The Dr. Hyman Show - Exclusive Dr. Hyman+ Functional Medicine Deep Dive: Inflammatory Bowel Disease

Episode Date: March 5, 2024

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Hey podcast community, Dr. Mark here. I'm so excited to offer you a seven-day free trial of my revolutionary new platform called Dr. Hyman Plus. For seven days you get special access to all the private content included in Dr. Hyman Plus entirely free. It's so easy to sign up. Just go to Apple Podcast on your phone and click try free button on the Doctors Pharmacy podcast. You'll get exclusive access to ad-free Doctors Pharmacy podcast episodes and functional medicine deep dives where a practitioner dives into topics like heart health, muscle health, insulin resistance, and more to help you understand the root cause of specific ailments and walk you through the steps to improve your health today. You'll also get access to all my Ask Mark Anything Q&As where

I answer the community's biggest health and wellness questions. Because I'm so sure you're going to love this platform, I'm offering you free access to all of this content for seven days and a teaser of my brand new Functional Medicine Deep dive episode, diving deep into one of the most important topics in health. Head on over to the Doctors Pharmacy podcast on Apple podcast and sign up for your free trial right now. Okay, here we go. Hi, I'm Dr. Dawn Bolio. I am professor of medicine at Vanderbilt University. I specialize in inflammatory bowel disease. I'm certified in functional medicine through the Institute of Functional Medicine, and I'm looking forward to talking to you about functional medicine and IBD. term that we use to describe a disorder that has chronic inflammation of your GI tract.

The two most common forms of IBD are Crohn's disease and ulcerative colitis. About 10 to 20% of patients, we consider them to have indeterminate colitis. And pretty much that just means that they kind of haven't declared themselves one way or another yet. So IBD has a cycle of inflammation that really just can't be stopped. Patients with inflammatory bowel disease get inflamed for numerous reasons. For example, like the use of NSAIDs, antibiotic exposure, some kind of infection. And these are triggers that cause inflammation. And this mucosal inflammation causes an abnormal immune response, which is very complicated.

And someone who doesn't have IBD, when they have this inflammation, they're able to downregulate that, as you can see that here in the slide. Whereas patients with IBD, they're unable to downregulate this inflammation, and it causes this chronic cycle of inflammation resulting in inflammatory bowel disease. The symptoms of IBD can vary depending upon where the inflammation is. Here you can see a list of signs and symptoms of uncontrolled inflammatory bowel disease such as weight loss, diarrhea, abdominal pain, extra intestinal manifestations, which we'll talk about a little bit. And patients also can have fevers with uncontrolled inflammation. It's important to remember that IBD is a spectrum. And just because you have IBD, the person next to you also might have IBD. That doesn't mean it's actually the same disease in

the way that it needs to be treated or how it kind of, how you feel. So features that we know that are associated with high-risk disease progression are patients that are diagnosed at a young age and extensive bowel involvement, so long segments of inflammation in your GI tract, and patients that have Crohn's disease, so perianal disease, stricturing disease, and fistulizing disease are all high risk for disease progression. Here you can see a picture of a patient with ulcerative colitis. Ulcerative colitis has to start in your rectum. It's circumferential. It is continuous and works its way up.

Even though there's the word ulcer in the name, there's really not discrete ulcers in your colon, but the whole area is ulcerative. Inflammation can only be in your colon, not anywhere else. If it goes anywhere else, then it's not what you see. If you have a stricture in your colon with ulcerative colitis, you need to rule out any kind of malignancy. The location of the inflammation in your colon with ulcerative colitis, you need to rule out any kind of malignancy. The location of the inflammation in your colon, that is kind of what we call it. So if you have inflammation just in your rectum, we call that ulcerative proctitis. If you have inflammation in the left side, then we call that left-sided inflammation or proctosigmoiditis. If you have inflammation that passes the splenic flexure, which is that first

turn, we call that pancolitis. The difference in Crohn's disease is Crohn's disease can be anywhere from your mouth all the way down to your rectum. It's important to know the location of inflammation because that determines how we treat the patient. Crohn's can be tricky. If you have inflammation in your small intestine, you may present like a patient with celiac disease or just have abdominal pain without diarrhea. If you've got Crohn's just in your colon, you may present with constipation and may not have diarrhea. Here you can see in this picture of patients that has Crohn's, they have discrete ulcers, sometimes small, sometimes long and linear. But this is a patient who has Crohn's disease in their colon and Crohn's disease in their small

intestine. So Crohn's and UC, they're both IBD, but how are they similar? So both diseases can develop in your teenage years or young adults, although the disease can occur at any age. UC and Crohn's affect men and women pretty equally. The symptoms of UC and Crohn's disease are very similar at times. The causes of both UC and Crohn's are not known, but both diseases have similar contributing factors, such as the underlying genetics that was passed on by your parents. You have some kind of environmental and some kind of trigger, which results in an appropriate response by your body's immune system. How are Crohn's and UC different? So UC, like I said already, is limited to the colon and the inflammation is continuous

starting in your rectum and affects your innermost lining of your colon. Crohn's can be anywhere between your mouth and your anus, and there's healthy parts in between the inflamed areas. It can occur in all layers of the mucosal, and we call this transmural inflammation. Another thing that Crohn's can do is it causes perianal disease. So these are fistulas, skin tags, abscesses on your bottom. And this doesn't happen in a patient that has ulcerative colitis. I mentioned a little bit earlier, extraintestinal manifestations. And so extraintestinal manifestations are things that are associated with IBD,

but it's not in your GI tract. So IBD really isn't just in your gut. It can be anywhere. And you can find these extraintestinal manifestations in your skin, your eyes, joints, kidneys, liver, and in your blood. IBD can also be tricky because other disease states can mimic the symptoms of IBD. So you can think maybe that you do have IBD, but really it's something else. Here you can see there's different types of infections, other kinds of immune diseases, and different kinds of medications, chemotherapy, diverticular disease, multiple infections that can all cause symptoms similar to a patient with inflammatory palpancies. So how do we diagnose IBD? There's not just one test that diagnoses IBD, unfortunately, so that's why it can be a little bit tricky sometimes. You have to do blood work. You typically need an endoscopy or a

colonoscopy with biopsies. You definitely need to rule out infections. As we can see, there's numerous things that can cause the symptoms of IBD, so you want to rule out infection. Equal calprotectin is a very helpful test that detects protein in your stool for inflammation, and we use that often. You definitely need the clinical picture, and we want to talk to our patients. And often we need imaging with like a CT scan, an MRI, or a capsule endoscopy to further evaluate the small intestine. So there's not one factor alone that predisposes someone with inflammatory bowel disease. It's kind of an interplay of three domains. So you need to have the underlying genetics that predisposes you to IBD.

You have this change in your immune system and an environmental trigger because of all of these things. So, you know, the genes that we get that are passed down, we can't really change those. The environment that we live in, we can change. The biochemistry, which is resulting in the food that we eat, we can change. And so all of these things come together, push us as a human to either wellness or illness. And so, you know, we can't change the genes that we're given, but we can change the choices of where we live and how we live and what we eat. So what we do on a day-to-day basis can impact your overall health. This is why IBD and functional medicine is a perfect fit. Because all of these things come together

and affect a patient with inflammatory bowel disease. So the goals of functional medicine, there are many. But to me, I think of functional medicine as a way to balance the whole system. It's a self-discovery to create a map to guide you to a healthy state. And we need to figure out what's causing the imbalance within your system and provide things that create balance. Functional medicine always starts with good medicine. It's not a substitute for conventional medicine.

Conventional medicine is great. Functional medicine is a model to use for chronic complex disease. It's not for acute care. You know, trauma, car accident, stroke, heart attack, you know, this is where conventional medicine is amazing. Functional medicine does not come into play there. But for chronic complex disease, such as inflammatory bowel disease, there's a lot of things that we can do from a functional medicine standpoint to help adjunct care to what patients or what you may already be doing. There's been a lot of studies out there looking at environmental modifications and IBD disease activity.

There are numerous things in our environment that you can see here that can affect everyday IBD disease activity. There are numerous things in our environment that you can see here that can affect everyday IBD disease. One of these things is early life exposures. There's a lot of work being done on the pediatric side, looking at what babies and kids are exposed to when they're younger, which may affect their disease risk and progression later in the life. So we know things such as smoking, which is detrimental, breastfeeding, which is positive, can help rather disrupt the microbiome or support the microbiome. And when the microbiome is developing, this is when immunologic tolerance likely plays a role. One interesting topic is called the hygiene hypothesis.

So the hygiene hypothesis suggests that there's a delayed exposure to bacterial and parasitic infections may facilitate the development of chronic immune-mediated diseases like IBD. So changes in the gut microflora because of these things results in changes in our microbiome. So studies have shown that persons who are little, who live in homes with separate bedrooms, hot water, and sewage drainage have an increased risk of developing Crohn's disease. That doesn't mean we want to avoid any of these things. We definitely want high water. And I know a lot of kids want their own bedroom, but it kind of supports what this hypothesis is. So an inverse association between Crohn's and other immune modulating activities have been described and this supports this hypothesis. So it was first proposed to explain the rising incidence

of autoimmune disease in the developed world. So those with a higher number of siblings, larger family size, if you live on a farm, so if you live in the country versus urban, exposure to pets in early childhood, this allows for a more diverse microbiome and may decrease your risk for chronic immune diseases such as IBD. So things and triggers that we know that can be associated with IBD are medications. So there are a number of medications out there that we know can trigger IBD. NSAIDs is a big one of them. I don't like my patients taking NSAIDs on a general basis. And so it can trigger a flare in up to a third of patients. Aspirin can also

be known to do this. Postmenopausal hormonal therapy and oral contraceptives also have been shown a little bit to have a risk, but every single person is different. What I wanted just to kind of focus is on that there are triggers out there. And so you need to be mindful of the medications that you're taking. Nutrition. So nutrition is a huge thing when it comes to IBD, and we could take the whole hour just talking about nutrition. So we know that soluble fiber, so soluble fiber comes from fruits and vegetables, is metabolized by the intestinal bacteria to short-chain fatty acids, and that inhibits transcription of these pro-inflammatory mediators. So fiber helps maintain the integrity

of our epithelial barrier and our colon. So high consumption of omega-6 polyunsaturated fatty acids and low consumption of omega-3 PUFAs have been shown with an increased association of both UC and Crohn's. In a mice-mouse model, they show that vitamin D deficiency has increased risk in colitis in these mouse models. And when they give these mouse-mice vitamin D, this resolves the inflammation and suppresses the expression of inflammatory mediators. Low levels of vitamin D have an increased risk of Crohn's surgeries. And zinc also has been known to inhibit transcription of inflammatory mediators. So you see, you know, nutrition and the vitamins that we intake are very complicated, but it can, in fact, impact inflammation in our autoimmune disease. Another thing that we know that affects IBD is stress.

So stress results in a release of neurotransmitters, which can drive inflammation. Stress by also doing this can increase GI motility, increase mucus and water secretion. That's why a lot of people can have diarrhea when they get stressed out. Also, this results in mass cell degranulation and bacterial transfer into the mucosa, which also drives inflammation. So you can see there's multiple pathways in which stress can drive your underlying gut inflammation, which results in increasing in your IBD symptoms. So there's so many things out there and some that we've mentioned already that lead to altered intestinal permeability. So this potential breach of intestinal permeability, like you see here, from a multitude of triggers from food, nutrition,

stress, other diseases, toxins, infections, can lead to an altered intestinal permeability. And so this results in increased uptake of food antigens, then resulting in malabsorption, increased uptake of toxins and LPSs. And all this drives immune activation, inflammation, and systemic disease. So how do we address these triggers of intestinal permeability? And functional medicine is really good at doing that. Well, I hope you enjoyed that teaser of exclusive content that you get every single month with Dr. Hyman Plus.

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