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Sunanda Kane, MD, MSPH: Hello. I'm Dr Sunanda Kane. Welcome to Medscape's InDiscussion series on ulcerative colitis (UC). Today we'll be discussing diet in patients with UC with our guest, Dr Annie Feagins. Dr Feagins is an associate professor in the Department of Internal Medicine at The University of Texas at Austin Dell Medical School, a board-certified gastroenterologist, and director of the Center for Inflammatory Bowel Diseases in Austin, Texas. Welcome to InDiscussion.
Linda A. Feagins, MD: Thank you so much. It's great to be here. I appreciate the invitation.
Kane: Here's my first question. On what day of your practice in inflammatory bowel disease (IBD) was it that your UC patient said, "Dr Feagins, what should I eat?"
Feagins: Day one, if I had to guess. Absolutely.
Kane: Let's talk about that because it is such a big deal to patients, and there's a lot of misperceptions, misconceptions, and falsehoods out there about diet. You can start with some of the junk that's out there online or even some well-intentioned but misguided information patients may have heard from other providers before coming to you.
Feagins: One of the first things that comes up is patients being so restrictive in their diets. A big one is patients cutting out all the fiber in their diet, especially when they're in remission and still think they can't eat fiber. That's a big one I see a lot. In talking about diet with patients, I spend a lot of time going over what they're not eating and trying to help them reintegrate foods into their diet they should be eating. Fiber is a big one.
Kane: Let's talk a minute or two more about fiber. When you say fiber, what is it that you are looking at or talking about for an UC patient?
Feagins: People end up cutting out everything that's fiber, meaning a lot of good fruits and veggies and things they should be eating.
Kane: Sometimes what I try to talk to patients about is the difference between soluble and insoluble fiber, and how when they're having an active flare, they shouldn't necessarily be eating raw broccoli and celery stalks. But like you point out, when they're in remission, they should be eating the raw fruits and vegetables because it's going to be good for their cholesterol levels and their heart and weight. I would never say no to a patient wanting to eat oatmeal.
Feagins: Absolutely. That's one of the things we try to teach patients. Even when they're having more active disease, they can eat some fiber. They just need to remove some of the insoluble fiber — take the peels off veggies and cook their veggies better so they can digest them — so they don't have to cut out fiber completely.
Kane: Right. I've heard some providers say it doesn't matter what you eat, and I think they're being sort of lazy. What the provider really means is that food doesn't necessarily correlate to inflammation, but certainly food makes a difference in how you're going to feel. How do you feel about that?
Feagins: I absolutely agree. You stated it perfectly in that it gets oversimplified to "diet doesn't matter." It absolutely does matter. Malnutrition is a big issue in our patients with IBD and we need to be addressing it. It's certainly something I screen for in all of my patients in clinic. Beyond that, foods affect how people feel and what they eat. It may not affect the inflammation, but it affects their quality of life.
Kane: There is a difference between diet and nutrition, right? So, that's what you put in your mouth vs what is healthy and what you need to survive as a human being. Do you work closely with a dietitian or a nutritionist?
Feagins: I do. We have a multidisciplinary clinic where we have a dietitian who is GI focused in our clinic. It has been a wonderful thing to have because I know that a lot of practices don't have that resource. We work closely with her. We screen our patients for malnutrition. Anybody who wants to talk to her is welcome to — even if patients are not meeting those screeners and doing well with IBD, we like to have them talk with her about how to eat a healthy diet.
Kane: What are some of the other fad diets you come across that we should discourage our patients from doing? You mentioned the restrictive ones where they can't eat anything.
Feagins: There's certainly a lot of different diets out there. With Crohn's disease, we're seeing more data come out in regard to these different diets, but we don't have a lot of these data with UC. In speaking to the fad diets, there's the paleo diet. We don't have any data on the paleo diet in regard to our patients with UC. Generally what I am recommending for my patients is to focus on getting high-quality, whole foods and getting fruits and veggies, whole grains, and lean proteins — build them up in that way and focus on what they can eat. I like to focus on that instead of restrictions and cutting out.
Kane: I like that — to focus on what they can eat. What do you tell your patients about gluten?
Feagins: That's an interesting one. There are certainly not any great data showing that gluten causes inflammation and IBD. That said, I've had a number of patients who swear gluten causes their symptoms, and when they take gluten out of their diet, it makes a huge difference. With that, I start to speak about triggers for patients. Each patient is a little bit different, so I direct them to be mindful about their diet. If they can, work with a dietitian to try to figure out what the triggers are without taking everything out of their diet. In certain cases, people absolutely feel better taking gluten out of their diet. Is it really gluten that's causing those symptoms? That's hard to say. Is it something else associated with the gluten? There are wheat-like fructans that might be contributing to their symptoms more. Certainly, there are good data, as you're aware, that a low-FODMAP diet can really help our patients who have irritable bowel symptoms when they have inactive IBD.
Kane: For our listeners out there who may not be familiar with that term, when you say FODMAP, what does that mean?
Feagins: FODMAPs are various carbohydrates in the diet that some people don't tolerate well. We've found that taking these specific carbohydrates out of the diet will take away a lot of the symptoms patients have, including bloating or diarrhea and loose stools. It's a pretty restrictive diet. If you have someone eat a low-FODMAP diet, it's very difficult to maintain, and they can end up with vitamin deficiencies down the road. I always tell patients it's an experiment you do for a short period of time to try to figure out what makes you feel bad. You basically cut all these things out of your diet and then slowly add them back one by one to see which one of them may actually contribute to some of the GI symptoms that you are having. That way, you can just cut out the things that make you feel bad and not try to stay on this completely restrictive diet.
Kane: Got it. You used the term specific carbohydrate. Is the low-FODMAP diet the same thing as a specific carbohydrate diet?
Feagins: No, those are two different things. The FODMAPs are a group of various carbohydrates that aren't digested well, whereas a specific carbohydrate diet is a very restrictive diet that has different phases patients go through in regard to what they can eat in their diet. It's interesting, and I'd be interested to hear your thoughts on this as well. With that diet, I guess it originally started in patients with UC with Elaine Gottschall's book. Yet the data we have as far as randomized trials are more in Crohn's disease, not UC. We don't actually have any great data on that diet with UC.
Kane: Right. It's an N of 1, from her book where she said she cured her daughter of her disease.
Feagins: Yes.
Kane: How do you feel about the Mediterranean diet?
Feagins: In general, for IBD, that's the diet we have the most data on. It's usually what I recommend to my patients who want a general diet. It is the easiest to follow. Again, specifically for our patients with UC, we don't really have data for the Mediterranean diet, but we do have some in Crohn's disease. I think it's a great diet for patients to follow.
Kane: You live in Texas, so maybe it would be heresy for you to say in public, but what we do know is that beef — red meat — is proinflammatory. We just said that food doesn't make your disease worse, but it could make you feel worse. What do you think about the data just coming out in basic science about the interactions between the immune system and red meat? I think it's fascinating, actually.
Feagins: It really is interesting. The basic science and the clinical data haven't quite come together yet as we look at all these different components of food. In reviewing the literature out there, we see this a lot. The basic science data say that fiber should be better for patients. Meats seem to be more proinflammatory, and fats are more proinflammatory. Yet when we look at this in our clinical data, it gets much more muddied, and it's hard to discern what's going on. There was a study that looked at having patients consume less meat in their diet and if this ended up causing them less flares down the road. It didn't seem to make any difference. I'm actually a vegetarian myself, so even living in Texas, I don't have any pro-meat component to my stance. It's interesting to look at the data where it didn't make a big difference when folks cut back on the meat in their diet in regard to how many flares they had.
Kane: Unfortunately, humans are not like lab rats where we can just put them into a cage and feed them what we want and see what happens. I find that if we tell people to cut out one thing, they just substitute it with something else they don't realize is maybe just as bad or worse. I'm wondering whether in that study where people eliminated the red meat, did they start eating more of something else and then had a higher caloric intake? Like you said, it's so hard to tease away the pure science part vs the actual human being and the practical clinical side of things. The whole thing about dairy, we haven't touched on that. It's controversial as to whether just because you have UC, you are automatically lactose intolerant. What's your feeling about that?
Feagins: Gluten, like you mentioned before, is a big one that patients tell me they cut out all the time, and then dairy is the other one. A lot of people can tolerate dairy, so it's not something you automatically have to cut out. The times where I would even think about it is when a patient has active disease — it can irritate the gut more. If you already have some underlying lactose intolerance, certainly it's a time to maybe cut these things out. If you can tolerate it and you do fine, there's no reason to cut it out. That's one of the big things I'm always harping on with my patients. When you cut out dairy from your diet, you're not getting calcium anymore, and that's not good for your bones. I always want them to be eating the calcium rather than taking it as a supplement, if possible. If they are cutting dairy out, we're always trying to find other things they can eat with more calcium. That's definitely a big concern.
Kane: I think that when patients tolerate dairy, it's so much easier to recommend a little 6-ounce container of yogurt and the kefir shakes as a source for probiotics.
Feagins: Absolutely.
Kane: How do you feel about the sources of probiotics? Do you think that they should get probiotics from their food? In episode 2 of this series, Dr Hass and I had a discussion about alternative and complementary therapy, but I like the overlap here where we can talk about it from a different context.
Feagins: That's a great question. If we go back to wanting to base it on evidence-based data, there are not a lot of great data that probiotics make a huge difference as far as active disease. I'm not typically recommending it from that standpoint. But certainly, in patients with irritable bowel–type syndromes on top of their IBD, it can make them feel better, and if they tolerate it, great. In general, if they're wanting to take it and they're already taking it, I allow my patients to take it. I certainly like them to get nutrients in real food if they can, instead of through a supplement. But do I have any data to support that thought behind my recommendation? Not really. What do you tell your patients?
Kane: Again, the less processed their food, the healthier it is. I want to try to treat them as a whole person and not just as an inflamed colon. Clearly, the GI tract is the center of the whole body, in the center of the universe, but if there's more than five ingredients in a food and you can't pronounce or spell the majority of them, it probably shouldn't go in your mouth. Way back, there was talk about carrageenans and how they were the cause of IBD. It died down a little bit, but it's still interesting to me that the food industry actually took notice and there's less of it around. I'm wondering about some of the other things in our food supply that perhaps we should be making more noise about.
Feagins: Part of the push of recommending patients eat less processed food is to avoid all these additives that we don't understand as well. But certainly, the carrageenans and some of the other emulsifier ingredients seem to at least have some basic science data and maybe a little bit of preclinical data showing they potentially can worsen or cause IBD. They aren't great data, but I think these ingredients are worth avoiding if we can.
Kane: When you have a patient in the hospital with a bad UC flair, what are their dietary restrictions compared to when you're seeing them in the clinic?
Feagins: That's a great question. An issue that comes up a lot is patients who come in with flare-ups. Their providers often want to take away feeding them. I think that's a really important thing; we need to be feeding our patients with IBD and UC. Unless you think they have toxic megacolon and are headed to the operating room, we should be feeding them. What should we be feeding them? That's a bit harder. It's sometimes easier for these folks to eat at home than it is in the hospital because the hospital doesn't have as many clear dietary patterns. At least that's my experience in our hospital. Maybe you have more amazing meal plans in your hospital, but I find it a little bit harder. We want patients to be getting enough nutrition and calories and protein while eating things they can actually tolerate.
Kane: Yes. Can you believe we've been talking for over 20 minutes about this? We could probably go on for another 20, but I very much appreciate your insights and the information. Just to sum up, we have made it clear that food is an important part of everyday life. Triggers for GI symptoms — whether part of an irritable bowel–type of scenario or feeling cramping and not getting better from a colitis standpoint — are individualized. Making broad, sweeping statements to patients isn't necessarily in their best interest. We have some intriguing basic science data, but they have yet to translate into clinical data, other than to say that the fewer additives and preservatives in your food, the better. I think that's a nice way to finish. And ironically, we're taping this over lunch time, so maybe you're going to go have a nice, healthy salad. Annie, I really appreciate your time and you being with us today. And I want to thank all of our listeners for being here. Thank you so much for joining us. This has been Dr Sunanda Kane for InDiscussion.
Resources
Malnutrition and Quality of Life Among Adult Inflammatory Bowel Disease Patients
Role of Diet in the Development and Management of Crohn's Disease
Gluten-Free Diet in IBD: Time for a Recommendation?
Use of the Low-FODMAP Diet in Inflammatory Bowel Disease
Inulin and Oligofructose in Chronic Inflammatory Bowel Disease
Breaking the Vicious Cycle: Intestinal Health Through Diet (by Elaine Gottschall)
A Diet Low in Red and Processed Meat Does Not Reduce Rate of Crohn's Disease Flares
The Role of Carrageenan in Inflammatory Bowel Diseases and Allergic Reactions: Where Do We Stand?
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Cite this: Why Diet Absolutely Matters in Ulcerative Colitis - Medscape - Apr 20, 2023.
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