The ABC of IBD
The last few months have seen something of a blog hiatus, largely as a result of feeling disappointingly sub-par health wise.
Ups and downs are a given when you suffer with IBD, but I haven't had such an extended and hard-to-shake 'down' phase for quite some time. My usual coping strategies weren't working, and an overdue food intolerance test revealed at least part of the reason why: leaky gut is back with a vengeance! So I am working on first tackling that, before daring to expect any other sort of improvement.
As a result of this development, my previous fun food and cooking experiments have had to come to a screeching halt and I have very much gone back to basics in terms of diet. It's easy to get sucked into all the overwhelming and often contradictory information out there, and ultimately feel a bit lost about what the 'right' thing to do is, so sometimes it's good to just get back to the essentials. Both in terms of what you eat, but also in terms of understanding what you're dealing with.
On that note, let's get 'back to basics' in terms of exactly what IBD is - just the essentials, no fanfare, the ABC.
What is IBD?
IBD stands for Inflammatory Bowel Disease, which is the fairly self-explanatory overarching name for two chronic autoimmune diseases causing inflammation in the intestines or colon: Crohn’s Disease and Ulcerative Colitis.
The key distinctions between the two forms of IBD are the part of the digestive tract affected, and the ‘depth’ of inflammation in the tissue[i]. Ulcerative colitis (UC) only affects the colon (large intestine), and involves surface inflammation of the intestinal wall, usually spanning large, continuous areas. Crohn’s disease (CD) on the other hand, can affect any area of the gastrointestinal tract, most commonly the end of the small intestine (the ileum) and the colon[ii], and the inflammation of the gut wall can span the entire thickness of the tissue, well beyond superficial surface damage, but tends to be more localised to specific spots of the GI tract.
What is an autoimmune disease?
IBD is an autoimmune condition, which means the body’s immune system mistakenly attacks some of its own healthy cells, and then fails to turn off, so the immune reaction does not stop[iii].
The immune system is our in-built defense, our army of protectors, designed to identify, attack and kill off harmful invaders (viruses, bacteria, parasites, old boyfriends…). It is our body's defence against infection: white blood cells are released into the bloodstream to destroy the cause of the infection, which results in inflammation of tissue in the affected area. It’s supposed to. For instance, if you have an infection, the infection site will swell, perhaps produce pus, and you may develop a fever. This is the immune system upping its game in order to fight off the infection.
In autoimmune conditions, the immune system does not distinguish between invading ‘bad’ cells and its own ‘good’ cells, and so attacks indiscriminately and continuously, resulting in chronic inflammation. This self-attack is why conditions of this kind are called auto-immune diseases. In the case of IBD, this immune response is hitting the inner lining of the gut and some of the muscular tissue beneath[iv]. This unrestrained activation of the immune response appears to be a secondary reaction following an unknown initial trigger.
Signs and Symptoms
IBD symptoms vary, and can range from mild to severe, depending on the degree of the inflammation and where it occurs along the GI tract. It is common to experience periods of active illness followed by periods of remission.
Some symptoms common to both UC and CD include: diarrhoea, abdominal pain and cramping, increased bowel movements, blood in the stool, fatigue, reduced appetite, weight loss, malabsorption and nutritional deficiencies.
Some people also experience fever, joint pain/swelling, abscesses, fissures, anaemia, eye inflammation, skin inflammation, mouth ulcers, and even psychological symptoms such as depression and anxiety.
Contributing Factors
The cause of IBD remains unknown, but is likely multifactorial, involving the effect of immunological and environmental factors on a genetically-predisposed host[v]. In fact, common genetic variations in over 100 genes have been identified as increasing the risk of IBD[vi].
Typically, however, autoimmunity only expresses clinical symptoms following some kind of trigger. Theories as to what such a trigger could be cover a wide spectrum of possibilities, including infections, environmental factors, vaccines, chemical exposure, abnormal immune system response, hormone imbalance etc[vii].
Environmental factors contribute both to disease development and disease flares[viii]. Smoking is one important such environmental factor in IBD, but with seemingly different effects in UC and CD: never smoking or quitting smoking appears to increase the risk of UC, while smoking increases the risk and exacerbates the course of CD. The reason for this is unclear, but it seems that it is down to the potentially different effects of smoking on the small and large intestine[ix].
While stress or emotional upset does not cause IBD, many people experience a flare-up of symptoms when stressed, so at least to a certain extent, there seems to be a psychosomatic element involved.
Oral contraceptives and NSAIDs can also potentially aggravate IBD and cause flares of the disease[x].
The Conventional Medical Approach
There is currently no official cure for IBD, and treatment options vary depending on the severity of symptoms. Medications and treatment are aimed at relieving the symptoms by helping to control inflammation. These include[xi]:
Aminosalicylates or mesalazines (local anti-inflammatories)
Steroids, such as cortisone (used short-term to help ease inflammation flare-ups)
Immunosuppressants (to reduce the immune system’s over-activity and attack on the intestinal tissue)
Biologics (specific antibody-based treatments targeting a specific part of the immune system)
Antibiotics
Surgery
Unfortunately, however, while these medications can help reduce IBD symptoms, they do not address the root cause, and come with a number of side-effects, and as a result cannot be used for long periods of time without consequence. Side-effects can include pancreas and kidney problems, insomnia, high blood pressure, diabetes, osteoporosis, eye problems, increased risk of infection, and more[xii].
IBD and Diet
There can be no doubt as to the effect of diet on IBD, both in terms of prevention, and for healing and maintenance. Yet, even though IBD is a condition occurring in the digestive system, it is somehow not standard medical practice to consider the details of a patient’s diet. Dietary advice, if any, is often vague and merely a secondary consideration once medication has been prescribed.
However, in more recent years, there has been a welcome increase in information and awareness regarding the impact of diet on IBD. Multiple studies have shed light on the potential of certain diets or dietary patterns to result in the emergence of IBD symptoms, or to exacerbate an existing condition[xiii]. Several dietary protocols have emerged with the aim of healing the gut including: the GAPS Diet, the Specific Carbohydrate Diet, the Autoimmune Protocol, the Paleo Diet, and more.
When it comes to IBD, the question of what to eat or what diet to follow is ultimately a highly individual matter. A great deal will depend on the individual patient and the severity of symptoms at any given time. Moreover, there is absolutely no one-size-fits-all dietary approach, no single diet is beneficial to all IBD patients and at all disease stages: some people will heal on a particular diet, while others may not, or may even experience aggravated symptoms on the very same diet.
While there are many potentially helpful, and often conflicting, dietary protocols to choose from, they all have certain basic principles in common and tend to adopt the following twofold approach to healing: first, the removal of irritating/harmful foods and substances so as not to further irritate the inflamed bowel; and second, the inclusion of healing foods to support the immune system and facilitate tissue repair and normalisation of intestinal permeability.
As a result, the ‘ideal’ IBD diet involves eating real, unprocessed food which is easy to digest, anti-inflammatory, low in irritants/allergens, nutrient-dense, and most importantly, personalised to your own symptoms and tolerances[xiv].
Conclusion
IBD is ultimately a highly individual, complex condition, and there is no one way to cure, deal or even live with it. Different things work for different people. But what I feel confident in saying is that a multifaceted approach is definitely the best one to take. Whatever route you choose to follow (more on this here), whether you are taking the conventional medications or not, I recommend approaching the issue of IBD from multiple angles: the physical of course, the mental and the emotional. Even if you are symptom-free on meds, don't neglect your diet or psychological wellbeing, and don't underestimate the negative impact of stress. Eat well and in a way that makes sense to you and helps you feel good, make time for self-care, for rest and for the things that make you feel good. Don't push yourself, rather learn to listen to your body - it is the best judge of what is good for it!
References
[i] Xia, Bing, Crusius JBA, Meuwissen SGM, and Peña AS. "Inflammatory Bowel Disease: Definition, Epidemiology, Etiologic Aspects, and Immunogenetic Studies." World Journal of Gastroenterology. Baishideng Publishing Group Inc, 15 Oct. 1998. Web.
[ii] Butanis, Benjamin. “About IBD: Crohn's Disease and Ulcerative Colitis.” Inflammatory Bowel Disease (IBD) Diagnosis and Treatment Options | Johns Hopkins Inflammatory Bowel Disease Center, 17 Oct. 2016, www.hopkinsmedicine.org/inflammatory_bowel_disease_center/about_ibd/.
[iii] Blum, Susan S., and Michele Bender. The Immune System Recovery Plan: A Doctor's 4-step Plan To: Achieve Optimal Health and Feel Your Best, Strengthen Your Immune System, Treat Autoimmune Disease, See Immediate Results. N.p.: Scribner, 2013. Print. Page13.
[iv] Pinnock, Dale. Digestion: Eat Your Way to Better Health (The Medicinal Chef). N.p.: Quadrille (UK), 2015. Print. Page 49.
[v] Xia, Bing, Crusius JBA, Meuwissen SGM, and Peña AS. "Inflammatory Bowel Disease: Definition, Epidemiology, Etiologic Aspects, and Immunogenetic Studies." World Journal of Gastroenterology. Baishideng Publishing Group Inc, 15 Oct. 1998. Web.
[vi] Butanis, Benjamin. “About IBD: Crohn's Disease and Ulcerative Colitis.” Inflammatory Bowel Disease (IBD) Diagnosis and Treatment Options | Johns Hopkins Inflammatory Bowel Disease Center, 17 Oct. 2016, www.hopkinsmedicine.org/inflammatory_bowel_disease_center/about_ibd/.
[vii] Molina, V., and Y. Shoenfeld. "Infection, Vaccines and Other Environmental Triggers of Autoimmunity." Autoimmunity. U.S. National Library of Medicine, May 2005. Web.
[viii] Rogler, G., J. Zeitz, and L. Biedermann. "The Search for Causative Environmental Factors in Inflammatory Bowel Disease." Digestive Diseases (Basel, Switzerland). U.S. National Library of Medicine, 22 Aug. 2016. Web.
[ix] Karban, A., and R. Eliakim. "Effect of Smoking on Inflammatory Bowel Disease: Is It Disease or Organ Specific?" World Journal of Gastroenterology: WJG. Baishideng Publishing Group Co., Limited, 21 Apr. 2007. Web.
[x] Rogler, G., J. Zeitz, and L. Biedermann. "The Search for Causative Environmental Factors in Inflammatory Bowel Disease." Digestive Diseases (Basel, Switzerland). U.S. National Library of Medicine, 22 Aug. 2016. Web.
[xi] Butanis, Benjamin. “About IBD: Crohn's Disease and Ulcerative Colitis.” Inflammatory Bowel Disease (IBD) Diagnosis and Treatment Options | Johns Hopkins Inflammatory Bowel Disease Center, 17 Oct. 2016, www.hopkinsmedicine.org/inflammatory_bowel_disease_center/about_ibd/.
[xii] Jacob, Aglaée. Digestive Health with Real Food: A Practical Guide to an Anti-inflammatory, Low-irritant, Nutrient-dense Diet for IBS & Other Digestive Issues. N.p.: Paleo Media Group, 2013. Print. Page 74.
[xiii] Andersen, V., A. Olsen, F. Carbonnel, A. Tjønneland, and U. Vogel. "Diet and Risk of Inflammatory Bowel Disease." Digestive and Liver Disease : Official Journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver. U.S. National Library of Medicine, Mar. 2012. Web;
[xiv] Jacob, Aglaée. Digestive Health with Real Food: A Practical Guide to an Anti-inflammatory, Low-irritant, Nutrient-dense Diet for IBS & Other Digestive Issues. N.p.: Paleo Media Group, 2013. Print. Page 74.