THE MICROBIOME SUMMIT : Love Your Microbiome

The Inflammatory Bowel Disease Diet

Barbara Olendzki, RD, MDH

barbara-olendzki-rd-mph

Barbara Olendzki, RD, MDH

University of Massachusetts Medical School

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Overview

There are official dietary guidelines for conditions like heart disease, but there are no official guidelines for digestive diseases like Crohn’s Disease and colitis – Inflammatory Bowel Disorders (IBD) that affect the gut. Barbara Olendzki is a dietician who is working to change this. Taking a well-known diet from the past, the Specific Carbohydrate Diet (SCD), Barbara has developed the Anti-Inflammatory Diet for Inflammatory Bowel Disease (AID-IBD). In this interview, Barbara will explain the diet and share some of the success stories that she has seen with her patients.

Transcript

  • TRACEY:
  • Hi, Barbara. Thank you for joining me here today.
  • BARBARA:
  • Hi, Tracey.
  • TRACEY:
  • You were involved in a program at your hospital in Massachusetts that was looking to shift the treatment paradigm to one where the patients maybe have a little bit more control in inflammatory bowel disorder. You’re working with the patients on an anti-inflammatory diet. Would you mind explaining to us today how it all came about and what the diet is?
  • BARBARA:
  • I would love to because I get really excited about the diet, its potential and the effect that it can have in a beneficial way for patients and their quality of life. The IBD is such a devastating disease. It’s one that can take away someone’s potential for what they can do in the world. Because of not being able to get out of the bathroom, you know? Something as simple as that. It’s not something that they can talk about. So, the pharmacological medications that we currently have can work wonderfully well in some people and in others they don’t work so well, or they develop an intolerance to them after a while and they have breakthrough symptoms. So, the diet offers an opportunity for the patient to take back control of their lives. What this requires is a lot of change because it’s not an easy diet to follow. Usually, folks are not used to following a diet that doesn’t include wheat or corn and I have to sort of make a caveat because I suspect that the wheat that we have in the United States, for instance, is different than the wheat that you may have in Canada or the wheat that they may have in the rest of the world. Particularly, some of my patients have gone to Italy and have done okay with the wheat there. So, it’s not necessarily gluten that we’re targeting in this diet. Although by following a gluten-free diet you can avoid a lot of the sources of what we are targeting. I don’t like people going to processed gluten-free foods because they tend to contain binders that our patients with IBD have difficulty digesting. So, there are many details to the diet and we’ve posted a lot of these on our website but essentially it’s a wheat-free, corn-free, lactose-free diet avoiding sources of sucrose. We have a number of foods that can take the place of these foods. What usually happens, and I like to warn folks, is that when you go to a diet that is free of sucrose and lactose in particular the patients often have cravings. The cravings are something that are made up out of the sense of desire. They’re biological signals that are sent from adverse bacteria to the brain that they are starving. These adverse bacteria that are a part of the dysbiosis of inflammatory bowel disease are starving because we are depriving them of their food supply. This takes a few days, possibly weeks, to take place. Once it’s done, the patient no longer has these compelling cravings for these food items that patients have described to me as similar to when they quit smoking, or alcohol, or other types of things that feel addictive. Once we are past that point then it becomes easier for the patient to adhere to the diet because they’re not compelled anymore to go and search for these sources of food. There’s four components to the diet. Prebiotics which is the food for the beneficial bacteria, probiotics which are the beneficial bacteria and that includes fermented foods, yogurt, kefir, miso, sauerkraut, some of these other foods that we incorporate into the diet, as well as I often use supplements to get the patient going. And sometimes I have to increase the potency of the supplement to really impact in a strong way the patient gut. Over the years, use of antibiotics, we have cleared out our beneficial bacteria. Studies have shown us that many of these patients, most of these patients, are born without a diversity, a quantity of variety of beneficial bacteria in the gut to protect them against diseases of inflammation. We also see this in a number of other diseases such as Type 1 diabetes and other autoimmune diseases. So, with the diet then we can introduce …. the diet is a substrate, it’s a foundation for the beneficial bacteria, so it’s a reset. We kind of bring the patient back to baby gut and then advance and so the diet has three phases to it. The first phase is what we initiate when the patient is in a flare. At the beginning of the diet it’s a soft diet; it’s highly digestible. We deliver beneficial nutrients because this is …. also the third component of the diet is the nutrients that are necessary for human life and to boost the immune system. So, we can’t avoid that. It has to be enough carbohydrate, enough protein. And type of carbohydrates and proteins and beneficial fatty acids that can reset the immune system as well. So, it’s a combination of factors. Prebiotics, probiotics, beneficial nutrition, and the fourth one is avoidance of the foods thought to feed the adverse bacteria. In some of our previous studies, it’s astonished me that people are really good at avoidance and you would think that we’d be better at inclusion, which is a positive thing to me. But people don’t necessarily try new foods. I work particularly with adults. So, the taste buds are oriented towards these other foods that they’ve had lifelong and taste buds actually take, like, three days to a week to change. So, physiologically but mentally we have these ideas of what is pleasurable in our lives and so we’re making some substitutions. That’s where the recipes come in and I am a type of cook where I think of a recipe as a suggestion and so I just kind of look at ingredients more than I do the quantities of this or that. And I encourage my patients to experiment with flavours and herbs and spices which can be also beneficial. Turmeric is one such example of a root that can be used as a spice in Indian foods. It’s an anti-inflammatory. The dark, leafy greens like cilantro and dill and parsley are also a very, very good source of nutrients for the patient. The nice thing about the diet is that once the patient learns and it’s beneficial for the entire family, for kids, significant others, grandparents. It’s healthier than the one we have in the United States, our western diet, which is contributing to a lot of diseases and inflammation. Once they learn the diet …. we don’t take pleasure away. The pleasure of eating is always present. So, we also then have a change in the microbiome where the microbiome becomes protected against inflammation. We are always encountering bad bacteria everywhere, in what we breath, in how our food is prepared, in our hands. What we need is the beneficial bacteria to protect us against that and so this is the difference. Once the patient has an established microbiome, they’re less susceptible to the flares and so our first goal is to decrease the frequency and the duration of the flares that occur to the patient. And then it’ll be years before the patient flares. There are other factors to a flare in IBD such as stress, which is a big one. So, it’s not all about the diet, it’s also about life itself as many diseases always are. I get really excited about it because the diet is pleasurable, it’s tasty and it’s life-giving. And it can bring somebody back to where they can go out into the world again and reach their potential.
  • TRACEY:
  • Right.
  • BARBARA:
  • And it’s the greatest reward for me.
  • TRACEY:
  • You can tell that you’re a clinician, you can tell that you work with patients on an everyday basis. Do patients have some hesitation because maybe they’ve heard, from their gastroenterologist that this is an autoimmune disease diet isn’t going to help you here? Do you get some resistance sometimes from patients and is there do you think that the paradigm is shifting more to understanding that maybe there is some control here with diet?
  • BARBARA:
  • I think it’s shifting but change is always difficult in our world and I find the change is typical, not only with the patients but with the gastroenterologists and other doctors because they have been trained that it doesn’t matter what you eat and, in fact, many of the patients are directed to avoid fruits and vegetables, to avoid sources of fibre which can act as prebiotics in the diet and this can, long term, make the situation worse.
  • TRACEY:
  • Right.
  • BARBARA:
  • So, what we do is we change the textures of these beneficial foods so that the patient can absorb them. But the same is true of cardiovascular disease and diabetes where the patient may not feel that what they’re eating is affecting, say, their heart. But, of course it is, and so the American Heart Association and other worldwide organizations have cardiovascular recommendations. It’s puzzling to me that in something that is as intimate as a gastroenterological disorder doesn’t have the same guidelines. But I think we’re getting there with our current research.
  • TRACEY:
  • And you were leading the charge in this area for certain.
  • BARBARA:
  • I’m so happy to be a part of where we are going right now. I can’t wait to see what happens in the future because once it’s accepted by the clinical community it can be expanded as a part of their recommendations when they’re also providing pharmaceutical options. So, it’s not an “either, or” necessarily. But if you don’t need the medications then that’s a beneficial end result. If you do need the medications, the diet can work complementary so that you need less of the medications.
  • TRACEY:
  • Right. Yes.
  • BARBARA:
  • Provides the patients with more options.
  • TRACEY:
  • You mentioned that there’s different things that you’re targeting. So, you’re targeting the prebiotics and then you mentioned the probiotics. Is there a specific strain of probiotics that you think might be more favourable in an IBD patient?
  • BARBARA:
  • There’s one in particular that I use a lot in combination with the rest of the diet. It’s saccharomyces boulardii. It’s important that the strain is potent and viable. What we see with some of these over-the-counter probiotics is they may not be alive when the patient’s taking them. They may not be the right strain. I tend to work with a combination of strains because truthfully we don’t know yet what strain or, actually, I think it’s more of an ecosystem of strains that our patients with IBD are missing.
  • TRACEY:
  • Yeah, I think you’re right there. But it’s interesting that as part of your treatment protocol you have seen some favourable results with using the saccharomyces boulardii. At least it gives us a starting point.
  • BARBARA:
  • Right, and then I also would combine that with a multiple strain probiotic. So, one that offers, say, eight to 10 different strains and it’s a proven brand and it’s viable. So, those two would go together. Someone’s going to come up with putting them together to begin with but at this point it’s two different medications.
  • TRACEY:
  • Right. It seems with this diet you’ve pretty much thought of everything. I mean, you have the phase one and you sort of outline for patients you start here if you’re phase one, if this sounds like you, and then you’ve got phase two. Can you explain your phase system a bit to us?
  • BARBARA:
  • So, phase one is sort of the baby gut and that’s where the patient is ill. They are not tolerating foods but deliver the nutrients to them in liquid pureed form and so with adults it’s maybe easier to think of dips and soups and stews. Kids respond quite well to this also and so that lasts until the patient is recovering and so there are certain symptoms of that depending on the patient. Not everybody is bleeding but bleeding is one. I would wait until the bleeding ceases because that indicates to me that the patient has healed enough that we can increase the textures in the diet. And so, phase two is sort of where the textures are softened but not necessarily pureed. Many cooked foods are then introduced. We still have plenty of smoothies, homemade smoothies, so we can really deliver those nutrients in a very absorbable way. And phase three is where we get into the higher levels of digestion. Digestion as separate from the disease. They’re often confused as one and the same. Where the disease is a systemic situation, digestion is acute, meaning that what you are consuming, do you have the enzymes necessary to break down that food so that it can be absorbed properly? And so, sometimes we might work with some digestive enzymes as a supplement or sometimes the patient needs to just avoid particular foods that they find to be problematic. And a lot of this is genetically oriented. The Latinos and Asians tend to do better with legumes, for instance, and Caucasian population doesn’t do as well with legumes. That kind of thing.
  • TRACEY:
  • Interesting, interesting. That may have to do with the type of microbiome each has and coupled with their genetics? Is that what you think?
  • BARBARA:
  • It could. One of the questions that comes up …. so, I’ll ask myself a question. Do I have to stay on this diet forever? Can I go back to eating sugar and cookies and can I go back to eating pasta? And we do widen the variety of the diet and I think going organic can be quite important because I think the genetically modified foods are a part of the problem and I know there all kinds of genetic modifications but the ones in particular that I hypothesize to be problems are the ones where the farmers don’t want the bugs to eat their crops, which is a great idea but we have bugs too and we need to feed them. And so, it could be that our beneficial bacteria are quite susceptible to these genetically modified foods. And so, unless we find a way around that it’s hard for me to say, well, yes you can go back to eating these foods because my IBD folks are genetically sensitive to them. So, eventually it might lead to another flare. Patients will tell me – and I have people who have been on the diet for 15 years or more at this point and have done very well – and they will tell me no, if I eat bread two days in a row I’m in trouble. I can have it, you know, every once in a while as long as I don’t continue it. So, that’s generally what the patients look forward to and know you can’t have your old life back.
  • TRACEY:
  • Right. And I think the length of time that you have been working with patients on this diet, we have a lot to learn from you. How many patients do you think you have now followed on this diet?
  • BARBARA:
  • I have lost track. But there’s more patients every week and there are people who contact me through the internet. I have worldwide contacts, people in England, there’s a lady in Australia and her son. It’s very gratifying that not everybody has to see me in order to benefit from the diet. I want this to go everywhere. I want anyone who is suffering to learn about this and I have to give credit to the pioneers who have been before me. Elaine Gottschall who developed the specific carbohydrate diet set the stage for what I am doing now in our current research.
  • TRACEY:
  • Right. And you are also part of the research community. I mean, you published a paper in 2014 and that has sort of led you into other areas of research. Can you tell us a little about the research?
  • BARBARA:
  • I mean, I do a lot of research, truthfully, which is why I started asking questions to begin with when in the beginning a gastroenterologist threw up his hands and said, “Okay, go see Barbara and do the specific carbohydrate diet”, and it worked. And so I wanted to know why. I started doing research into the diet and I looked at all the foods that Elaine Gottschall had proposed for her original diet and I took my experience with cardiovascular and diabetes research and combined it with what I was finding in my gastrointestinal patients and that resulted in the IBDAID, the inflammatory bowel disease anti-inflammatory diet. Over the years, the University of Massachusetts now has established a centre for microbiome research and I’m so fortunate to work with established, fabulous, brilliant researchers. Basic scientists – and we do speak different languages; I speak food, they speak cells and the microbiome and how these things work on a very microscopic level. And they now have this, I call it a machine, I’m sure it’s got a fancier name than that, but it’ll do our DNA and RNA analysis of the stool of the patients and so we have embarked upon a study where patients come in and we have a baseline washout and we do the DNA analysis of the microbiome that is untouched before the diet, we initiate the diet, the patient follows that for three months. We have a teaching kitchen, I have research assistants, fortunately, who are helping me to help the patients. They’re putting a lot of work into this for no reward except getting their quality of life back through the diet. And then we’re following them after they cease receiving education about the diet to see what people do on their own. What happens to the microbiome after I’m no longer working with these patients? Because that’s important too. So, we’re trying to study so many different things and hoping to, along with other researchers – it’s a pretty hot area – working together with other researchers across the world in establishing dietary guidelines for patients with inflammatory bowel disease.
  • TRACEY:
  • That is so important. I can’t wait for the day that we actually have some dietary guidelines for inflammatory bowel disease.
  • BARBARA:
  • Officially. That are accepted by all.
  • TRACEY:
  • That’s right.
  • BARBARA:
  • Whether the patients follow it, that’s up to them but at least we’ll have something to offer the people who say, “Well, what am I going to eat and how can I get outside of the house without having to find a bathroom every 15 minutes”.
  • TRACEY:
  • And also, getting back to this shift in the treatment paradigm, to give them back some control. There’s something that they can actually participate in and learn a new skill and, you know, share it with their family and ….
  • BARBARA:
  • This is something they can do everyday to help themselves and there are simple ways of doing it. In the beginning, it does take time, effort, change, it’s hard but it gets easier because it’s something that you learn and you can live by.
  • TRACEY:
  • What does treatment success look like in your practice? What can patients expect?
  • BARBARA:
  • Treatment success is remission. I mean, ultimately. But, what we do to get there, there’s a step-by-step process and it might help if I told a story. There was a fellow that came in to see me and he was on sabbatical but truthfully he was disabled from his job. So, he’s a world-renowned professor of medical ethics, actually, and he is confined to his home. He comes in to see me because, as with many of my patients, the medications were not working for him. He was unable to resume his job and he was essentially living at home, secluded. We started on the diet and when I first saw him I had doubts that he would be able to because he came by himself and one of the factors that is most important for success is the family and the support that the patient has and he has 10 kids. All of them were grown, but a lot of grand kids and that’s a lot of temptations to put in front of somebody on an on-going basis and say, “Don’t eat it”, because their avoidance is a part of the diet including getting into the kitchen and preparing his own meals that were separate from the family. But he did it, Tracey, he did it. And his family started consuming his meals because they were better than the ones they had in the past. So, he wrote to me. We did a lot of correspondence with email and he said, do you think there’s a chance because he’s been invited to speak as one of the principal speakers at the World Health Organization on his profession. Is there a chance that he could go to Austria? Of course. He was stabilized. He was off medication. He called ahead to the hotel. Once he got to Austria he discovered it was easier to eat there than it is here in the United States. They had much more of a concept of fresh foods and ingredients that aren’t necessarily processed, or that they’re known, real foods. He sent me a picture and this was, for me, one of the best rewards I can ever think of, of the World Health Organization conference where he had received a standing ovation and he was able to impart what he can do and his potential which was not possible previous to this diet. He has since gone back to work and continues to teach and speak worldwide. That’s perhaps just one example but there are many.
  • TRACEY:
  • It’s so inspiring.
  • BARBARA:
  • It is.
  • TRACEY:
  • For people who love stats, do you have any stats for us?
  • BARBARA:
  • I do. Okay, so what I did was, on the impetus of one of my gastroenterology colleagues who said you need to go back and you’ve got to see what does the patient have to do to be successful on the diet? How compliant do they need to be? So, I went through every one of my patients and in the beginning you need to be more compliant, as close to 100 percent as you can get. But then once you have established a better microbiome the answer to that is 80 percent of the time you need to be compliant. And so, it doesn’t have to be an angel and I’ve known very few – maybe zero angels – to go through life with adherence of this diet. But we need to have the four components and the patients sort of get used to them. That avoidance, good nutrition and that means fruits and vegetables, micronutrients, good macronutrients, prebiotics and probiotics. But 80 percent is essentially, and above, is what seemed to be the level of success where patients were able to achieve remission and significant reduction in symptomatic pain, bleeding, that sort of thing.
  • TRACEY:
  • Barbara, thank you so much for everything that you’ve shared with us today. Your knowledge and your pioneering ways are something for us all to admire. Thank you very much.
  • BARBARA:
  • Thank you so much. I really appreciate being a part of what you’re doing.