Against the Grain – Details, episodes & analysis

This is my review of Zeposia (Ozanimod), a new once a day oral medication for moderate to severe ulcerative colitis. I go over the True North Study (https://www.nejm.org/doi/full/10.1056/NEJMoa2033617) in detail including efficacy and safety data. I have no conflicts of interest with any pharmaceutical companies. These are my opinions regarding Zeposia and other medications based on my personal/clinical experience and review of the literature. 

Dr. Shriram Jakate is Professor Emeritus in pathology at Rush University Medical Center. He has a particular expertise in GI and liver pathology and has been interpreting slides from patients with Crohn's and colitis for over several decades. I consider him to be the best GI pathologist I have encountered in my career and during this podcast we have a wide ranging discussion about interpretation of IBD pathology. We discuss the pathologic features of Crohn's and ulcerative in detail and also go over IBD mimickers (including NSAID induced inflammation), C diff, pouchitis and rethinking the classification of IBD subtypes. 

This is a show on some of my favorite ready-made food items. These would be considered processed foods to some degree, but definitely less processed than the types of things you would find at The Dollar Store or even a regular grocery store chain. Sometimes it’s nice to have food on hand that you don’t always have to prepare. I understand there are diet purists out there that don’t eat anything unless it is made from scratch. However, for those who are not able to dedicate a lot of time to cooking, these types of food products can help to reduce the time burden. Most of the products I mention would be compatible with the various diets used for inflammatory bowel disease including the Specific Carbohydrate Diet though there may be exceptions depending on the particular diet or stage you are in. Why are thes foods ok for IBD? Because they don’t have the food additives, refined flours or sweeteners that may be detrimental (though I understand even making that statement is controversial). I don’t receive any money or sponsorship from the companies that make these products so these are my unbiased opinions.

I’m happy to announce that my clinic is now equipped for video and telephone visits. For those who would like more personalized attention, you can schedule an appointment with me. I only treat adults - those 18 years old or over. You can email me at samir3@gmail.com for more information about a virtual appointment if you are interested.

This show will focus on the effect of stress on Crohn’s disease and ulcerative colitis. I will define stress as the feeling of being challenged by a threatening event or evolving situation. Everyone experiences some degree of stress in life, but when it becomes chronic and perceived as severe, it can have adverse health effects. Many patients attribute their initial diagnosis and subsequent flares to stressful life events. But does stress actually make the inflammation of inflammatory bowel disease worse? I review what the literature says and also present a case of a patient with Crohn's colitis who subsequently had a normal colonoscopy with normal biopsies after decreasing stress in his life. As a disclaimer, this is just an anecdote and does not constitute evidence. I am not recommending stress reduction as a primary treatment modality for IBD without adjunctive appropriate medical therapy.

References:
The Brain-Gut Axis and Stress in IBD by Bernstein: https://www.ncbi.nlm.nih.gov/pubmed/29173525

Manitoba Registry showing stress not associated with intestinal inflammation:
https://www.ncbi.nlm.nih.gov/pubmed/26077178

UC patients with more inflammation with more stress:
https://www.ncbi.nlm.nih.gov/pubmed/?term=10811330

Mindfulness Based Interventions in IBD by Hood et al : https://www.ncbi.nlm.nih.gov/pubmed/29173527

Wim Hof Method Paper: https://www.wimhofmethod.com/uploads/kcfinder/files/PNAS.pdf

Today we are going to tackle Coronavirus, specifically SARS-CoV-2 which causes the disease COVID 19 in relation to gastrointestinal symptoms and disease. I will be interviewing Dr Kaushal Majmudar who is one of our great GI fellows at Advocate Lutheran General Hospital. He recently did a Grand Rounds for our GI department on this very topic and went over all the recent data regarding pathogenesis, treatment and also recommendations from various GI societies for specific clinical scenarios regarding liver disease, endoscopy and inflammatory bowel disease. This will be valuable information for clinicians in all specialties and definitely for those working in GI. Though at times this does become technical at certain points, it will be valuable information for the non-physician audience too. At the end I will give my own thoughts about COVID 19 and IBD with comments on the relevance of the hygiene hypothesis, infusion centers and specific risks of medications. As a disclaimer, we are not the CDC or members of committees creating the guidelines that will be discussed. Opinions are our own. This is an open discussion and should not be interpreted as medical advice.

Dr. Mitsuro Chiba is an MD, PhD is a gastroenterologist and researcher at Akita City Hospital, Kawamoto, Akita City, Japan.
He believes that inflammatory bowel disease is a lifestyle disease mediated mainly by a westernized diet, and has had many subsequent publications detailing his use of a plant based, semi-vegetarian diet.
He began to provide a plant-based diet for patients with inflammatory bowel disease at Nakadori General Hospital (Akita City, Japan) in 2003, and then continued to provide the diet at Akita City Hospital since 2013. We had a very detailed discussion regarding his well cited paper "Lifestyle-related disease in Crohn’s disease: Relapse prevention by a semi-vegetarian diet" published in 2010 which demonstrated the efficacy of using a plant based diet in combination with infliximab for induction of remission then maintenance with a plant based diet alone.
Though Dr. Chiba’s English is excellent, special thank you to Dr. Chiba’s daughter Kaeko who helped with translation at certain points of the interview.
This podcast should not be interpreted as medical advice as a plant based diet is not FDA approved for the treatment of inflammatory bowel disease.

Dr. Chiba's study:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2877178/

Lester Breslow's 1980 publication regarding healthy habits:
https://www.sciencedirect.com/science/article/pii/0091743580900420

This is my much anticipated interview with Judy Herod who has been on the Specific Carbohydrate Diet (which we will often abbreviate as SCD) for over 50 years for ulcerative colitis with rapid clinical response and sustained drug-free remission. Her mother is the late Elaine Gottschall, biochemist and author of Breaking the Vicious Cycle: Intestinal Health Through Diet which is the book that describes the SCD protocol in detail and started the food/ibd movement several decades ago. Judy has likely been using dietary therapy for her ulcerative colitis longer than anyone else in the world. There are many parents who have young children on the SCD. I thought it would be valuable to hear from someone who has been on this protocol for so long to perhaps get a sense of what life can be like using SCD as a treatment strategy long term. As a disclaimer, this podcast should not be interpreted as medical advice as the SCD is not as of yet an FDA approved treatment for Crohn’s or ulcerative colitis.

SCD Website: http://www.breakingtheviciouscycle.info/

Barbara Olendzki RD, MPH, LDN is Associate Professor of Medicine and the Nutrition Program Director of the Center for Applied Nutrition at the University of Massachusetts. She is passionate about research and clinical care of patients with inflammatory bowel disease (IBD), cardiac concerns, cancer, diabetes, obesity, and other inflammatory diseases. She has 20 years of experience in the nutrition field. She created the IBD-anti inflammatory diet (IBD-AID) which is based on the Specific Carbohydrate Diet but with an emphasis on pre and probiotics, healthy fats and textures of foods. It also includes certain carbohydrates like oatmeal and other foods that are otherwise forbidden on the SCD.
She published a case series in 2014 of 11 patients with IBD who went on her dietary protcol. Most of these patients had failed one or more medications, or medications had no effect or there was a loss of response. After using the IBD-AID, all patients were able to de-escalate medical therapy to some degree and all had symptoms reduced. Since that publication, she has updated the protocol and kindly shared her insights regarding implementing the IBD-AID clinically. As a disclaimer, this is not an endorsement or recommendation of this diet for the treatment of IBD as the IBD-AID has not been FDA approved for this purpose.
Barbara's website can be found here: https://www.umassmed.edu/nutrition/

Two guests for you today! The first is Andrew Kornfeld (andrew@ibd.coach | https://www.facebook.com/andrew.kornfeld.18) who holds degrees in neuroscience and psychology from UCSC and has won awards for his work in science education. He has Crohn’s disease and has been able to achieve clinical drug free remission through a protocol he developed after doing his own extensive research with a lot of trial and error. Andrew is the founder of IBD Coach (http://www.ibd.coach) which offers consulting & educational services for IBD patients to develop their own personalized treatment protocol in coordination with their health and medical team.
My other guest is Lucy Mailing who has a PhD in Nutritional Sciences from the University of Illinois where her research focused on understanding how diet and exercise affect the composition and function of the gut microbiome in states of health and disease. She was recently named an Emerging Leader in Nutritional Sciences by the American Society for Nutrition and has authored several peer-reviewed journal articles related to the gut microbiome and health. Lucy is also a staff research associate for Kresser Institute and writes about evidence-based gut and skin health on her blog at NGmedicine.com. Lucy plans to continue her training and complete her MD at the University of Illinois in 2024.

We had a wide ranging discussion about several topics in IBD including the strengths and limitations of conventional medicines, potential to reform IBD care, health insurance, supplements, dietary therapy, mitochondrial function, candida, Genova testing amongst many other topics. As a disclaimer, I am not endorsing or recommending any of the supplements or protocols discussed in this podcast as they have not been FDA approved to treat Crohn’s or colitis. This is an open discussion and should not be interpreted as medical advice.

Dr. Michael Briggs is a physicist who had ulcerative colitis which he claims to have "functionally cured" using a system he developed called The Briggs Protocol. He read every article on IBD he could get his hands on and wrote a document called "Understanding the Pathogenesis of Inflammatory Bowel Diseases, and moving towards a 'Functional Cure'" which has been circulating on internet forums. You will learn about his approach to inducing remission, healing the epithelial barrier to stop bacterial translocation and then maintaining the barrier to prevent relapse. We discussed things like bupropion, limitations of the SCD/paleo diet, resistant starch and fiber, butyrate, hydrogen sulfide, fecal transplant, supplements, lectins, wim hof and this is only a fraction of the topics covered. As a disclaimer, I am not endorsing or recommending this protocol for treatment for IBD as it has not been studied in the form of clinical trials and is not FDA approved.