explain the symptoms. In either case, we encourage patients to communicate with their insurance company prior to procedures to ensure they will cover the cost.

How can I get a colonoscopy if I don’t have insurance?

Call your health provider to see what resources may be available for free or low-cost colonoscopies. They can help navigate patients to centers that accommodate people who do not have insurance

Your stool—a very basic fact of life—is a good reflection of your health. It provides insight into the quality of your diet and, potentially, may indicate certain diseases, such as cancer. While changes in bowel habits are usually not a cause for alarm, they can indicate potential issues. How can you tell if your stool is healthy, and when is it time to see a doctor?

Pascale White, MD, MBA, MS, FACG

In this Q&A, Pascale White, MD, MBA, MS, FACG, Director of the Gastroenterology Clinic, and Associate Professor of Medicine (Gastroenterology), Icahn School of Medicine at Mount Sinai, discusses how to monitor your bowel movements for potential problems, and offers simple tips on how to eat for better gut health.

How often should I be having bowel movements and what should they be like?

Every individual has their own baseline bowel habits, which are largely affected by diet and can vary in frequency for all of us. Here are some general guidelines:

• Some bowel frequencies can vary anywhere from three times a day to every other day.
• Healthy stool is soft formed, typically sausage-shaped, and should be easy to pass.
• The color is typically brown but sometimes varies based on what you eat. In some cases, color may indicate a potential health issue. For example, if your stool is very pale or clay-colored, it may be something you ate or could be a sign of liver disease.

What changes indicate I should see a doctor?

We all experience changes in bowel movements, and occasional changes typically do not indicate a problem. However, if you are experiencing a big change in your typical pattern, you should speak to a doctor, especially if you experience:

• Stool that is black and tarry or contains red blood (indicates potential internal bleeding, hemorrhoids, inflammatory bowel disease, or colon cancer)
• Hard pellet-like stools that are difficult to pass or will not pass (indicates constipation)
• Bowel movements that are completely watery (diarrhea)
• Stool that is pencil-thin or ribbon-like (indicates potential colon cancer, polyp, or other lesion causing narrowing of your large intestine)

What can I eat to ensure good colon health?

You should eat a lot of fiber—including fruits, vegetables, nuts, and legumes—which bulks up stool and keeps it moving along, and also produces substances your colon needs. Generally, you should eat 20 to 30 grams of fiber daily. Keep in mind that eating fiber (particularly insoluble fiber) may cause some bloating or loose stools, but it is generally well tolerated. You should also drink plenty of water to prevent constipation.

What foods should I avoid?

You should avoid red meat in general, which is high in fat and does not contain fiber, and especially processed meats, such as sausage, bacon, and deli meat. The process of curing and smoking meat generates carcinogenic compounds that can promote changes in the colon cells that can lead to cancer.

What are some easy ways to include more fiber in my diet?

Here are some simple steps:

• Plan your meals and prepare them in advance. For example, making overnight oats before bed is a great way to ensure you are getting fiber in the morning.
• Look for ways to make easy switches to what you normally eat. When eating out, get a salad, ideally one with dark, leafy greens, instead of fries. Instead of drinking fruit juice, eat the whole fruit.
• Swap white potatoes for sweet potatoes, which are higher in fiber, and leave the skin. Make sandwiches with whole grain bread instead of white bread.
• For a snack, grab a bag of nuts instead of a bag of chips.
• You may also find that food-tracking apps are a great way to ensure you are getting enough fiber and other nutrients every day.

What are some other ways to maintain good colon health?

Exercise, moderate your alcohol intake, and do not smoke. If you are over the age of 45, or are considered high risk for colon cancer due to health issues or family history, you qualify for a colonoscopy. The procedure not only screens for colon cancer and other potential issues, but also allows us to remove polyps that can turn into cancer. Stool tests may also help identify potential issues, though they are not as effective as a colonoscopy.

If you are one of the more than three million people in the United States living with inflammatory bowel disease (IBD), you are likely struggling with anxiety around food. Many living with IBD associate specific foods, or even whole food groups, with getting sick, and so they avoid many foods. This common misconception has led many with the disease to become malnourished.

Stephanie Gold, MD

In this Q&A, Stephanie Gold, MD, Instructor of Medicine (Gastroenterology) at the Icahn School of Medicine at Mount Sinai, explains why IBD patients struggle with food anxiety, how they can overcome this problem, and where to get more information.

What is IBD, and how is it different from having a food intolerance or allergy?
IBD is a condition that includes Crohn’s disease and ulcerative colitis. Both are characterized by chronic inflammation of the gastrointestinal tract that often leads to diarrhea, abdominal pain, and rectal bleeding. IBD can also lead to fatigue, weight loss, malnutrition, and vitamin and mineral deficiencies. Specific foods are not known to trigger IBD flares. IBD is different from irritable bowel syndrome (IBS), food allergies, and food intolerances, as it is a chronic inflammatory condition of the entire digestive tract (Crohn’s disease), or specifically, the large intestine (ulcerative colitis), which can inhibit absorption and impair digestion.

How common is malnutrition among people with IBD, and what are the symptoms?
While the exact prevalence of malnutrition in patients with IBD is unknown, we estimate that about 30 percent of patients seen in our outpatient IBD clinic are malnourished, and up to 80 percent of those requiring hospitalization are malnourished. Malnutrition can produce few or mild symptoms, or it can result in more serious symptoms of increased fatigue and weakness, as well as specific symptoms associated with vitamin and mineral deficiencies, such as rash, mouth ulcers, muscle spasm, pins and needles, loss of appetite and irritability, and many other symptoms.

Why do many people with IBD have food anxiety, and how does this affect their everyday lives?
Patients with IBD often associate their gastrointestinal symptoms—abdominal pain, diarrhea, rectal bleeding, nausea or even vomiting—with the foods they eat. More specifically, patients commonly believe that a food they ate immediately prior to the development of an IBD flare or complication is the cause of their worsening disease, and naturally tend to avoid these foods in the future. While certain foods may contribute to gastrointestinal symptoms in some patients, food does not directly worsen IBD or cause disease flares. Unfortunately, IBD-related food anxiety can lead to a very restrictive diet overtime, which can result in long-term malnutrition and vitamin and mineral deficiencies.

I have IBD. What should I eat?
All patients with IBD are unique and therefore should discuss diet and nutrition with their gastroenterologist. However, in general, here at Mount Sinai, we encourage our patients with IBD to eat a wide variety of foods and to have an overall healthy diet that is rich in fruits and vegetables, lean proteins, whole grains, and heart healthy fats. While many used to believe that all patients with IBD need to avoid fruits and vegetables, we now understand that the micronutrients and certain types of fiber found in fresh produce can be very beneficial for the gastrointestinal tract. While raw fruits and vegetables may contribute to symptoms in some IBD patients, texture modification, such as peeling, cooking, and even pureeing specific, easier-to-tolerate fresh fruits and vegetables, can make these vital foods better tolerated in patients with active disease or ongoing symptoms. However, we guide dietary recommendations based on type of IBD as well as disease location, activity, and complications, and therefore, it is really important for patients to seek specific nutrition guidance from their gastroenterologist or dietitian. This is especially true of those with an ileostomy or intestinal narrowing (stricture), as this requires additional dietary modification. There is a lot of ongoing research in this area, and we hope to be able to better define a more specific, ideal diet for IBD patients in the future.

What resources are there to help me improve my diet?
It is essential that people with IBD ensure they are getting adequate nutrition from a wide variety of foods. The best thing they can do is seek out professional guidance from a registered dietitian who specializes in working with IBD patients. Since there is not one specific diet that we can recommend for all patients with IBD, a registered dietitian can help evaluate and broaden the diet based on your specific disease type, location, activity, and current symptoms. To find a dedicated IBD dietitian, you can ask your gastroenterologist for a referral. In addition, many of the gastroenterology societies, including the American Gastroenterological Association, have lists of registered dietitians who specialize in IBD that are available to the public. Patients with IBD should feel empowered to ask their gastroenterologist any nutrition-related questions and inquire about additional support from a registered dietitian when needed.