Hong Kong and Macau are among the top three regions in Asia with the highest prevalence of inflammatory bowel disease (IBD).[1]
What is IBD?
Inflammatory bowel disease includes Crohn’s disease (CD) and Ulcerative Colitis (UC). Its primary characteristics include repetitive episodes of inflammation of the digestive tract.[2]
Other symptoms of inflammatory bowel disease include diarrhoea associated with blood and mucus, abdominal pain and tenesmus (a continual urge to go to the toilet), and severe urgency to go to the toilet.
Pain on the lower left side is more associated with ulcerative colitis, and on the right side is Crohn’s disease.[3]
This inflammation is said to be autoimmune in nature, with the interaction between the gut and the immune system being a good place to start with the origin story.
Whilst this interaction between the gut and the immune system is vital, the reason why IBD occurs is still unclear.
The true origin of IBD is still a mystery. For example, a study has shown smoking increases the risk of developing Crohn’s disease. In contrast, smoking potentially protects against Ulcerative colitis, maybe even improving its course![4]
Both Crohn’s disease and Ulcerative colitis are similar in the way they present. The location of the inflammation is often a signal of which condition is developing. For example, ulcerative colitis typically has inflammation in the lower colon and rectum. In comparison, Crohn’s disease sees inflammation higher up in the digestive tract.
The spectrum of the inflammation, whether mild, moderate or severe, will also be a part of the diagnosis.
Unfortunately, along with other autoimmune conditions, inflammatory bowel disease is not considered curable. You can, though, achieve endoscopic remission where no inflammatory or disease activity is detectable via endoscopy or colonoscopy.[5]
This long road to remission doesn’t mean there aren’t ways to manage it and reduce the frequency of flare-ups.
I’ve seen it happen, and we’re going to be looking at the first steps to take control if you’ve been recently diagnosed or are looking to gain more control over the repetitiousness of the episodes.
There are a few ways to go about this. The first is using diet, the second is via nutritional supplements, and the third is via herbal medicine.
Each of these pillars has its part to play.
In this article, I will focus on two vital dietary changes and what I think the first supplement to discuss with your healthcare practitioner should be. Herbal interventions for IBD deserve their own article!
Let’s start with the dietary elements first.
Malnutrition is a primary symptom of inflammatory bowel disease.
One study has the incidence of malnutrition in IBD as high as seventy per cent, depending on the definition of malnutrition.[6]
It’s one of the most important considerations aside from inflammation as it worsens the prognosis and increases the incidence of complications, mortality and quality of life in IBD.[7]
Malabsorption occurs more in Crohn’s disease than ulcerative colitis because of the broader locations of inflammation seen in Crohn’s disease.[8]
There are a few main reasons why malabsorption becomes a problem. The first is the inflammation itself. Inflammation in the intestines shortens the contact time between nutrients and the gut surface, making it difficult for nutrients, including essential amino acids from protein, to be absorbed.[9]
Long-term inflammation can also cause a decrease in muscle synthesis along with malabsorption problems.[10]
Unfortunately, common medications used to treat IBD can cause pancreatitis in some cases and vomiting, diarrhoea, anorexia and appetite loss.[11]
All of which can contribute to the malabsorption problem.
Because of this, annual screenings of nutrients such as Vitamin B12, Folate, Vitamin D, Iron, Zinc and Selenium are some key indicators that need to be measured annually.[12]
Muscle loss or sarcopenia is another consideration with IBD. In one study, over forty per cent of the six hundred and fifty-eight patients had sarcopenia or degeneration of their muscles.[13]
This muscle loss also presents more overtly in people who have IBD and obesity simultaneously. Estimates show that up to one of fifth of IBD patients now also have obesity which masks the loss in lean body mass.[14]
Increasing dietary protein is the first place to start in IBD, especially during a flare-up.
Focusing on protein in the diet can improve levels of sarcopenia (muscle loss) and preserve muscle in IBD. A recent study from 2021 recommended that dietary protein consumption for those with IBD should be around 1.2 gms -1.5 gms per kilogram of body weight daily.[15]
Fibre is also essential; however, it can worsen IBD.
A review of twenty-six publications totalling over four thousand participants with IBD assessed total fibre intake.
In conclusion, the review found that individuals with IBD had lower fibre consumption than healthy controls.[16]It would make sense to attend to this as a priority, knowing what we do about the anti-inflammatory effect of fibre.[17]
However, some patients experience short-term benefits from reducing their fibre intake.
So what’s up with that?
Well, a possible answer to this is something we touched on earlier in the article—the interaction between the immune system and bacteria in your gut or the microbiome.
In a study released towards the end of 2022, a particular form of fibre, part of the fructose group called fructans, was isolated to cause inflammation in patients with IBD potentially.
If you are familiar with some other articles in this section of the website, you may have come across one titled “Function over food”.
It outlines why a poor digestive function can often give the impression that food is causing digestive symptoms when it is actually the food’s interaction with digestion that’s the problem.
Returning to our study on fibre and IBD, Crohn’s disease and Ulcerative Colitis we see a similar situation.
This study revealed that people living with IBD had reduced amounts of the bacteria responsible for breaking down certain forms of fibre.
A result of this reduced capacity to break down the fibre was that it then remained intact, causing an immune response and inflammation. This inflammation would then exacerbate IBD symptoms leading to either a new flare-up or the worsening of an existing one.[18]
Comprehensive digestive testing may help to identify deficiencies in the colonic bacteria that break down fibre.
Your healthcare practitioner can mitigate these deficiencies before increasing dietary fibre consumption.
Specific stool testing can also look at the levels of end products produced by fibre called short-chain fatty acids. These end products have been aptly named “post-biotics” and are essential to restore the microbiome by providing an energy source to important bacteria. Significantly for IBD, short-chain fatty acids can reduce inflammation in the digestive system.[19]
What happens if you are one of the people who feel worse when you increase your fibre intake?
One study suggests waiting for clinical remission.
An opinion piece released in 2021 found when fibre intakes were attended to at the right time, tolerability and short-term benefits increased in IBD patients.[20]
For some, this might mean relying on medication to reach clinical remission before considering fibre intake.
However, it does confirm that fibre, along with other positive dietary changes such as low refined and processed food consumption and hydration, can benefit IBD in the long term.[21]
For some with IBD, having a healthy fruit and vegetable intake may not be enough.
We mentioned some of the vitamin and mineral considerations earlier. In some cases, we know that blood levels of certain nutrients rise and fall in response to inflammation. For example, iron stores (ferritin) and copper increase but folate, zinc and selenium decrease in response to inflammation.[22][23]
In particular, vitamin D, typically low in many different parts of the community, plays a significant role in managing IBD’s two key aspects: muscle loss and inflammation. Up to fifty per cent of people living with IBD could be vitamin D deficient.[24]
A five-year study followed just under one thousand people with IBD who were either low in vitamin D or had normal levels. A higher frequency of pain interventions, CT scans, and hospitalisations was needed for those in the inadequate vitamin D group. The low vitamin D group also had a poor health-related quality of life and significant worsening of pain.[25]
Studies like this five-year one are great examples of what I refer to as “low-hanging fruit” when it comes to IBD.
For example, just yesterday, I used a quote that comes up a lot in practice – “a complex problem doesn’t always require a complex solution.”
IBD, Crohn’s disease or ulcerative colitis, is undoubtedly a complex problem.
With that said, even in this short article, we’ve covered how correcting your protein intake, using a vitamin D supplement and choosing the right time to increase your fibre intake can benefit IBD.
Hope this helps xx
References
[1] https://www.idd.cuhk.edu.hk/hong-kong-and-macau-among-top-three-regions-in-asia-with-the-highest-incidence-of-inflammatory-bowel-disease-cuhk-establishes-registry-to-increase-public-awareness/, viewed 9th February 2023.
[2] McDowell C, Farooq U, Haseeb M. Inflammatory Bowel Disease. [Updated 2022 Jun 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470312/
[3] McDowell C, Farooq U, Haseeb M. Inflammatory Bowel Disease. [Updated 2022 Jun 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470312/
[4] Lakatos PL, Szamosi T, Lakatos L. Smoking in inflammatory bowel diseases: good, bad or ugly?. World J Gastroenterol. 2007;13(46):6134-6139. doi:10.3748/wjg.v13.i46.6134
[5] Kim KO. Endoscopic activity in inflammatory bowel disease: clinical significance and application in practice. Clin Endosc. 2022;55(4):480-488. doi:10.5946/ce.2022.108
[6] Lin A, Micic D. Nutrition Considerations in Inflammatory Bowel Disease. Nutr Clin Pract. 2021;36(2):298-311. doi:10.1002/ncp.10628
[7] Bischoff SC, Bager P, Escher J, et al. ESPEN guideline on Clinical Nutrition in inflammatory bowel disease [published online ahead of print, 2023 Jan 13]. Clin Nutr. 2023;42(3):352-379. doi:10.1016/j.clnu.2022.12.004
[8] Nishikawa H, Nakamura S, Miyazaki T, Kakimoto K, Fukunishi S, Asai A, Nishiguchi S, Higuchi K. Inflammatory Bowel Disease and Sarcopenia: Its Mechanism and Clinical Importance. Journal of Clinical Medicine. 2021; 10(18):4214. https://doi.org/10.3390/jcm10184214
[9] Jeejeebhoy KN, Duerksen DR. Malnutrition in Gastrointestinal Disorders: Detection and Nutritional Assessment. Gastroenterol Clin North Am. 2018;47(1):1-22. doi:10.1016/j.gtc.2017.09.002
[10] Martínez-Arnau, F.M.; Vivas, R.F.; Buigues, C.; Castillo, Y.; Molina, P.; Hoogland, A.J.; Van Doesburg, F.; Pruimboom, L.; Fernández-Garrido, J.; Cauli, O. Effects of Leucine Administration in Sarcopenia: A Randomized and Placebo-controlled Clinical Trial. Nutrients 2020, 12, 932.
[11] Clark R, Johnson R. Malabsorption Syndromes. Nurs Clin North Am. 2018;53(3):361-374. doi:10.1016/j.cnur.2018.05.001
[12] Jeejeebhoy KN, Duerksen DR. Malnutrition in Gastrointestinal Disorders: Detection and Nutritional Assessment. Gastroenterol Clin North Am. 2018;47(1):1-22. doi:10.1016/j.gtc.2017.09.002
[13] Ryan E, McNicholas D, Creavin B, Kelly ME, Walsh T, Beddy D. Sarcopenia and Inflammatory Bowel Disease: A Systematic Review. Inflamm Bowel Dis. 2019;25(1):67-73. doi:10.1093/ibd/izy212
More references!
[14] Lomer MCE, Cahill O, Baschali A, et al. A multicentre Study of Nutrition Risk Assessment in Adult Patients with Inflammatory Bowel Disease Attending Outpatient Clinics. Ann Nutr Metab. 2019;74(1):18-23. doi:10.1159/000495214
[15] Forbes A, Escher J, Hébuterne X, et al. ESPEN guideline: Clinical nutrition in inflammatory bowel disease [published correction appears in Clin Nutr. 2019 Jun;38(3):1486] [published correction appears in Clin Nutr. 2019 Jun;38(3):1485]. Clin Nutr. 2017;36(2):321-347. doi:10.1016/j.clnu.2016.12.027
[16] Day AS, Davis R, Costello SP, Yao CK, Andrews JM, Bryant RV. The Adequacy of Habitual Dietary Fiber Intake in Individuals With Inflammatory Bowel Disease: A Systematic Review. J Acad Nutr Diet. 2021;121(4):688-708.e3. doi:10.1016/j.jand.2020.12.001
[17] Kuo SM. The interplay between fiber and the intestinal microbiome in the inflammatory response. Adv Nutr. 2013;4(1):16-28. Published 2013 Jan 1. doi:10.3945/an.112.003046
[18] Armstrong HK, Bording-Jorgensen M, Santer DM, et al. Unfermented β-fructan Fibers Fuel Inflammation in Select Inflammatory Bowel Disease Patients. Gastroenterology. 2023;164(2):228-240. doi:10.1053/j.gastro.2022.09.034
[19] Varela E, Manichanh C, Gallart M, et al. Colonisation by Faecalibacterium prausnitzii and maintenance of clinical remission in patients with ulcerative colitis. Aliment Pharmacol Ther. 2013;38(2):151-161. doi:10.1111/apt.12365
[20] Kuang R, Binion DG. Should high-fiber diets be recommended for patients with inflammatory bowel disease?. Curr Opin Gastroenterol. 2022;38(2):168-172. doi:10.1097/MOG.0000000000000810
[21] Limketkai BN, Hamideh M, Shah R, Sauk JS, Jaffe N. Dietary Patterns and Their Association With Symptoms Activity in Inflammatory Bowel Diseases. Inflamm Bowel Dis. 2022;28(11):1627-1636. doi:10.1093/ibd/izab335
[22] Gerasimidis K, Edwards C, Stefanowicz F, et al. Micronutrient status in children with IBD: true deficiencies or epiphenomenon of the systemic inflammatory response. J Pediatr Gastroenterol Nutr. 2013;56(6):e50-e51. doi:10.1097/MPG.0b013e31828f1e86
[23] Gerasimidis K, Bronsky J, Catchpole A, et al. Assessment and Interpretation of Vitamin and Trace Element Status in Sick Children: A Position Paper From the European Society for Paediatric Gastroenterology Hepatology, and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2020;70(6):873-881. doi:10.1097/MPG.0000000000002688
[24] Fletcher J, Cooper SC, Ghosh S, Hewison M. The Role of Vitamin D in Inflammatory Bowel Disease: Mechanism to Management. Nutrients. 2019;11(5):1019. Published 2019 May 7. doi:10.3390/nu11051019
[25] Kabbani TA, Koutroubakis IE, Schoen RE, et al. Association of Vitamin D Level With Clinical Status in Inflammatory Bowel Disease: A 5-Year Longitudinal Study. Am J Gastroenterol. 2016;111(5):712-719. doi:10.1038/ajg.2016.53
