Sunday, November 25, 2012

Meal Size

Smaller or Larger Meals With IBD?

Because diet is integrally linked to symptoms in IBD, a lot of focus is put on what to eat.  Less focus is put on when to eat, though several diet strategies have different recommendations.  Three squares a day is the old standby, while some diets recommend as many as seven micro-meals.  Alternatively, one big meal makes planning easier.  Looking at mealtimes objectively requires a bit of history of how we got to the current norm.
Back in the old times – before David Hasselhoff made wearing shirtless jackets cool.  Before Farah Fawcett’s swimsuit showed how cold the water was.  Before Jimmy Hendrix faded in a Purple Haze.  Back in those times we had the food icons known as Ward and June Cleaver.  I know – what do they have to do with food?  The 1950’s as portrayed on Leave it to Beaver presented what we still think of as the “typical” meal schedule.  A hearty breakfast, maybe some bacon and eggs with a piece of toast and some coffee.  For lunch, a sandwich and an apple, and can of soda.  For dinner, a salad then a roast turkey and gravy, stuffing, mashed potatoes, and some carrots.  Finally, a slice of apple pie for dessert.  Many of us grew up with the idea that this is the “traditional” way meals are structured.  But history tells us a different story.

In hunter-gatherer times, eating was feast or famine.  With no effective way to preserve many types of food, it was consumed when available, and weight (largely fat) was put on to get folks through lean times.   Once folks settled down, consumption became somewhat more regular.  In Roman times, the wealthy ate a single large meal at lunchtime, with an occasional smaller meal later in the day.  During the middle ages, breakfast became a popular addition.  Dinner as we know it didn't come about until the availability of cheap lighting – bedtime came about with sundown prior to that.  The regularized three meals we know today largely evolved during the industrial revolution.  Shift work required breakfast be eaten early, that lunch be portable and taken mid-shift, and dinner come beyond the late afternoon. (1)

Today, we have the flexibility to eat on whatever schedule we desire, so what is best for symptom abatement?  Most of the advice from competent sources centers around frequent, smaller meals.  For example:

  • The Mayo Clinic notes you may “feel better eating five or six small meals” a day. (2)
  • The NY Times recommends “Eat small amounts of food throughout the day.” (3)
  • UNC’s Medical School provides the guidance that smaller,  frequent  meals may avoid some of the  “backed  up” type feelings associated with near blockages (pain, bloating, gas) (4)

Though these are recommended, there isn’t any direct evidence of a specific meal size conferring global benefit to the underlying disease.  That said, what about the quality of life issues noted above by UNC’s guidelines?

In terms of meal effect, the largest concern of most IBD patients is the post-meal urgency to use the bathroom.  Urgency is caused by stimulation of the lower part of the large intestine, the rectal ampulla, distending.  Both chemical and nervous triggers contribute to this.  In general, the large intestine produces 3-4 movements a day, and they can result in the need to defecate if they result in fecal matter being deposited in the rectal ampulla.  Otherwise, the intestinal movements just move the future feces further toward the rectum. 

One of the primary triggers for intestinal motility is the consumption of food (which kicks off the whole digestive process).   This can result in urgency after eating a meal (or during the meal for an extended meal).  The urgency is generally not proportional to the amount eaten, as that food has many hours of transit time left to reach the end of its journey - there is no evidence that the smaller meal movements contribute to urgency more or less than larger meal movements.   * Meal size also impacts the rate the stomach empties.  Smaller, lighter meals empty quicker.  Larger meals take longer to empty.  (5)

 Because the stomach emptying is a trigger for the whole intestinal system to kick-in, eating smaller meals can result in more movements.  On the other hand, eating smaller meals may mean less bloating in the intestines 3-4 hours post-mealtime, resulting in a more “comfortable” gut.  Smaller meals also allow oral drugs to flow to the small intestine more evenly (and not “wait” for the full digestion to occur), showing a benefit for those on oral steroids.  Plus, if you need to take medication frequently during the day, having a small meal coincide with that may be necessary if it is a “take with food” drug. (6,7)

In general, intestinal motility slows down approximately four hours after eating.  If you are travelling and need to increase your chances of not having a bowel movement in-transit (while stuck in rush hour traffic, for instance), eating fewer meals timed appropriately can be a lifesaver.  The same goes for events where a bathroom may not be accessible. (5)

There have been no extensive objective studies showing any evidence of a positive effect on symptoms based on frequent small meals, or on fewer larger meals.  The clinical evidence is not present to support a recommendation either way.   Because of this, allow your lifestyle and what you can individually tolerate to dictate meal size and frequency.

Bottom Line

  • Eating frequent, small meals complementing the consumption of medicine is a good idea.
  • One or two larger meals if tolerated are just as good if oral medicines aren’t a factor.
  • When travelling or attending an event where facilities are limited, meal planning may require you to not eat 4 hours before the event to avoid triggering increased intestinal motility. 

* Note:  Diarrhea is not associated with increased intestinal motility, but reduced intestinal motility. For IBD sufferers, there can still be loose stool movements with increased motility, but in the water rush with traditional diarrhea the intestines are generally not in motion.

(6)    S.S. Davis, J.G. Hardy, M.J. Taylor, D.R. Whalley, C.G. Wilson.  The effect of food on the gastrointestinal transit of pellets and an osmotic device (Osmet).  International Journal of Pharmaceutics.  1984.
(7)    S S Davis, J G Hardy, J W Fara. Transit of pharmaceutical dosage forms through the small intestine.  Gut, 1986.

Saturday, November 17, 2012

Stress, Depression, and IBD

Stress and IBD

Depression is a very real disorder that is comorbid with IBD.  The holiday season gets kicked off this week with Thanksgiving (family, food, and football).  The stress of travel and the focus on consumption are enough to give IBD sufferers an extra helping of distress, and can be an aggravator of depression.

Traditionally, the holiday season is associated in the public mind with an increased suicide rate.  In reality, the overall suicide rate drops during the holiday season.  (1)  A lower suicide rate, however, does not mean that there aren’t stressors.  With IBD, additional stress can exacerbate symptoms, which can deepen depression, which can exacerbate symptoms, which can deepen depression….

There are multiple types of stress, both acute and chronic.  Acute stress can be caused by a singular event, such as a pending layoff at work.  Chronic stress can be due to a life situation, such as caring for an incapacitated loved one.   Acute stress has well known but short term gastrointestinal effects – predominantly an increase in water into the colon and increased motility, leading to diarrhea.  The GI effects of longer-term stress are less well understood.  The majority of literature shows that there is a small amount of increase in inflammation and a lower immune response due to chronic stress.  For IBD sufferers, this translates into a higher rate of symptom occurrence and an increased likelihood of a flare.   It is especially difficult to disentangle the stress from the disease itself from outside stressors, leading to a confusing landscape.  Unfortunately, traditional stress reduction techniques haven’t shown a consistent benefit in IBD sufferers in terms of disease-related symptoms abating, but they do have the same overall effects that non-suffers benefit from.  (2,3) 

Depression and IBD

Depression is psychological disorder defined as having a “depressed mood and/or loss of interest or pleasure in life activities for at least 2 weeks and at least five of the following symptoms that cause clinically significant impairment in social, work, or other important areas of functioning almost every day”

·         Depressed mood most of the day.
·         Diminished interest or pleasure in all or most activities.
·         Significant unintentional weight loss or gain.
·         Insomnia or sleeping too much.
·         Agitation or psychomotor retardation noticed by others.
·         Fatigue or loss of energy.
·         Feelings of worthlessness or excessive guilt.
·         Diminished ability to think or concentrate, or indecisiveness.
·         Recurrent thoughts of death (4)

Any IBD suffer recognizes several of these as impacts of the underlying Crohns or UC.  All IBD sufferers have had weight issues (sometimes unintentional gain on steroids, or unintentional loss when flaring), fatigue is common with the disease, and the need to be constantly vigilant for a nearby bathroom can affect the pleasure of common activities.  Major depression is much more likely to strike IBD sufferers over their lifespan by almost twofold (27% for IBD sufferers v. 12% for the general population), and the most likely time is at the time of diagnosis.(5)

Because of the increases likelihood of depression, both patients and providers should be on the lookout for the onset of symptoms.  Treatment is available in the form of both psychological (e.g. Cognitive Behavioral Therapy) and pharmacological (e.g. Selective Serotonin Reuptake Inhibitors –SSRIs) approaches.  Your GI doctor can recommend a mental health professional that deals specifically with those who have a chronic illness.

While this blog focuses on those with IBD itself, thought must be given to the friends and family also.  Seeing a loved one suffer and feeling helpless to do anything about it can take as much of a psychological toll as being affected with the disease itself.   The holiday season is a time for celebration with friends and relations, and a time for reflection.  If depression appears to be affecting someone you care about, take the opportunity of holiday closeness to discuss it.

Have a safe and happy Thanksgiving!

(1)     David P. Phillips PhD, John S. Wills.  A Drop in Suicides around Major National Holidays.  Suicide and Life Threatening Behavior, 1987.
(2)    J E Mawdsley, D S Rampton.  Psychological stress in IBD: new insights into pathogenic and therapeutic implications.  Gut, 2005.
(3)    Robert G Maunder MD, FRCPC.  Evidence that stress contributes to inflammatory bowel disease: Evaluation, synthesis, and future directions.  Inflammatory Bowel Diseases, 2005.
(4)    DSM-IV-TR.
(5)    Lesley A. Graff PhD, John R. Walker PhD, Charles N. Bernstein MD.  Depression and anxiety in inflammatory bowel disease: A review of comorbidity and management.  Inflammatory Bowel Disease, 2009.

Wednesday, November 14, 2012

Inflammatory Bowel Disease: By the Numbers

IBD Epidemiology

Epidemiology is the study of disease patterns in a population.  It tends to look for trends in disease progression, and for clusters of activity on a meta level.  Epidemiological studies are good for identifying environmental causes of disease, geographic or racial predispositions, and correlative information that can focus future studies on finding root cause.  For those of us suffering from IBD, the numbers from these studies also provide information on how prevalent the disease is and what the progression will probabilistically look like.

Overall, the current incidence of IBD is as follows:

  • Ulcerative Colitis:  0.5–24.5 per 100,000 persons
  • Crohn’s Disease:  0.1–16 per 100,000 persons(1)

Aggregating and averaging the numbers (which will be shown below not to be a very good representation, except for global comparison to other diseases), approximately one out of every 5,000 people globally are diagnosed with IBD.  It is hard to pin down incidence rates to an exact number due to varying standards of care globally, lack of consistent diagnosis (IBD is frequently misdiagnosed as Irritable Bowel Syndrome or general gastroenteritis upon presentation of the initial symptoms and later refined), and lack of data in many regions.  Additionally, because IBD generally presents itself between the ages of 15 and 35, areas with very low life expectancies and a history of other gastrointestinal illnesses may have underrepresented numbers (i.e. if you die of cholera or amoebic dysentery at 25, it may never be known if you had concomitant IBD).

Certain populations definitely have higher rates of IBD than others.  In general, the following are significantly more likely to have diagnosed IBD based on current data:

  •          Caucasians, specifically those of Northern and Western European decent.
  •          Females (only with Crohn’s and only to a small degree)
  •          Individuals living in urban areas.
  •          Smokers.
  •          Individuals with a blood relative (especially a sibling) with IBD.
The incidence of IBD in most of Southeast Asia is very low, though the rate of increase is fairly high. In the US, the combined prevalence is approximately 5 people per 1,000.  It has been postulated that this may be due to a change in diet or lifestyle, though the introduction of a pathogen that favors of other climates or genetic mixing cannot be ruled out.  To further complicate things, it may be a multifactor issue – a genetic predisposition in an individual that comes into contact with a specific pathogen (or class of pathogens) that flourishes due to a particular lifestyle (though it would be nice to be reductionist and find a single cause).(2)

The other side of epidemiology of interest to those with IBD focuses on disease progression and outcomes.  One question everyone has when first diagnosed is what is the prognosis?  There will be a definite impact to quality of life, but the impact on quantity of life is difficult to determine.  There are a few studies that have looked at this, however, that can shed some light on the statistical probability in these areas.

In terms of progression, “complicated” disease is defined by the introduction of irreversible tissue damage.  Standard inflammation can go down with treatment or time, and the tissue can repair itself.  Lesions that form scar tissue, however, don’t self-repair.  Strictures and fistulae are representative of complicated disease that requires surgery or aggressive medication therapy to treat properly.  Complicated disease can present at any time (I was initially diagnosed with Crohn’s after my first fistulotomy), and in some patients it never progresses beyond the early disease stages.  Complicated disease stats for Crohn’s are as follows:

  •          At Diagnosis:  19-38%
  •          After 10 years:  56-65%
  •          After 20 years:  61-88%(3)
For both Crohn’s and Ulcerative Colitis, the age of onset plays a major factor in disease progression.  Those diagnosed at an earlier age show a more rapid progression to complicated disease.(4)  Additionally, the trends toward complicated disease are moving in a good direction – preliminary studies are showing that early diagnosis and more aggressive treatment may delay or stave off the onset of complicated disease.  Therapeutically this is ascribed to immunomodulators, and may look even better once the new generation biological have been in use for an extended period. (5,6)

In terms of impact on overall lifespan, the measurement used is standardized mortality ratio, or SMR.  For Ulcerative Colitis, the SMR is close to 1.0, which means that the number of deaths in UC patients compared to the normal population in a given period of time is the same.  For Crohn’s disease, the SMR is approximately 1.4, which means those with Crohn’s disease have 40% more deaths when compared to the normal population in a given period of time.   In general, the effects are on the overall mortality – in terms of the number of individuals that die directly from the disease (e.g. due to toxic megacolon or similar complications), the numbers are 1-3% of sufferers.  Overall, those with hospitalizations and surgeries under their belt for IBD (and therefore complicated disease) have a higher SMR.  (7) 

*Note the difference between incidence and prevalence above.  Incidence is the rate of occurrence of the disease (number of cases that occur over a period of time) – prevalence is the total population.  Incidence shows if a disease is become more or less common and changes with treatment.  Prevalence shows the total number of people impacted at any given point.

 Bottom Line

  •        IBD is on the rise everywhere, though better diagnoses and other factors may contribute to this rise.
  •        Approximately 5 per 1,000 people in the US have IBD. 
  •         Crohn’s disease patients, especially those with complicated disease, have a statically lower life expectancy.  UC patients generally do not have a statistically lower life expectancy.

(1)    Loftus EV.   Clinical epidemiology of inflammatory bowel disease: incidence, prevalence, and environmental influences. Gastro May 2004.
(2)    Michael Economou, MD, PhD, Georgios Pappas, MD.  New Global Map of Crohn’s Disease: Genetic, Environmental and Socioeconomic Correlations.  Inflammatory Bowel Disease, 2007.
(3)    Edouard Louis.  Epidemiology of the Transition from Early to Late Crohn’s Disease.  Digestive Diseases, 2012
(4)    Corinne Gower-Rousseau, Francis Vasseura, Mathurin Fumery, Guillaume Savoye, Julia Salleron, Luc Dauchet, Dominique Turck, Antoine Cortot, Laurent Peyrin-Biroulet, Jean Frédéric Colombel.  Epidemiology of inflammatory bowel diseases: New insights from a French population-based registry (EPIMAD).  Digestive and Liver Disease, 2012.
(5)   Barbara D. Lovasz, Petra A. Golovics, Zsuzsanna Vegh, Peter L. Lakatos.  New trends in inflammatory bowel disease epidemiology and disease course in Eastern Europe.  Digestive and Liver Disease, 2012.
(6)   Charles N Bernstein, Edward V Loftus Jr, Siew C Ng, Peter L Lakatos, Bjorn Moum.  Hospitalisations and surgery in Crohn's disease.  GUT 2011.
(7)   Christian P. Selinger MBBS, MRCP, Rupert W. Leong MBBS, FRACP, MD. Mortality from inflammatory bowel diseases.  Inflammatory Bowel Disease, 2012.

Wednesday, November 7, 2012


Probiotics and IBD

The human intestines contain approximately 100 trillion (yes, that's 100,000,000,000,000) bacterial cells from up to 1,000 species.  Bacteria play a definitive role in gastrointestinal health, as anyone who has encountered a bad strain of clostridum difficile (C. Diff) or escherichia coli (E. Coli) can attest.  Bacteria also play a positive role in the digestive system - the standard flora keep out bad microbes and assist in digestion of certain categories of food, including carbohydrates.  The role of bacteria is so critical, doctors are experimenting with fecal transplants (the topic of a future posting) to treat IBD and other conditions.

Probiotics are bacteria (or yeasts) that are widely believed (and have been shown) to have a positive impact on intestinal operations. There are many different bacterial strains marketed as probiotics, but the two most common are Lactobacillus (and other lactic acid bacteria or LAB) and several members of the Bifidobacterium family.  They  are both acid-resistant and can tolerate a fairly low pH, allowing them to successfully transit the stomach.  Lactobacillus is commercially used for fermentation, most commonly in the product of active yogurt cultures.

Probiotics have been shown to have some positive effects in clinical trials in controlling diarrhea (1) caused by antibiotics.  Because Cipro and Flagyl are common IBD treatments for everything from C. Diff to closing of fistulae, this shows promise as an adjunct therapy.  The effect size isn't great and there is no consistency in what strains to use (though LAB strains were the most common), but there were very few adverse effects.  Probiotics come in two primary forms - as part of incidental intake in food consumption or as a dietary supplement. Based on the higher quality studies reviewed, there doesn't appear to be any need to use specific supplements - fermented milk and yogurt showed similar efficacy.

Unfortunately, the news for long term use of probiotics in the maintenance of remission in both Crohns and UC is not well supported.  The latest meta-analyses show no statistically significant benefit for maintaining remission in either Crohns or UC (2) and conclude that, at present, there is no clinical reason to recommend them as a therapy.  The current research isn't overly extensive, however, and the door is open for better, more comprehensive studies in this area.

Outside of the supplement arena, the main food containing probiotics, yogurt, has many varieties and quite a few known benefits.  It is a well documented source of protein, vitamins B6 and B12, calcium, and riboflavin.  Additionally, it can sometimes be better tolerated than an equivalent amount of milk due to the breakdown of lactose in the souring process.  It can be eaten alone, used as a sauce (e.g. tzatziki) or used as a substitute for eggs when making breaded dishes (give it a try!)

Bottom Line

  • Probiotic supplements have shown no benefit for long term use in Crohns and UC to date in large, well-formed studies.
  • Consumption of yogurt and other probiotic-containing foods has general health benefits and minimal side effects.
  • Probiotic use in the treatment of antibiotic-related diarrhea has reduced the frequency and duration of symptoms.  Consumption of yogurt or fermented milk as an adjunct therapy should be considered for acute cases.
(1)  Probiotics for the Prevention and Treatment of Antibiotic-Associated Diarrhea: A Systematic Review and Meta-analysis, Susanne Hempel, PhD; Sydne J. Newberry, PhD; Alicia R. Maher, MD; Zhen Wang, PhD; Jeremy N. V. Miles, PhD; Roberta Shanman, MS; Breanne Johnsen, BS; Paul G. Shekelle, MD, PhD, JAMA 2012

(2)  (Probiotics for maintenance of remission in ulcerative colitis, Naidoo K, Gordon M, Fagbemi AO, Thomas AG, Akobeng AK, Cochrane Review 2011 and Probiotics for maintenance of remission in Crohn's disease, Rolfe VE, Fortun PJ, Hawkey CJ, Bath-Hextall FJ, Cochrane Review 2008