What’s Your Gut Telling You?

[MUSIC PLAYING] Welcome, everyone. I'm Dr. John Whyte, the Chief Medical Officer at WebMD. Crohn's disease is a type of inflammatory bowel disease that affects nearly 800,000 Americans. We're still learning more about the cause, particularly the role of our immune system. But what's the role of diet? Does that really make a difference?

What about stress? And what might cause a flare? I have two experts joining me today to help provide the answers. Dr. Thomas Ulman. He's the Chief of the Division of Gastroenterology at Montefiore Medical Center, Professor of Medicine at Albert Einstein College of Medicine, and a member of the National Scientific Advisory Council of the Crohn's and Colitis Foundation. And Dr. Shannon Chang, the Director of Clinical Operations of the Inflammatory Bowel Disease Center at NYU Langone Medical Center and the Chair Emeritus of the Medical Advisory Committee of Greater New York Chapter for the Crohn's and Colitis Foundation. Doctors, thanks for joining me.

Thanks for having us.

Thanks.

I want to start off, we were talking beforehand about exactly what Crohn's is and sometimes the confusion between Inflammatory Bowel Disease (IBD) and Irritable Bowel Syndrome (IBS). So let's just set the playing field and start off with explaining that distinction.

So IBD is Inflammatory Bowel Disease, which means that there is evidence of some inflammation somewhere within the GI tract. For Crohn's disease, that's somewhere between what we call mouth to anus. For ulcerative colitis, that's limited to the colon.

IBS, on the other hand, or Irritable Bowel Syndrome, is a condition of exclusion, meaning that you've done that evaluation and you haven't been able to find any evidence of anything wrong necessarily inside. So that's going to be a big distinction between the two.

And it's a different constellation of symptoms in IBS. So when we talk about issues, diseases like Crohn's disease, what's the rule of genetics, Dr. Ullman? So if you have a family history, what's your chances then, of developing Crohn's?

Yeah, so a great question. And I'd first like to almost set the table, if you will, by noting that we really don't know the cause of Crohn's disease. We don't know--

Still?

Still don't know. 2023, and we don't have it down. And it's really a constellation of symptoms and a bit of involvement-- sometimes a lot-- of active inflammation somewhere in the gastrointestinal tract, as Dr. Chang just pointed out. And we've done a huge number of genetic studies.

We're now over 200 identified genes that are likely involved in the development of Crohn's disease and it's cousin or sister disease called ulcerative colitis. But we know very little about the function of those specific genes. But genetics clearly plays an important role.

However, not so important that it's the only thing. If you are an identical twin and your identical twin has Crohn's disease, you only have about a 20% to 50% chance of developing Crohn's disease over your life. And for--

What about if your parent has it?

Yeah, so if your parent has it or if you are a parent about to have a child and the parent has Crohn's disease, about a 5% or 1 in 20 chance only. And that actually translates similarly with dizygotic twins or fraternal twins. I'm a parent of fraternal twins, so I care about these things.

And we classify Crohn's as an autoimmune disease. So what's the relevance of that when we're trying to manage patients? And what should they know about how it might impact other issues?

So when we talk about treatment, a lot of the treatments that we have target different parts of the immune system to try to modulate that immune system. So a lot of times patients say, "Oh, I don't want to go on immunosuppressant." And I try to explain to them that the etiology of the inflammation is your immune system getting a little bit dysregulated.

And so in order to kind of set things back the right way, we do use some of these medications that target specific parts. But I do emphasize that we're not shutting down the immune system. We're just sort of picking the parts that tend to contribute the most to the inflammation.

That's a good point. And we were talking beforehand about the role of the gut. Everyone's talking about gut bacteria. We hear it about heart disease, as well as the colon and the GI system. So what really is the role of gut bacteria in terms of the etiology of Crohn's, as well as what may cause flares of Crohn's?

So it's an immune disorder. We know that, not just because when we manipulate the immune system, we can get great treatment success, or sometimes no treatment success. But that tends to be our target. Our real target is the active inflammation that's there. And not so much an autoimmune disorder, but an immune disorder.

What it is, it's the immune system attacking normal constituents of the gut. They're not attacking the human cells that are necessarily-- the human tissue that's there, that gets inflamed, is sort of an innocent bystander in a sense. It's the normal gut bacteria and normal gut contents that aren't bacterial, whether it's viruses, fungi, whatever else is sitting there that our immune system misperceived as a threat and throw everything they have at those bugs. And the same kind of inflammation that would happen if there was a legitimate bacterial infection is there, but there's no bacterial infection.

It's not an infection. It's the normal gut constituents that the immune system is misdiagnosing or perceiving as a threat when there's really no threat at all. And so manipulating the immune system becomes how we try to treat because of this immune disorder.

But then on the other side, people could say, well, what if I manipulate the gut bacteria. Can that, then, impact my condition? And sometimes we talk about the role of diet. And I mentioned to you, I get the question from patients all the time, Dr. Whyte, what should I be eating, what shouldn't I be eating if I have Crohn's disease?

So Dr. Chang, what advice do you give them in terms of what's on the good list and maybe what's not so good to be eating if you have Crohn's?

Right. So this is a great question. And I think that the key is to kind of keep it big picture here. We do recommend sort of this whole foods, less processed foods diet. There is evidence to show that preservatives in foods in animal models can increase the risk of inflammation in general. So we do recommend trying to stay away from that junk food. But otherwise, we are recommending avoiding a lot of high-fat animal means, such as red meat.

It doesn't mean that you can't have a burger from now and then if you want to have something like that. But in general trying to stick to the lean meats, seafood, chicken, turkey, that kind of thing. And then trying to avoid the animal fats. You know, less butter, more of that sort of olive oil or vegetable oil, things like that.

And then what role does lifestyle play? Does stress really impact symptoms?

I really wish that we had answers on the diet side of things. But just in terms of lifestyle, right, our goal as caregivers for these patients is to make their lives as normal as possible. And so a healthy lifestyle is always good for that whenever we can recommend it. I'd love to say that there's oodles of literature that support "Oh, yeah, healthy lifestyle patients do a whole lot better."

But do you think poor diet and stress causes flares? Or is there something else going on?

I think they are definitely contributors to flares. Whether they themselves precipitate a flare or the perception that something's not right isn't clear. I mean, all sorts of life stressors will make the disease worse or the perception of the disease worse, which is just as important, right? So whether that's divorce, whether that's a death in the family, something horrific like that definitely makes Crohn's disease patients flare or believe that they're flaring. There's no question.

I think Dr. Ulman and I have both in clinical practice seen patients that are going through incredible amounts of stress. And I think organically, it can affect their inflammatory bowel disease. But to touch on the point of the diet. Again, I think that in general I have seen patients that try to control their disease just with diet alone. And there's varied success with that.

I think it depends on that patient and how severe their inflammation is. But we do routinely counsel on diet because it is an important part of what you put into yourself and also how you feel. We know, of course, that the food that you eat affects how you feel. I did want to highlight that Crohn's and Colitis Foundation does have a website called Gut Friendly Recipes that is a nice way to help guide meal planning in a way based on what type of inflammatory bowel disease you have, concomitant conditions like celiac disease.

If you want a specific diet, they have recipes sort of tailored towards that. So it's an interesting thing you should check out.

Oh, that could be very helpful to a lot of people. We talked about trying to make life as normal as possible given their symptoms. Having Crohn's itself can lead to more stress. Part of it is around bowel hygiene, right, in terms of the urgency of having to go to the bathroom. You've also mentioned some tools out there that exist to help patients who have Crohn's disease better manage their bowel routine.

Can you tell us about that?

Right. So a big part about living with IBD is being able to live a normal life. And one of the main symptoms is bowel urgency. And so something that is able to be shared with patients is something called the "We Can't Wait" App. That app actually helps identify compassionate institutions or businesses that have available restrooms for the public. So we do encourage people to look at that as well.

Well, doctors, I want to thank you for taking the time today to talk about what some of the causes might be, as well as the role of diet and lifestyle in Crohn's disease. So, thank you.

Thank you.

Thanks.

[MUSIC PLAYING]