Lifestyle Medicine in Inflammatory Bowel Disease

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[Letter]. Perm J 2018;22:18-062 [Full Citation]

https://doi.org/10.7812/TPP/18-062

E-pub: 07/20/2018

Re: Bodai BI, Nakata TE, Wong WT, et al. Lifestyle medicine: A brief review of its dramatic impact on health and survival. Perm J 2018;22:17-025. DOI: https://doi.org/10.7812/TPP/17-025

Dear Editor,

We enjoyed greatly the article “Lifestyle Medicine: A Brief Review of Its Dramatic Impact on Health and Survival” written by Bodai et al.¹ The article encourages and inspires us.

Following World War II, Japan experienced an economic, nutritional, and epidemiologic transition. Stroke (apoplexy) replaced tuberculosis as the leading cause of death in 1951. Three diseases (cancer, coronary heart diseases, and stroke) became the main causes of death, accounting for about two-thirds of all deaths. Japan’s Ministry of Welfare designated these diseases “adult diseases” in 1956 in an attempt to diagnose and treat the diseases early in persons in their prime. Forty years later, in 1996, the term “adult diseases” was replaced with “lifestyle-related diseases,” considering the importance of lifestyle starting at childhood for prevention of chronic diseases. At that time, diabetes mellitus and hypertension were added to the three diseases above to form the five major lifestyle-related diseases. Consequently, “lifestyle disease” is a familiar term to the Japanese people.² It is obvious that the majority of diseases we face are chronic diseases (lifestyle diseases) caused by an unhealthy lifestyle.^1,3 Therefore, incorporation of a healthy lifestyle in medicine, namely lifestyle medicine, is fundamental for prevention and treatment of chronic diseases.^1,3 Bodai et al described the effect of lifestyle medicine in obesity, diabetes, cardiovascular disease, and cancer.¹ We want to comment on our experience of lifestyle medicine in inflammatory bowel disease (IBD): Crohn disease (CD) and ulcerative colitis (UC).

We regard IBD as a lifestyle disease mainly mediated by westernized diets, which tend to cause reduced gut microbial diversity.^4,5 We have provided a primarily plant-based diet (PBD) (lacto-ovo-vegetarian diet) for all IBD inpatients since 2003.⁴ Meat and fish are served once every 2 weeks and once a week, respectively. Sweets are not served. Fruits, vegetables, legumes, potatoes, and yogurt are served daily. We also provide information on healthy lifestyle habits: No smoking, regular physical activity, moderate or no use of alcohol, regularity of meals, and not eating between meals.⁶ We give each patient a dietary and lifestyle recommendation on discharge. We recommend a PBD for meals, active exercise, and maintenance of healthy lifestyle. We have 15 years of experience of such lifestyle medicine involving more than 159 patients with UC and 70 patients with CD.⁷ In CD, infliximab combined with PBD induced remission in 44 consecutive cases without fail.⁸ This remission rate is excellent considering that around 30% of sufferers are primary nonresponders to infliximab. PBD is effective in the maintenance of remission in CD: 100% and 90% at 1- and 2-year follow-up, respectively.⁴ This remission rate is achieved without scheduled maintenance therapy with infliximab. We recommend a short period of educational hospitalization for patients with mild UC to replace their omnivorous diet with a PBD. The cumulative relapse rates after educational hospitalization at 1 and 5 years of follow-up were 2% and 19%, respectively.⁹ Although our patients were mild cases, these relapse rates are far better than those reported in the literature (28% to 50% at 1 year and 57% to 78% at 5 years). PBD score,⁷ which evaluates adherence to the PBD, was significantly better relative to baseline both at short-term (14 months) and long-term (47 months) follow-up.⁹ We now treat mild cases of UC with PBD first, not medication.^9,10 PBD without medication can induce remission in a subset of patients with mild UC.^9,10 Our success with lifestyle medicine in IBD was greater than we expected and as dramatic as that described by Bodai et al¹ in representative chronic diseases. It is regrettable that the PBD menu and dietary guidance for PBD by a registered nutritionist are not currently covered by health insurance.

Mitsuro Chiba, MD, PhD
    Chief of the Inflammatory Bowel Disease Section, Akita City Hospital, Japan

Kunio Nakane, MD, PhD
    Chief of the Gastroenterology Division, Akita City Hospital, Japan

Masfumi Komatsu, MD, PhD
    Director of Akita City Hospital, Japan

How to Cite this Letter

Chiba M, Nakane K, Komatsu M. Lifestyle medicine in inflammatory bowel disease [Letter]. Perm J 2018;22:18-062. DOI: https://doi.org/10-7812/TPP/18-062

References

1.    Bodai BI, Nakata TE, Wong WT, et al. Lifestyle medicine: A brief review of its dramatic impact on health and survival. Perm J 2018;22:17-025. DOI: https://doi.org/10.7812/TPP/17-025.
2.    Ohno Y, Yanagawa H. Manual for prevention of life-style related diseases. Tokyo, Japan: Nanzando Co; 1999.
3.    Hyman MA, Ornish D, Roizen M. Lifestyle medicine: Treating causes of disease. Altern Ther Health Med 2009 Nov-Dec;15(6):12-4.
4.    Chiba M, Abe T, Tsuda H, et al. Lifestyle-related disease in Crohn’s disease: Relapse prevention by a semi-vegetarian diet. World J Gastroenterol 2010 May 28;16(20):2484-95. DOI: https://doi.org/10.3748/wjg.v16.i20.2484.
5.    Chiba M, Tsuda H, Abe T, Sugawara T, Morikawa Y. Missing environmental factor in inflammatory bowel disease: Diet-associated gut microflora. Inflamm Bowel Dis 2011 Aug;17(8):E82-3. DOI: https://doi.org/10.1002/ibd.21745.
6.    Breslow L, Enstrom JE. Persistence of health habits and their relationship to mortality. Prev Med 1980 Jul;9(4):469-83. DOI: https://doi.org/10.1016/0091-7435(80)90042-0.
7.    Chiba M, Nakane K, Takayama Y, et al. Development and application of a plant-based diet scoring system for Japanese patients with inflammatory bowel disease. Perm J 2016 Fall;20(4):62-8. DOI: https://doi.org/10.7812/TPP/16-019.
8.    Chiba M, Tsuji T, Nakane K, et al. Induction with infliximab and plant-based diet as first-line (IPF) therapy for Crohn disease: A single-group trial. Perm J 2017;21:17-009. DOI: https://doi.org/10.7812/TPP/17-009.
9.    Chiba M, Nakane K, Tsuji T, et al. Relapse prevention in ulcerative colitis by plant-based diet through educational hospitalization: A single-group trial. Perm J 2018;22:17-167. DOI: https://doi.org/10.7812/TPP/17-167.
10.    Chiba M, Tsuda S, Komatsu M, Tozawa H, Takayama Y. Onset of ulcerative colitis during low-carbohydrate weight-loss diet and its treatment with plant-based diet: A case report. Perm J 2016 Winter;20(1):80-4. DOI: https://doi.org/10.7812/TPP/15-038.

Response to Drs Chiba, Nakane, and Komatsu

To the editors:

On behalf of the authors, I wish to thank the Drs Chiba, Nakane, and Komatsu for taking the time to review our article regarding Lifestyle Medicine and for preparing their insightful response. It is apparent that they have done extensive work in the area of the serious and often debilitating disease: Inflammatory bowel disease (IBD), and how it can be affected by lifestyle changes. Their work further demonstrates that yet another chronic illness, in addition to those described in our article, can be substantially affected by altering the lifestyle that contributes to such chronic conditions.

Our article places strong emphasis on inflammation as a common denominator in the majority of chronic conditions that are responsible for a significant portion of our health care expenditure. Additionally, the article specifically mentions the strong association of inflammation and the development of colorectal malignancies, the incidence of which is much higher in patients with IBD, who have been shown to have a substantially increased risk of developing other malignancies such as breast cancer.

Our current understanding of disease is in its infancy. Dr Chiba et al reinforce the urgent need to move forward in exploring alternative treatment options in the management of chronic diseases, using lifestyle alterations as opposed to the prescribing of medications that treat only symptoms and fail to address the root causes of these conditions.

Many equate screening for disease with prevention. Modern screening technologies may find malignancies, but in no way are they preventive. Medicine must evolve into being truly preventive, not reactive. Dr Chiba et al have made a major contribution to moving health care forward with their extensive work in the field of IBD. We are totally in concurrence with their conclusion that dietary guidelines, focusing on a whole food, plant-based diet as treatment for chronic diseases is not only needed, but must be implemented.

We appreciate Dr Chiba et al’s call for further support for the much-needed paradigm shift in the future of medicine.

Balasz I Bodai, MD
   Director, The Breast Cancer Survivorship Institute
   Sacramento, CA