Cleveland Clinic in Cleveland
Two aspects of inflammatory bowel disease must be addressed as part of a whole-person care approach: the impact of nutrition and stress. Sadly, we don’t talk about either enough.
What and what not to eat can be a source of significant anxiety for our patients and are questions they often raise. A dietitian can help improve the nutrition aspect of IBD in a few ways. First, they can provide important patient education on the link between nutrition and health, which is of particular significance in our society, where processed and fast foods are so prevalent. A dietitian also can help patients choose and follow a diet with proven treatment benefits. As a recent study (see below) showed, both the Mediterranean diet and the specific carbohydrate diet (SCD) yield clinical benefits.
The psychosocial aspect of IBD is something else we don’t discuss enough. Many of our patients report that stress plays a role in the behavior of their disease. People with IBD also are more likely than the general population to be anxious and depressed. We’re not sure whether stress, anxiety and depression develop in response to IBD or whether they are somehow pro-inflammatory and possibly act as triggers of bowel disease. Regardless, given the impact on our patients, finding the right ways to cope with and manage this aspect of their health is as important as choosing the right medical and surgical treatment.
IBD Diets Improve Clinical Symptoms
The SCD—which excludes grains, most sugars, starches and processed foods—has gained a small but loyal following since its introduction to the IBD community in 1987. However, despite anecdotal reports of efficacy and some recent case series showing clinical improvements, many patients with IBD find it prohibitively restrictive.
Now, a randomized study comparing the SCD and the more accessible Mediterranean diet—which emphasizes olive oil, fruits, vegetables, nuts and cereals, as well as moderate intake of fish, poultry and wine—showed the latter is as effective as the SCD in achieving symptomatic remission. The 194-person study, which was presented at the 2021 Crohn’s and Colitis Congress in an oral presentation by James Lewis, MD, of the University of Pennsylvania, in Philadelphia, found that 47% of participants following the SCD and 44% of those adhering to the Mediterranean diet experienced symptomatic remission after three months.
Stacy Cavagnaro, RD, an IBD dietitian at Cleveland Clinic’s IBD Medical Home, in Cleveland, said the results show both diets are “pretty much even, and the Mediterranean diet also has the advantage of proven benefits for cardiovascular health and in protecting against colorectal and prostate cancer.”
To date, Cavagnaro has used both diets in the clinic, but she recommends the SCD only “if someone is up for a drastic change.
“The restrictiveness of the SCD can be a problem for patients who have already had to cut out foods due to their disease,” she said. “Cutting out all starches makes it hard to put on weight.”
With the new data, Cavagnaro said, “the Mediterranean diet may become our go-to diet for IBD patients.”
Virtual Reality for Anxiety in IBD
Stephen Lupe, PsyD, a clinical health psychologist at Cleveland Clinic’s IBD Medical Home, uses several interventions to improve the psychological well-being of his patients with IBD. They range from cognitive-behavioral therapy to gut-directed hypnosis, and from relaxation training to mindfulness-based techniques that reduce the impact of stress on IBD.
Now, a study presented at the 2021 Crohn’s and Colitis Congress (abstract P046) showed that six minutes of breathing-focused virtual reality can significantly reduce anxiety and pain in IBD patients.
“It’s neat to think that patients can train in mindfulness or other modalities in the VR setting even while they’re in the physician’s waiting room,” Lupe said. The VR field is a “hotbed of research, with promising results,” he said, and the technology may even have potential as an adjunct to medical treatment.
In general, Lupe said, the gastroenterology community has come far in recognizing that psychological health is an important aspect of IBD care. “The traditional paradigm has always been a mind–body dualism, and I think that’s starting to break down,” he said. “We’re seeing humans more as integrated systems.”
Stress had been found to increase levels of interleukin-6 and cortisol, and it can cause epithelial tight junctions to loosen, opening the door to more inflammation, Lupe said. “Psychological health clearly impacts the way the body functions.”
—Compiled and written by David Wild
This article is from the May 2021 print issue.