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Inflammatory Bowel Diseases

  • When it comes to carbohydrates, opinions abound. They have been both vilified and promoted as essential dietary components. This dichotomy, however, does not reflect the fact that all carbohydrates are not created equal. Gastroenterologists have coined the term FODMAPs to encompass specific carbohydrates found within many different foods that have greater potential for causing gastrointestinal distress. These carbohydrates can contribute to symptom causation in patients with gastrointestinal disorders such as bloating, irritable bowel syndrome and inflammatory bowel disease.

    What are FODMAPs and how do they cause GI symptoms?
    The acronym "FODMAPs"– Fermentable Oligo–, Di– and Monosaccharides and Polyols—describes a group of previously unrelated short–chain carbohydrates and sugar alcohols. These include fructose, lactose, fructo– and galacto–oligosaccharides (fructans and galactans) and polyols (such as sorbitol, mannitol, xylitol and maltitol). FODMAPs are poorly absorbed in the small intestine for a variety of reasons. For example, fructose does not move efficiently across the brush border due to poor transport mechanisms across the epithelium.1 Lactase, the enzyme responsible for metabolizing lactose, is reduced in activity after weaning.2 Due to their poor absorption as well as their small size, FODMAPs are osmotically active and increase intestinal water content. They are rapidly fermented by gut bacteria, leading to increased gas production. Greater intestinal water content and gas production leads to bowel distension, which translates into adverse gastrointestinal symptoms such as abdominal pain, bloating and motility changes.3

    Where are FODMAPs found?
    FODMAPs are found in foods of various shapes and sizes. They can be found in local fast–food joints and packaged foods filled with additives. Processed foods hide FODMAPs well, especially those with added sweeteners. Conversely, they can be found in fresh meals at restaurants and stores catering to health and wellness. Ironically, some of the healthiest foods contain FODMAPs, including certain fruits, vegetables and legumes. Foods with high–FODMAP content include:

    • Fruits: mangoes, apples, pears, watermelon, apricot, avocado, blackberry, cherry, lychee, nashi, nectarine, peach, plum, prune, persimmon, canned fruit, fruit juice, dried fruits
    • Vegetables: asparagus, beetroot, broccoli, Brussels sprouts, cabbage, eggplant, fennel, garlic, leek, okra, onion, shallots, spring onion, cauliflower, bell pepper, mushroom, sweet corn
    • Legumes: baked beans, chickpeas, kidney beans, lentils
    • Dairy: milk from cows, goats or sheep, custard, ice cream, yogurt, soft unripened cheeses
    • Grains: wheat, rye
    • Sweeteners: honey, corn syrup, high–fructose corn syrup, fructose, sorbitol, mannitol, isomalt, maltitol, xylitol
    FODMAPs and functional gastrointestinal disorders
    A low–FODMAP diet has emerged as a key player in the treatment of functional gastrointestinal disorders (FGIDs). FGIDs are the most common gastrointestinal disorders and account for nearly half of all patients with gastrointestinal problems who are seen by doctors and therapists. In these disorders, no structural abnormalities are found by endoscopic testing, imaging or labwork. However, there may be problems with intestinal movement, sensitivity of nerves supplying the intestine, or issues with the way in which the brain controls these functions. Two common types of FGIDs include bloating and irritable bowel syndrome (IBS).4 Patients with these disorders can present with a variety of gastrointestinal symptoms. Unfortunately, current pharmaceutical treatments typically offer only mild palliation for most patients.1 The idea that a low–FODMAP diet can treat FGIDs is intuitive. The majority of patients with IBS report food as a trigger of symptoms.5 The physiologic basis for symptom causation in many FGID is intestinal distension, and intestinal distension can induce symptoms like abdominal pain and bloating. It's important to keep in mind that FODMAPs are not thought to cause the underlying FGIDs. Rather, avoiding FODMAPs is a way to alleviate symptoms from FGIDs.1 Evidence to support use of the low–FODMAP diet in IBS and other functional GI disorders is accumulating. Studies have shown that following this diet can lead to a significant decrease in symptoms in the majority of patients with IBS. Most recently, a high–quality randomized controlled trial published in Gastroenterology reported that a low–FODMAP diet effectively reduced functional GI symptoms and suggested that it be used as first–line therapy in patients with IBS.5 The low–FODMAP diet has already enjoyed widespread application in other parts of the world for FGID including Australia, New Zealand and Europe with good efficacy.5

    FODMAPs and inflammatory bowel disease
    A low–FODMAP diet has been helpful in certain patients with inflammatory bowel disease (IBD). Crohn's disease and ulcerative colitis are chronic inflammatory disorders of the gastrointestinal tract thought to be due to a complex interaction of genes, environmental factors and immune regulation. They are typically treated with anti–inflammatory medication. Patients with IBD often have symptoms due to functional gut disturbance. In these patients, increasing anti–inflammatory therapy is unlikely to be helpful. A pilot study evaluated patients with IBD and concurrent functional gut symptoms. After following the low–FODMAP diet, about half of these patients experienced symptomatic improvement, including decreased abdominal pain, diarrhea and bloating.6 The low–FODMAP diet can be considered for IBD patients with concurrent functional gut symptoms.

    Is FODMAPs forever?
    If your gastroenterologist prescribes a low–FODMAP diet, does this mean you can never eat another FODMAP–containing food again? It's important to remember that FODMAPs do encompass some foods with high nutrient densities. In fact, certain FODMAPs exert prebiotic effects. Prebiotics are nondigestible food ingredients that can lead to improved health. Bacterial fermentation of prebiotics can yield short–chain fatty acids like butyrate, which nourishes the colonic epithelium, favors the growth of beneficial gut bacteria and inhibits the growth of harmful gut bacteria.7 Nectarine, garlic, onion, nuts, legumes, rye and wheat are examples of FODMAPs that function as prebiotics.8 If you are following a strict low–FODMAP diet, you can obtain prebiotics from non–FODMAP foods such as bananas, kale, chard, brown rice and oatmeal. The low–FODMAP diet should be followed for a period of six to eight weeks, after which foods with the highest nutrient densities should be slowly reintroduced in small quantities with monitoring for tolerance. These foods include fruits, vegetables and legumes.

    What steps can you take to decrease FODMAPs in your diet? If you have functional gastrointestinal symptoms and you are prescribed the low–FODMAP diet, it's important to work with both your physician and nutritionist for proper implementation of this diet. If you are generally in good health with occasional gastrointestinal symptoms such as bloating, you may want to keep an eye on your daily FODMAP intake. Studies have shown that even healthy individuals, when fed a high–FODMAP diet, can develop increased gas production.9 There are a few steps you can take to decrease dietary FODMAP intake:

    1. Cut out FODMAP grains such as wheat and rye. Look for alternatives like quinoa, millet and brown rice.
    2. Cut out dairy products. Use nut–based milk substitutes instead.
    3. Decrease consumption of packaged foods, particularly ones with long ingredient lists.
    4. When enjoying FODMAP fruits, vegetables or legumes, keep a food journal and determine which serving sizes you tolerate best.
    References:
    1. Gibson, Peter R., and Susan J. Shepherd. "Evidence–based dietary management of functional gastrointestinal symptoms: The FODMAP approach." Journal of Gastroenterology and Hepatology 25.2 (2010): 252–8.
    2. Misselwitz, Benjamin, et al. "Lactose malabsorption and intolerance: pathogenesis, diagnosis and treatment." United European Gastroenterology Journal 1.3 (2013): 151–9.
    3. Shepherd, Susan J., Miranda CE Lomer, and Peter R. Gibson. "Short–chain carbohydrates and functional gastrointestinal disorders." The American Journal of Gastroenterology108.5 (2013): 707–7.
    4. "Welcome to IFFGD." International Foundation for Functional Gastrointestinal Disorders. Web. 22 Mar. 2014.
    5. Halmos, Emma P., et al. "A diet low in FODMAPs reduces symptoms of irritable bowel syndrome." Gastroenterology 146.1 (2014): 67–5.
    6. Gearry, Richard B., et al. "Reduction of dietary poorly absorbed short–chain carbohydrates (FODMAPs) improves abdominal symptoms in patients with inflammatory bowel disease—a pilot study." Journal of Crohn's and Colitis 3.1 (2009): 8–14.
    7. Mullin, Gerard E. Integrative Gastroenterology. New York: Oxford UP, 2011. Print.
    8. Cho, Sungsoo, and Nelson Almeida. Dietary Fiber and Health. Boca Raton, FL: CRC, 2012. Print.
    9. Ong, Derrick K., et al. "Manipulation of dietary short chain carbohydrates alters the pattern of gas production and genesis of symptoms in irritable bowel syndrome." Journal of Gastroenterology and Hepatology 25.8 (2010): 1366–73.

  • The next several months we will look at the group of conditions that are characterized by pathologic evidence of inflammation of the intestinal tract. The clinical signs most commonly seen in pets with inflammatory bowel disease often reflect the location of the intestinal lesions. Vomiting, diarrhea, and/or weight loss are usually observed. Lesions affecting the upper GI (gastrointestinal) tract (stomach and upper small intestine) are more likely to cause vomiting, whereas lesions of the lower small intestinal tract and colon are more likely to cause diarrhea.

    Causes of inflammatory bowel disease are numerous and include parasites (whipworms, giardia), fungi (histoplasmosis, protothecosis), bacteria (Salmonella, Campylobacter, pathogenic E. coli), food allergy/ hypersensitivity, cancer, and idiopathic (unknown cause named by the type of pathogenic white blood cells seen in biopsy specimens such as eosinophilic, lymphocyticplasmacytic).

    Most commonly, the idiopathic classification of inflammatory bowel disease is seen in dogs and cats. While there is no known cause of the disease, most doctors suspect some type of allergy as this is an immune disease. The allergy or sensitivity might be due to the diet (mild cases can respond to dietary manipulation), bacterial antigens, or self-antigens (an autoimmune disorder). Allergies to food components usually involve cereal grains, meats, and rarely eggs.

    Leaky Gut Syndrome, Intestinal Dysbiosis, Intestinal Hyperpermeability
    Leaky Gut holds that in some people and pets, whole proteins leak through the wall of the digestive tract due to a hyperpermeable condition, and enter the blood, causing allergic reactions. These reactions may include food allergies, arthritis, autoimmune diseases, impaired nutrient absorption, and chemical sensitivities. It is theorized that many chronic diseases, often treated for years with various conventional medications, may in fact result from leaky gut syndrome.

    One organism that has been postulated to be responsible for some of the signs seen in people and pets is the common yeast Candida albicans. This yeast has been observed to enter the bloodstream from the intestinal tract, and may cause chronic allergies. Overgrowth of this yeast and other organisms may occur in pets with chronic intestinal disease and in pets undergoing chronic antibiotic or NSAID therapy. The organisms can produce toxins that cause leaky gut syndrome. The increased intestinal permeability may allow greater absorption of the microorganisms and their toxins, causing further harm.

    Holistic doctors often attempt gastrointestinal detoxification, using enzymes, prebiotics, probiotics, glutamine, and so forth, for pets with many diseases in an attempt to heal a leaky gut that may be contributing to clinical signs or disease.

    Glutamine
    Glutamine, or L-glutamine, is an amino acid derived from another amino acid, glutamic acid. There is no daily requirement for glutamine as the body can make its own. High-protein foods such as meat, fish, beans, and dairy products are excellent sources of glutamine. Severe stresses may result in a temporary glutamine deficiency.

    Glutamine plays a role in the health of the immune system, digestive tract, and muscle cells, as well as other bodily functions. It appears to serve as a fuel for the cells that line the intestines, (it serves as a primary energy source for the mucosal cells that line the intestinal tract). Because stress on the intestinal cells that can occur in chronic inflammatory bowel disease can increase the need for glutamine as the body replaces the cells lining the intestinal tract, glutamine is often recommended for pets with chronic bowel disorders.

    It has also been suggested as a treatment for food allergies, based on the leaky gut syndrome. Preliminary evidence suggests glutamine supplements might reduce leakage through the intestinal walls, and is highly recommended for pets with various bowel disorders.

    Glutamine being one of the body’s amino acids, is thought to be a safe supplement when taken at recommended dosages. Because many anti-epilepsy drugs work by blocking glutamate stimulation in the brain, high dosages of glutamine may overwhelm these drugs and pose a risk to pets with epilepsy. If your pet is taking antiseizure medications, glutamine should only be used under veterinary supervision.

    Maximum safe dosages for young children, pregnant or nursing women, or those with severe liver or kidney disease have not been determined; similar precautions are probably warranted in pets. Recommended dosages in pets are 250 to 3000 mg daily.

    Conventional Therapy
    Most pets with inflammatory bowel disease are treated with various anti-inflammatory medications, including corticosteroids, sulfasalazine, or in serious cases the chemotherapy agent azathioprine. These therapies are often combined with antimicrobial medications (tylosin, metronidazole). Usually the pet is treated with a high dose of anti-inflammatory medication and is slowly, over several months, weaned off the medicine or weaned to the lowest dose that controls the clinical signs. There is potential danger in using high doses of corticosteroids, including side effects such as pancreatitis, increased susceptibility to infection, and gastrointestinal ulceration or perforation. Using gastrointestinal protectant medications such as sucralfate, misoprostol, or omeprazole may decrease some these side effects.

    Next month we look at specific natural diets you can make that are designed for pets with inflammatory bowels disease. And in future months we’ll review orthomolecular therapy, plant enzymes, prebiotics and probiotics that may help with numerous gastrointestinal symptoms.