Your in-depth guide to bowel health
Bowel cancer is sneaky and insidious. While other cancers are much more aggressive, faster-growing and virulent, bowel cancer develops and grows with few obvious symptoms and bodily changes, so people simply don’t know they have it. Often by the time it’s detected, the cancer can have spread widely and metastasised, which directly affects the likelihood of effective treatment and survival.
The bowel is a subject we don’t talk about very often. Many people put the topic into the category of mysterious and slightly embarrassing bodily functions and most pay little attention to what’s happening down there. There’s little open discussion about bowels, so even if you do pay attention, it’s still hard to know what is normal and what to look out for.
However, a basic working knowledge of your digestion and bowel habit means you can monitor your health and act early. Bowel cancer does give early warning signs you can look out for. If the cancer is caught early enough, it can be effectively treated and the survival rates are high. Through monitoring your bowel and knowing what’s normal and what to look out for, bowel cancer can be caught early.
You can also markedly reduce your cancer risk through diet and lifestyle changes. The likelihood of getting bowel cancer is strongly related to what we eat and how we live our lives. It is a largely preventable cancer. By changing your diet and taking other lifestyle measures you can benefit your health both now and into the future. Having a healthy bowel can improve so much of your health, not just your cancer risk.
Your digestive system is long and complex. It stretches from your mouth to your bottom. Through the processes and functioning of this system, the food you eat is broken down into its basic nutrients. Protein is cut up into amino acids, carbohydrates to glucose and fats into smaller, simpler units, while vitamins, minerals and antioxidants are extracted. It’s through the activities of the digestive system that the food you eat is separated into the components used by your body.
The bowel is a roughly 1.5-metre-long muscular tube that includes the large intestine and the rectum. It connects the small intestine to your anus and is the very last section of your digestive system. While the rest of your digestive system is busily breaking down and extracting nutrients, it’s the bowel that Deals with the leftovers. While food contains many nutrients we need, we don’t use everything. Moreover, the digestive process itself creates by-products and waste material. These leftovers are concentrated and stored in your bowel, before being expelled from your body as faecal matter, when you have a bowel movement.
By the time food gets to the bowel, it has already passed through your stomach and small intestine. Most of the nutrients have been removed. By this stage the food you have eaten is unrecognisable from its original form. What’s left is mostly made up of undigested food, sloughed-off dead cells, indigestible fibre, intestinal bacteria, mucus, pigments and dietary fats.
The mixture also contains a lot of water, which comes from the food we’ve eaten and the liquids we’ve drunk. One of the main functions of the bowel is to extract most of this water for use by the body. As the faecal matter travels down the bowel, it’s converted from about 1.4 litres of sludgy material into about 1 cup of firmer, more compressed matter, which is passed when you have a bowel movement.
The role of bowel flora
The bowel also contains a vast and diverse population of bacteria. There are more bacteria in your large intestine than there are cells in your body. While there is still much that is not known about these critters, they do play an important role in both overall health and that of the bowel.
One of their important roles is fermenting unabsorbed carbohydrates and fibre to release energy and short-chain fatty acids. These short-chain fatty acids improve the health of the bowel lining, stimulating the replacement of cells and protecting the lining from mutation.
Bowel flora also play a key role in your immune system. The bacteria stimulate the gut mucosa to produce antibodies to pathogens, reduce inflammation and assist in the prevention of allergies.
These bacteria are also responsible for manufacturing some nutrients, including vitamin K and biotin (one of the B group of vitamins).
While many people ignore it, your bowel can indicate a lot about your internal health. How often, how much and the characteristics of your stools give clues to health problems, digestive and otherwise. If you’ve ever been to see a naturopath you will have been extensively questioned about your bowel habit: frequency, colour, texture, consistency and whether it floats or sinks. This is not just a weird obsession; this common, regular bodily function can offer insight and guidance to many aspects of health.
The big question from patients is always, “What’s normal?” There aren’t hard and fast rules to answer this. We’re all different, have our own digestive idiosyncrasies and eat different diets. This means a normal bowel movement for one person may be unusual for another. However, there are some general guidelines that indicate a healthy bowel.
As a general guide, it’s normal to have a bowel movement between three times a day and three times a week. More than that and your stools are likely to be too loose and your digestion too fast. You’ll be passing watery diarrhoea-like stools and losing excess water. Plus you won’t be adequately absorbing the nutrients from the food you eat.
If your bowel movements are less frequent, they’re probably too hard and you may have difficulty passing them. A hard stool often means people strain when going to the toilet, which increases your risk of conditions like haemorrhoids and diverticulitis. You’ll also probably experience more bloating and abdominal discomfort.
Some people have bowel movements you can set your clock by, while for others it’s more varied. For some, the urge to defecate is strongest in the morning. Getting up in the morning stimulates your bowel, which can trigger a movement. Another common time is just after eating, when the stomach expands. This stimulates the gastrocolic reflex and a subsequent bowel movement. For others, the urge to defecate may be triggered by drinking coffee.
Stools are normally medium to light brown in colour. However, your stool can change colour short-term, depending on what you’ve eaten or drunk. For example, if you eat a lot of spinach or beetroot, pigments from those foods can turn your stool green and red respectively. Having a few too many glasses of alcohol will also affect the colour, often turning it a dark brown.
Black, tarry, sticky stools and pale or clay-coloured stools need to be investigated. The first can be a sign of bleeding in the upper digestive tract, while pale stools indicate possible liver or gall bladder problems.
While stool characteristics vary from person to person, there are some basics that indicate good bowel health. If yours are very different from this ideal, follow the diet and lifestyle advice in the section on preventing bowel cancer.
The ideal bowel movement would be:
Formed but not hard: Faeces are normally about 75 per cent water. Any more than this and it will break up and not hold its shape. If it contains less water, the stool will be hard and difficult to pass.
Cylindrical not flattened: Your stool should be cylindrical in shape. Flattened or pencil-thin stools should be investigated by your doctor.
Fairly bulky and full-bodied: These are easier to pass and reflect a healthy bowel.
Textured but not too messy: While it’s OK for your stool to come out in two or three pieces, it shouldn’t make too much mess, either in the toilet bowl or on your bottom.
Easy to pass: Your stool should be soft enough to pass easily, without straining or pain.
Smelly, but not too strong or pungent: It’s normal for faeces to smell and it’s normal for that smell to be unpleasant. However, it shouldn’t be strongly offensive. Some foods do affect the smell of faeces in the short term, particularly asparagus, cabbage and other cruciferous vegetables.
In The Bowel Book, Michael Levitt writes, “The human gastrointestinal system was designed to operate best where stools resemble the shape and consistency (although not the colour!) of an unripe banana.”
There are about 12,600 new cases of bowel cancer each year in Australia and about 4700 people will die from this condition. In New Zealand, almost 2600 cases are diagnosed annually with around 1100 deaths. Bowel cancer is more common in men, with the likelihood of getting bowel cancer one in 17 for men compared with one in 26 for women.
If discovered and treated early, when the cancer is still localised in the bowel, it has a high cure rate. However, less than 40 per cent are discovered early and, once it has spread through the bowel wall and into the local lymph nodes, survival rates start declining. It’s because bowel cancer is often not discovered until this late stage that it’s one of the leading causes of cancer death in Australia.
Causes and who is at risk?
Bowel cancer can occur in any part of the colon or rectum. The direct cause is a mutation in the cells of the bowel lining. However, the reasons for this mutation occurring are complex and difficult to predict. There are certain known risk factors and commonalities among sufferers of bowel cancer (see box).
Bowel cancer risk factors
Age: Bowel cancer is more common in older people. It’s very rare in the under-40s, with most occurrences in people over 50 years of age.
Family: Having an immediate member of your family with bowel cancer increases your risk. The more relatives with the condition, the more your risk increases. However, in about 80 per cent of cases there is no family history. For most people, what you eat and how you live your life are much more significant in the development of bowel cancer.
Low-fibre diet: Bowel cancer is more common in people with low-fibre diets. In Africa and Asia, where people eat a lot of vegetables and wholegrains, the incidence of bowel cancer is much lower than in Australia and the US.
Other diseases: People with inflammatory bowel conditions such as Crohn’s disease and ulcerative colitis are more at risk of developing bowel cancer.
Polyps: Polyps are small, benign growths that occur in many places in the body. They’re particularly common in the large intestine. About one person in four over the age of 50 will have bowel polyps. While polyps are extremely common and most are not cancerous, most bowel cancers do start off as polyps.
Meat eating: Diets high in red meat and fat are associated with an increased risk of bowel cancer. Processed meats are particularly bad. The more of these foods you eat, the more likely you are to develop bowel cancer.
Lifestyle: Smoking, being overweight, drinking excess alcohol (particularly among women) and not exercising are all significant risk factors for cancers in general. This is also true of bowel cancer.
Looking for signs
Everyone’s a bit embarrassed about their poo. It’s one bodily function most people just don’t like to think about and certainly don’t talk about. In consequence, many people pay no attention and are quite unaware of what’s going on with their bowel habit.
However, as noted, bowel cancer is an insidious, progressive condition. Symptoms don’t appear quickly. Instead, it’s small changes, occurring over a longer period of time. If you’re not paying attention, it’s easy to miss the signs and symptoms of bowel cancer.
The most significant symptom is a change to your bowel habit that persists for longer than a couple of weeks. This could be a change to constipation or diarrhoea, long, thin, pencil-like stools or a feeling of not being able to empty the bowel completely. A persistent change in bowel habit needs to be investigated. It’s one of the best early warning signs.
Bleeding from the anus or any sign of blood in the stool is another symptom. You may notice this on the toilet paper or in the toilet bowl. It may be bright red or a darker colour. While the most likely causes of rectal bleeding are not bowel cancer, it’s important to have this change investigated.
Regular abdominal pain or bloating that persists for longer than a couple of weeks should be investigated, as should unexplained fatigue, weight loss or loss of appetite. If the cancer is situated high up the bowel, away from the anus, it may be difficult to detect any bleeding. The blood will be mixed in with the stool. This is called occult blood and is hard to detect with the naked eye. However, occult bleeding can cause persistent blood loss and subsequent anaemia. If you have anaemia for the first time, or it keeps recurring and particularly if you’re over 50, it’s worthwhile being checked for bowel cancer.
These symptoms are not uncommon and are usually a sign of something much less serious than bowel cancer. However, if you do experience any of these symptoms, particularly if they persist longer than a couple of weeks, visit your GP and get them investigated.
If your GP suspects bowel cancer, commonly the first thing they will do is a physical examination. This involves feeling the abdominal area for any lumps and also doing a rectal exam. While it’s common practice, this is not a very effective way to diagnose bowel cancer. Rectal exams are invasive and cannot discover cancers further up the colon. Plus, an abdominal examination can only detect larger masses and is always going to be inconclusive. At this stage, people are usually referred to a specialist: a gastroenterologist.
Currently, the primary test for diagnosing bowel cancer is a colonoscopy, whereby a thin, flexible tube with a camera on the end is inserted into the anus and gently pushed up into the bowel. It allows the gastroenterologist to actually see the inside wall of the bowel, enabling them to thoroughly check for abnormal masses and possible malignancies.
Colonoscopies are performed as a day procedure in hospital. People are sedated throughout, although a full anaesthetic is not used. During the procedure, polyps can be removed and biopsies taken of any suspicious lumps. These are then sent to a pathology lab for diagnosis.
Colonoscopies are not painful, but they are uncomfortable. Before the procedure you are required to drink a solution of salts. This is a laxative that induces diarrhoea. Complete emptying of the bowel before the colonoscopy is important, so the bowel wall can be fully visualised. You may also feel fatigued and unwell for a couple of days after the colonoscopy.
Although colonoscopies are performed regularly and are relatively safe, like all medical procedures they are not completely without risk. Documented complications can include respiratory distress from the sedation, arrhythmia and perforation of the colon. It should be noted these are relatively rare, with complications occurring in only 0.5 per cent of colonoscopies.
If the biopsy taken during the colonoscopy confirms bowel cancer, other tests will be done to check whether it has spread. These may include imaging tests such as X-rays, ultrasound, MRI or CT scans. Blood tests may also be done to check liver function, white and red blood-cell counts and other blood markers.
At the end of this process, the gastroenterologist can make an assessment as to whether the individual has bowel cancer, whether it has spread and how serious it is.
Treating bowel cancer
The standard medical treatment is surgical removal of a section of the bowel. The operation is called a bowel resection. With the patient under general anaesthetic, the surgeon will cut into the abdomen and remove the area of the bowel affected by cancer. Usually, this means taking out about 20–25cm of the bowel. The two ends are then rejoined.
Sometimes, if the cancer is located very low in the rectum, there may not be enough bowel on either side to make a join. In this case, an opening is made in the abdomen and the bowel is connected to that. Faeces are then emptied into a bag attached to the abdominal skin. This is called a stoma or colostomy, but is only necessary in about 5 per cent of cases.
If the cancer has spread beyond the bowel, chemotherapy and/or radiation therapy may also be recommended. This can be used before surgery to shrink the tumour and allow its complete removal with fewer complications. Post-surgery, it may also be used to kill any cancer cells missed or any that have spread to the lymph nodes and other organs.
Complementary treatment options
Along with conventional treatment, there’s a whole range of complementary treatment options that can assist when diagnosed with bowel cancer. You would also benefit from seeing a naturopath, herbalist or nutritionist to complement your conventional treatment. Given the high level of potential success from conventional treatment, the complementary practitioner would concentrate on supporting you physically and emotionally during that treatment.
It’s important to keep your doctor informed of any complementary therapies you’re taking. Some supplements are unsuitable for use just before surgery, while others can interact with chemotherapy agents.
On first being diagnosed of bowel cancer
Being diagnosed with cancer can be overwhelming. It can cause a whole range of reactions from fear and anger through to questioning of “why me?” and uncertainty about the future. During this frightening time, nurturing your emotional health is important for your overall wellbeing.
There are many ways to cope with the stress and fear of a cancer diagnosis. The most important step is to recognise you need help and take action early. Understanding the effects of the illness and managing your stress and emotional health will help you maintain a positive physical, emotional and spiritual outlook on life.
Be assertive and try to find out all you can about what’s happening to you. Ask questions and discuss treatment options with your health practitioners and family. Maintaining an involvement in what’s happening to you gives you some control over your health.
Dealing with the diagnosis
- Learn to relax. Try meditation, yoga or controlled breathing.
- Have regular massages.
- Take some regular time out to concentrate on yourself.
- Seek professional help (eg counsellors, support groups).
- Bach and bush flower essences can provide strong emotional support during this time. The Bach flower Rescue Remedy mixture provides wonderful all-round support. The bush flower essences angelsword, grey spider flower and waratah can all help with fear and shock, while dagger hakea, southern cross and sunshine wattle can bring a sense of acceptance and hope for the future.
- Herbal medicines for stress and anxiety include passionflower, Siberian ginseng, skullcap and oats. (If you are uncertain about what to take, consult a herbalist or naturopath.)
- Don’t just soldier on in isolation — seek out care and support during this emotionally difficult time.
During conventional treatment
Bowel cancer is strongly associated with diet and lifestyle. Once you are over the initial shock of diagnosis and into the treatment for bowel cancer, this can be a good time to start making positive changes. This is important for both your immediate and long-term health. Follow the advice in the final section of this report, ‘Prevention and maintaining bowel health’.
Reducing excess weight, improving your diet, giving up smoking and the other strategies outlined are not necessarily easy changes to make. However, they are vital for your long-term bowel health.
Bowel cancer treatment also places a heavy stress on your body. If you combine the load of metabolising drugs with the bodily stress of surgery and the anxiety about what’s happening to you, it’s little wonder your body has a higher requirement for basic nutrition. At times during the treatment for bowel cancer, it’s also common for people to go off their food. If this is the case, a protein powder combined with a good-quality multivitamin and mineral supplement are vital. This provides basic levels of nutrition.
Continue to take care of your emotional health during this time. Attending support groups, talking to close friends and learning to relax will all help during treatment.
After conventional treatment
When I have clients with cancer, my preference is always to let the chemotherapy do its work and then use herbs and supplements to restore vitality and improve the immune system afterwards. There’s a number of herbs and supplements that will improve your bowel health following conventional treatment.
Supporting the immune system
Post-surgery and particularly post-chemotherapy is a time when your immune system and energy levels are suffering. Vitamin C, along with the herbs echinacea, astragalus and Siberian ginseng, will improve your energy levels, rebalance your immune system and help your body recover from surgery and other therapies.
Bowel flora support
After treatment, it’s vital to restore the health and balance of your bowel flora. As discussed, these act as anti-inflammatory agents and also help maintain the health of the bowel lining. Eating yoghurt is unlikely to be enough to effectively restore the bowel flora. Instead, use a probiotic supplement containing a range of bacteria such as Lactobacillus acidophilus and Bifidobacterium lactis, along with fructo-oligosaccharides (FOS), the primary food source for bowel flora.
Glutamine is an amino acid that both assists bowel health and is also believed to reduce healing time post-surgery. Glutamine supports the integrity of the bowel lining, reduces the risk of cell mutation and can alleviate symptoms such as diarrhoea and constipation.
Diet & lifestyle
Continue making the changes outlined below in ‘Prevention and maintaining bowel health’. These are the long-term, rest-of-life changes you need to make to ensure your recovery from treatment and long-term health.
Prevention and maintaining bowel health
Bowel cancer is largely a result of diet and lifestyle. Despite the family link and other causes, in most instances it’s a highly preventable condition. Moreover, when it does occur, bowel cancer can be effectively treated and has a high likelihood of cure — as long as it’s caught early enough.
Maintaining bowel health
- Eat plenty of fibre.
- Eat more fruit and vegetables.
- Limit red and processed meat.
- Eat more fish.
- Limit junk food.
- Limit alcohol.
- Increase exercise.
- Maintain a healthy weight.
- Quit smoking.
- Protect your bowel flora.
Know what’s happening in your bowel
Bowel movements are a normal bodily function. We all do them on a regular basis. By paying more attention to your bowel and any changes that may occur, you can catch health problems early and get them treated. Remember that only 40 per cent of bowel cancer is detected at the early stage when it can be most effectively treated.
It’s important to know what’s normal for you. How often do you usually have a bowel movement and what is it normally like? Through knowing what’s normal for you, you can also spot when changes occur. These changes may indicate something is wrong.
What to do: Get to know your bowel habit. If that habit changes for more than a couple of weeks, go to see your doctor and get that change investigated. It’s also recommended that people over 50 have regular faecal occult blood testing, about every two years.
Eat plenty of fibre
A diet high in fibre is vital for a healthy bowel. It will also provide significant protection against bowel cancer. Fibre dilutes faecal matter, bulks up the stool, makes it easier to pass and reduces bowel transit times. High-fibre diets also encourage healthy bowel flora and provide plenty of fuel for the production of short-chain fatty acids, which protect the bowel lining against cell mutation and cancer.
Adult women should eat at least 25 grams of fibre daily, while men need at least 30 grams. However, according to the Colorectal Surgical Society of Australia, most people are only eating about 20g per day.
What to do: Eat plenty of fibre-rich foods every day. These include fruit, vegetables, nuts and seeds, legumes, cereals and breads. Add more vegetables into your daily diet and snack on fruit, nuts and seeds. Plus, choose wholegrain bread, rice and pasta, and buy a high-fibre breakfast cereal. The table at the end of this article gives an idea of how much fibre is in some basic foods.
Eat more fruit and vegetables
Packed full of fibre, antioxidants and vitamins, fruit and vegetables are foods to eat more of. They will both reduce your risk of bowel cancer and also improve your bowel health overall. Fruit and vegies contain fibre that bulks up and softens the stool, making it easier to have regular bowel movements.
Fruit and vegies are also packed with vitamins and antioxidants including carotenoids, phenols and flavonoids. These antioxidants trap free radicals and prevent oxidative damage to cells. Eating a lot of fruit and veg will also help you stay within a healthy weight range. Nutritional guidelines are to eat at least five servings of vegetables and two of fruit each day. However, at present in this part of the world, only 5 per cent of men and 10 per cent of women are eating this amount.
What to do: To make sure you’re getting enough, eat about three cups of vegetables and two pieces of fruit per day. Add fruit to your breakfast cereal or use it as a snack. Add more vegetables to your lunch; snack on carrot sticks and cherry tomatoes in the afternoon; and then make half your evening meal vegetable-based. /p>
Limit red meat & processed meats
A diet high in red meat, particularly processed meats, can cause bowel cancer: the higher the intake, the higher your risk. On average, for every 50g of red meat you eat per day, the risk increases by 15 per cent. This figure is even higher for processed meats: for every 50g you eat the risk of bowel cancer increases by 21 per cent.
Red meat is high in saturated fats, which are associated with an increased cancer risk. Plus, eating red meat and processed meats is associated with the ingestion of potentially carcinogenic compounds such as amines, nitrates and polycyclic aromatic hydrocarbons [World Cancer Research Fund. Food, nutrition, physical activity, and the prevention of cancer: a global perspective. American Institute for Cancer Research. Washington. 2007].
What to do: Eat no more than 500g (cooked weight) of red meat per week and avoid processed meats like bacon, salami, ham and sausages.
Eat more fish
Fish contains omega-3 poly-unsaturated fats. These are believed to be protective against bowel cancer. They are anti-inflammatory and directly inhibit cyclo-oxygenase-2, an enzyme implicated in the cancer development process. Fish are also high in selenium and vitamin D, both of which are linked to reduce cancer risk.
What to do: Replace some of the red meat in your diet with more fish. Choose fish that is high in omega-3s while also being low in pollutants such as mercury. The best sources are mackerel, silver warehou, Atlantic salmon, canned salmon and canned tuna in oil, herrings and sardines. Try to eat fish at least three times a week.
Limit junk food
Junk food is generally high in sugar, salt and overall kilojoules. It’s also mostly low in vitamins, fibre and antioxidants, the antithesis of how we need to eat to improve bowel health and prevent bowel cancer. Plus, the more junk food you eat, the less likely you are to be eating the good foods that maintain bowel health and protect against bowel cancer.
What to do: Steer clear of junk food and highly processed foods. Limit these to occasional meals, rather than every-day foods. Instead fill your diet with plant-based foods, wholegrains and more fish.
Limit your alcohol intake
It’s becoming clear that, while small amounts of alcohol can benefit your health, in larger quantities it’s very damaging. This is also true with cancer risk. While many people don’t know it, an increased alcohol intake will push up your risk of most cancers, including bowel cancer.
What to do: Limit your daily intake of alcohol to one standard drink for women and two for men. Know what a standard drink is and avoid binge drinking.
Increase your physical activity
Exercise is important for your overall wellbeing but it also improves bowel health. It stimulates the bowel and guards against constipation. Plus, regular exercise has been found to protect against bowel cancer. There are many benefits to regular exercise and since the early 1990s it’s emerged as a key lifestyle change for reducing cancer risk.
What to do: Aim for 30–60 minutes a day of moderate physical activity — brisk walking, for example.
Maintain a healthy weight
Being overweight and particularly having excess abdominal weight are risk factors for bowel cancer. Body fat is not distributed evenly around our bodies. It accumulates under the skin around the muscles of the upper arm, buttocks, belly, hips and thighs. It also builds up around the organs deeper inside your body. It’s this intra-abdominal or visceral fat that is most problematic in bowel cancer.2
What to do: Maintain a healthy weight and check your waist measurement. This is a good predictor of health risk, given it monitors the intra-abdominal fat levels. For men, aim for a waist measurement under 94cm, while women should aim for under 80cm.
The more you smoke and the longer you have smoked, the stronger the chances of developing bowel cancer.
What to do: Quit smoking as soon as you are able. There are lots of resources to assist you, including patches and gums. Call the Quit line (details at the end) or speak to your health practitioner about ways to stop smoking.
Protect your bowel flora
As outlined above, having a well-balanced and diverse bacterial colony in your bowel protects against ill-health. The balance of bowel flora can be harmed by many things, including some medications, low-fibre diets and gastro-intestinal disorders. Constipation and diarrhoea can also affect the balance of bacteria.
What to do: Protect your bowel flora by eating a high-fibre diet along with good-quality yoghurt. Limit your intake of coffee and alcohol, both of which affect bowel flora. If you are concerned about your bowel Health, also consider taking a probiotic supplement, such as acidophilus, which can help return your bowel to balance.
Bowel cancer is one of the most preventable cancers that affect us. The lifestyle and diet changes that reduce bowel cancer risk are the same ones that will improve your overall health. They’ll also give you more energy and make you feel better. Take steps now, improve your wellbeing and prevent bowel cancer.
References available on request
Cancer Council Australia, T: 13 11 20, W: www.cancer.org.au Cancer & bowel research trust, T: 1800 350 480, W:
The smoking Quit line, T: 131 848, W: www.quitnow.info.au
Kathryn Elliott is a nutritionist and herbalist. She practises at the Source of Wellness in Gladesville. Kathryn also writes a professional blog, Limes & Lycopene, which includes articles, recipes and healthy diet advice. W: www.kathrynelliott.com.au.
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