So many of the patients we talk to have issues related to their gut, whether it be a gut specific issue, or whether the gut is communicating with other parts of the body such as the pelvic floor, the upper digestive tract, or perhaps even the brain. These types of gut disturbances are not only debilitating, but are uncomfortable to talk about.
November marks Crohn's and Colitis awareness month and with it we are breaking down barriers so we can talk about everything poop related. Crohn’s disease and Colitis are two subtypes within the umbrella of Inflammatory Bowel Disease (IBD). In both instances, there is substantial inflammation along the colon itself, leading to symptoms such as malabsorption, intestinal bleeding, pain and cramping with urgency, and potential weight loss.
While there is no cure for either disease, there are many treatment options on the market that range from oral tablets, rectal suppositories and intravenous infusions of biologics. Whatever treatment works best for the patient, the goal is to reduce the inflammation and therefore put the patient into remission where quality of life is once again resumed.
In the last decade (or less), one emerging treatment approach has been to try to replenish the gut with ‘good’ bacteria and change any bacteria that may be increasing the inflammation, increasing gut motility (and ‘having to go’ so often) and potentially even increasing cravings for junk. The community of bacteria and other microorganisms in the digestive tract is what we call the microbiome, and is a very active field of study where researchers and pharmaceutical companies alike are aiming to find a way to use the microbiome as a tool for IBD.
We caught up with Kristina Campbell, a renowned Canadian microbiome science writer who has worked with many of the prominent companies in the field. Additionally, Kristina has published two microbiome books, one of which is a cookbook to get people on the right track with nourishing their gut microbiomes.
Kristina, can you get us started with the basics in terms of how the gut microbiome is being thought of as a tool for IBD?
By now, researchers have found dozens of conditions where the intestinal microbiome is altered compared to people without that condition. And for IBD, the alterations are especially obvious. People with IBD have fewer bacteria that thrive in a dark, oxygen-free environment (that is, anaerobes). And a large-scale project called the Human Microbiome Project 2 showed that during flares, the microbiome seems to change rapidly, like an erratic radio signal. Researchers are coming around to the idea that the gut microbiome is part of an intricate dance with the immune system and is part of how IBD arises -- one of several factors that create the 'perfect storm'.
The conundrum is that changes in the gut microbiome look slightly different for every person with IBD. So there's no test you can take that tells you whether your microbiome is IBD-like vs. healthy. There's no threshold of 'bad' bacteria that everyone with IBD reaches, because it's highly individual.
Nevertheless, the gut microbiome is definitely gaining prominence as a tool for addressing IBD -- both for prevention and treatment. To understand more about prevention, at least one long-term study in multiple countries is now looking at people who develop IBD and whether they had had certain predisposing factors in their microbiomes beforehand. And for treatment, a number of different companies are testing out microbiome-targeting interventions that could make a difference to the disease once it's established. These might either replace or complement existing drug regimens for those with IBD.
Are there companies out there to watch out for?
There are some promising therapies coming out of pharmaceutical start-ups, using very different approaches. For example, Rebiotix is testing a “Microbiota Restoration Therapy” drug, which is a cocktail of live microbes (basically a controlled, pared-down version of a fecal transplant) that would shift the gut microbiome to achieve clinical benefit in IBD. The French company Enterome is taking a different approach, mimicking a well-functioning gut microbiome and putting pressure on the immune system via specific molecules.
What do patients need to be aware of when getting their microbiome tested?
If people get their microbiome tested, they should be aware that the test will not tell the doctor anything they can’t already tell from the standard clinical tests. There is no valid gut microbiome test that’s clinically actionable at the moment. It may be interesting to just see your results and speculate on how you could change them by using tools such as diet, but there are no guarantees that anything you do along those lines would be beneficial. This is coming, but it requires a lot more research and validation!
So then, should we start to get excited about fecal transplants?
With fecal transplants -- basically blending up stool from a healthy person and administering it to someone with IBD -- they’ve shown moderate success for ulcerative colitis (UC), but not Crohn’s disease. For UC, it seems to work well some of the time, and poorly other times, but researchers haven’t really figured out why this is the case. It might have to do with the exact community of microbes in the fecal donor -- some communities are more therapeutic than others. The big risk with fecal transplant, though, is that you can test the fecal sample rigorously but you cannot be sure if you’ve tested for every possible pathogen. So you can inadvertently transfer pathogens or antibiotic-resistant bacteria in the sample, which can be really dangerous for people who are already immunocompromised. I think the future is going to be about controlled therapies that mimic fecal transplants, such as the one by Rebiotix mentioned above.
Bringing it all the way back to the basics - the things we do have control of: food. Can you go into the premise of your book? Why did you focus on microbiome-supporting foods? Are these good for people who have IBD, not have IBD?
The Well-Fed Microbiome is mainly for people in general good health, or those with occasional symptoms. So it’s not specifically aimed at people who have IBD. ‘Phase 1’ for people with digestive symptoms has low-FODMAP recipes that are meant to calm things like bloating, distension, and gas. Then the ‘phase 2’ is for when the symptoms have gone away, to maintain a fairly high-fiber diet with lots of variety, which is basically the best diet we know of to maintain a diverse, well-fed microbiome.
For people with IBD, it’s a classic phenomenon that everyone has a slightly different diet that helps keep their symptoms in check. With the cookbook, some recipes might work and some might not work. At this stage it’s basically trial and error for each person -- but believe me, researchers are certainly trying to determine the best diet for those with IBD on an individual level!
We see so much about probiotics which - you know compared to 5 years ago this is a huge revolution - but what about prebiotics?
Prebiotics are substances that help feed beneficial bacteria in the gut -- so they’re a promising way to change the microbes for the better in IBD. So far there’s not enough research to know exactly which prebiotics could help and in which amounts, but watch this space in the years ahead! Prebiotics are very attractive because they are often types of fiber that can be incorporated into your diet quite easily.
What’s the most important message to get across about the microbiome and IBD?
I think preventing IBD in the first place is the low-hanging fruit for how we can leverage the microbiome. This means if you have close relatives with IBD, pay close attention to your diet and other IBD risk factors such as smoking. Make sure you’re sticking as close as you can to a Mediterranean diet pattern, because people with that type of diet have a better chance of avoiding IBD. This applies no matter what your age -- older adults are increasingly getting the IBD diagnosis, so now is the time to shift your diet accordingly. Sweet drinks and processed meats, for example, may act through the microbiome to predispose you to IBD. So it’s best to avoid them except for special occasions.
If you live with IBD, take the chance to educate your family members (i.e. people who share genes with you) about the dietary risks, and support them in getting varied sources of fiber in their diets! Other than that, stay tuned because I think in the next five years we will see some novel microbiome-focused therapies on the market that could make a big difference to your condition.
Kristina thank you so much for your time. I think in terms of the microbiome, we have distilled this topic down to something our readers can really grasp on to. Hopefully we see some advancements in the near future. As always, please keep doing what you’re doing!