The Guts and Bolts of the Diet and a Look into the Microbiome

Mounting evidence suggests that particular aspects of human health and disease may be attributable to the trillions of microbes that inhabit our gastrointestinal tract, collectively referred to as the gut microbiota. Evidence suggests that pathologic changes to the microbiota (termed “dysbiosis”) are associated with a wide variety of medical outcomes, and therefore therapeutic manipulation of the microbiota is a major area of research interest. As part of the mini-symposium entitled Manipulating the Gut Microbiome for Human Health, Dr. Olendzki presents on the Inflammatory Bowel Disease Anti-Inflammatory Diet (IBD-AID)

Assessment of Diet in Patients with Inflammatory Bowel Disease: A Collaboration of Behavioral and Basic Scientists

Introduction: Clinical research to develop treatment for inflammatory bowel disease (IBD) is focusing on a nutritional regimen restricting certain carbohydrates while incorporating the use of an optimal diet that includes pre- and probiotic foods. Current assessments are not able to measure elements of this nutritional regimen, thus we developed a food frequency questionnaire (FFQ). This FFQ will be utilized in a prospective study of IBD patients following an anti-inflammatory diet (IBD-AID) developed by us and used clinically at UMASS. We will track the bacterial communities inhabiting the microbiome of patients to determine diet-dependent changes, and their relation with patient wellbeing. Objectives: 1) Develop an FFQ capable of identifying dietary components important to IBD: prebiotics, probiotics, beneficial nutrient intake, and avoidance of certain foods. 2) Determine diet-dependent changes of the gut microbiome. Hypothesis: This study will show the microbiome of patients adopting the IBD-AID converge to one or more healthy \u27enterotype\u27 signatures, as compared to a non-IBD-AID control group. Experimental design: Patients record daily FFQ. Foods and food groups (270) are categorized and grouped according to criteria of interest. Each food has a referent by which the patient can compare their own consumption. A scoring system satisfying dietary guidelines and components of the IBD-AID will be utilized. Twice per week patients collect stool samples for microbiome analysis. Microbiome composition and ecological metrics are compared to identify components influenced by the IBD-AID, and to separate bacterial \u27enterotype\u27 signatures of patients before, during and after diet intervention. We are currently recruiting patients

Beverage Consumption Among Low-Income Hispanics with Uncontrolled Type 2 Diabetes

This study sought to describe beverage consumption, caloric contribution of beverages to total caloric intake, and associations between beverage consumption and metabolic factors among a sample of low-income Hispanics participating in a trial of a diabetes self-management intervention. Findings: Treatment strategies to improve glucose control and reduce diabetes complications among Hispanics are needed. There is a high consumption of calories from beverages, accounting for one-fifth of total caloric intake, among this high-risk Hispanic population. Milk, juices, fruit drinks and regular soda are particular sources of calories. Beverage consumption is associated with metabolic markers, including HbA1c, cholesterol, blood pressure, BMI and waist circumference, and may thus increase risk for diabetic and cardiovascular complications in this population. Beverage consumption among low-income Hispanics warrants further clinical and research attention, including development of interventions that target all liquid calories, not just sugar-sweetened beverages. Targeting beverage consumption through simple messages that are in line with the literacy challenges posed by this population may be feasible. The vast benefit of clarifying a single food group that can be modified to reduce risk factors of diabetes and obesity in this population cannot be overstated

Anti-Inflammatory Diet for Inflammatory Bowel Disease (IBD-AID)

Background: Inflammatory Bowel Disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), are chronic, immune-mediated inflammatory conditions of the gastrointestinal tract, which have increasingly been linked to dysbiosis, or an imbalance in the gut microbiome. Standard of care for IBD involves an often-evolving combination of anti-inflammatory, antibiotic, and immunomodulatory medications; however, the pharmacological approach is never curative, and medications routinely become ineffective for individual patients. Partially fueled by the increasing inadequacy of pharmacologic treatment regimens, there is emerging interest from patients regarding diet and its role in the pathogenesis and treatment of inflammatory diseases, demanding more in-depth and substantiating research from the medical community. The Anti-Inflammatory Diet for IBD (IBD-AID), which is derived and augmented from The Specific Carbohydrate Diet (SCD), is a nutritional regimen that restricts the intake of pro-inflammatory carbohydrates such as refined sugar, lactose, and most grains, while maximizing anti-inflammatory foods including those with prebiotic and probiotic properties. We have previous results from a case series of 11 patients with IBD showing symptomatic improvement (by Harvey Bradshaw Index scores) and downscaling of medication regimens in all 11 patients after 4 weeks on the IBD-AID. Objectives: The purpose of this small prospective study was to further assess the efficacy and feasibility of the IBD-AID intervention for the treatment of CD, and to provide pilot data for a larger application. Methods: The sample included 17 patients with biopsy-confirmed Crohn’s disease. Participants were offered the treatment diet (IBD-AID) (n=12) or standard medical care alone (control) (n=5). Patients in the IBD-AID group were required to attend one individual nutrition counseling session and three IBD-AID-specific cooking classes at the University of Massachusetts Medical School’s Shaw Building teaching kitchen. The control group continued with usual care. For all participants, demographic, clinical, and symptom data were obtained from baseline and follow-up questionnaires; dietary composition was monitored by weekly dietary recalls and food journals. All participants continued to follow with their gastroenterologists throughout the study duration. Study duration was 2 months after 70% adherence to the diet for IBD-AID participants, and 2 months after baseline for control participants. Consistent with the goals for any treatment used for CD, efficacy measures included: 1) reduction in symptomology, as measured by the validated Harvey Bradshaw Index (HBI); 2) reduction in the need of immunomodulatory and anti-inflammatory medications; and 3) normalizing trend in circulating inflammatory markers (i.e., CRP and ESR), albumin, and hematocrit. Feasibility measures included participant retention, dietary compliance, and participants’ self-assessments of difficulty in maintaining the diet. Results: A total of 15 enrolled patients with confirmed diagnosis of Crohn’s Disease, 5 in observation arm, 10 in intervention arm. Significant trends in dietary composition included significant increases in prebiotic and favorable dietary components, and decrease in adverse foods for the group as a whole (paired t-test values 0.0016, 0.0344, 0.0085, and 0.0014, respectively). For those patients on medication at baseline and with complete follow-up (n=9), one-third were able to decrease doses of or discontinue these medications. In addition, lab values reflected symptomatic improvements in two of our intervention patients, with changes in CRP, ESR, and hematocrit levels of -55.9 and -1.4, -30.0 and -15.0, and +5.4 and +0.3, respectively, with corresponding symptomatic improvements (HBI scores 1à7 and 8à0, respectively). No significance can be assigned, however, due to low sample size and loss to follow-up. Feasibility measures include a significant loss to follow-up rate of 33.3%, as well as an average “difficulty score” of 3.1, reflecting participants’ views on the difficult nature of “sticking with” the IBD-AID (scored on scale of 1-5, very easy to very difficult). Conclusion: Despite the study’s limitations, as well as because of them, several conclusions can be drawn. The trends noticed in the participants’ dietary component reports, and supported by participants’ self-evaluation, reveal that it is relatively easy to eliminate problem foods from the diet, but adding unfamiliar foods, particularly from the probiotic category such as plain yogurt, kimchi, miso, sauerkraut, etc., is a huge barrier to maintaining compliance. This trend may be a partial reflection of the Western food and dieting culture in which our daily meals are relatively homogenous. We are also brought up from a young age learning that “dieting” and “healthy eating” means cutting out the bad, but not necessarily bringing in the good and/or new. Despite lack of statistical significance, the two patients who exhibited normalizing lab values, in combination with their improved HBI scores, suggest the possibility of a real and meaningful benefit from IBD-AID for those able to comply with the dietary and lifestyle changes. In terms of the diet’s feasibility, the considerable loss to follow-up in this study may reflect a variety of issues, one of which may be the well-established medical and psychosocial complexity of IBD patients. This element is important for clinicians to keep in mind, and reflects the need for additional support and close follow-up when it comes to facilitating lifestyle change in this population. It also has implications for the diet itself, which should be re-examined to simplify or reframe in order to maximize generalizability and access for a greater percentage of IBD patients. Overall, this small study highlights the need for larger-scale research to draft clinical nutrition guidelines and further legitimize the utility of preventive clinical nutrition in Western medicine

Neighborhood Differences in the Availability of Healthy Foods in the City of Worcester

INTRODUCTION. Neighborhood food environment is important to healthy eating. The availability and proximity of healthy foods has been shown to affect dietary quality, obesity, and overall health. We surveyed food stores throughout City of Worcester to assess the variability of food availability in neighborhoods and inequalities in access to fresh produce, unprocessed foods, and other healthy food options by neighborhood socioeconomic status (N-SES). METHODS. Where permitted by the store manager, the Community Nutrition Environment Evaluation Data Systems (C-NEEDS) survey was completed inside the store by trained staff. Healthy Food Availability Index (HFAI; range 0-56) and Unhealthy Food Availability Index (UFAI; range 0-39) were calculated for each store. Higher HFAI indicates higher availability of healthy food items, and higher UFAI indicates high availability of unhealthy foods. Median household income and car ownership data were derived at the census tract level as measures of N-SES using the 2013 US Census American Community Surveys 5-Year estimates. RESULTS. Convenience stores (mean HFAI 7.9, UFAI 21.1) had lower availability of both healthy and unhealthy foods than grocery stores (HFAI 32.4, UFAI 29.8). However, convenience stores had a higher proportion of unhealthy foods to healthy foods. Neighborhoods with lower median income and car ownership had a greater density of convenience stores. Neighborhoods with higher SES and car ownership had less access to convenience stores. Grocery stores in higher SES neighborhoods had more healthy food options. DISCUSSION. These results demonstrate that residents in lower SES neighborhoods may be disadvantaged when it comes to availability of healthy foods. These neighborhoods have higher density of convenience stores that may promote an unhealthy eating environment. Residents in these neighborhoods may wish to make healthy choices, but without access to a car may be unable or unwilling to walk to the nearest store where healthy alternatives are available

Position of the American Dietetic Association: total diet approach to communicating food and nutrition information

It is the position of the American Dietetic Association that the total diet or overall pattern of food eaten is the most important focus of a healthful eating style. All foods can fit within this pattern, if consumed in moderation with appropriate portion size and combined with regular physical activity. The American Dietetic Association strives to communicate healthful eating messages to the public that emphasize a balance of foods, rather than any one food or meal. Public policies that support the total diet approach include the Dietary Guidelines for Americans, MyPyramid, the DASH Diet (Dietary Approaches to Stop Hypertension), Dietary Reference Intakes, and nutrition labeling. The value of a food should be determined within the context of the total diet because classifying foods as good or bad may foster unhealthful eating behaviors. Alternative approaches may be necessary in some health conditions. Eating practices are dynamic and influenced by many factors, including taste and food preferences, weight concerns, physiology, lifestyle, time challenges, economics, environment, attitudes and beliefs, social/cultural influences, media, food technology, and food product safety. To increase the effectiveness of nutrition education in promoting sensible food choices, food and nutrition professionals should utilize appropriate behavioral theory and evidence-based strategies. A focus on moderation and proportionality in the context of a healthful lifestyle, rather than specific nutrients or foods, can help reduce consumer confusion. Proactive, empowering, and practical messages that emphasize the total diet approach promote positive lifestyle changes

Treatment of Rheumatoid Arthritis with Marine and Botanical Oils: Influence on Serum Lipids

The gap in mortality between patients with rheumatoid arthritis (RA) and the general population (1.5–3.0 fold risk) is increasing. This disparity is attributable mainly to cardiovascular disease (CVD), as the CVD risk is comparable to patients with diabetes mellitus. The purpose of this study is to determine whether borage seed oil rich in gamma-linolenic acid, fish oil rich in eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), or the combination of both oils are useful treatments for dyslipidemia in patients with RA. We randomized patients into a double blind, 18 month trial. Mixed effects models were used to compare trends over time in serum lipids. No significant differences were observed between the three groups: All three treatment groups exhibited similar meaningful improvement in the lipid profile at 9 and 18 months. When all groups were combined, these treatments significantly reduced total and LDL-cholesterol and triglycerides, increased HDL-cholesterol, and improved the atherogenic index. All improvements observed at 9 months persisted at 18 months (P < 0.001 verses baseline). Conclusion. Marine and botanical oils may be useful treatment for rheumatoid arthritis patients who are at increased risk for cardiovascular disease compared to the general population

Treatment of Rheumatoid Arthritis with Marine and Botanical Oils: Influence on Serum Lipids (poster)

Background: Over the past 30 years substantial progress has been made in the medical and surgical management of patients with rheumatoid arthritis (RA). Despite this progress, there is an increasing gap in mortality between patients with RA (1.5-3.0 fold risk) and the general population. This disparity is mainly attributable to cardiovascular disease (CVD) as the CVD risk is comparable in RA patients as to patients with diabetes mellitus. Although the reasons for this gap are not entirely clear, the traditional risk of abnormalities in lipid profiles appears to be enhanced by a chronic increase in inflammatory cytokines, resulting in accelerated atherosclerosis. Study Objective: The object of this study was to determine the effect of marine (fish oil) and botanical oils (borage oil) on lipids (TC, HDL, LDL, TG), a risk factor for cardiovascular disease in patients with RA. The main outcome (to be presented elsewhere) was to determine whether a combination of borage seed oil rich in gammalinolenic acid (GLA) and fish oil rich in eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) is superior to either oil alone for the treatment of RA. Population and Setting: The study was an 18 month randomized, double-masked comparison of borage seed oil, fish oil, and the combination of both oils in RA patients with active synovitis. Intervention: Patients received 3.5 gm omega-3 fatty acids daily in a 2.1gm EPA/1.4 gm DHA ratio (7 fish oil and 6 sunflower oil capsules daily); or 1.8 gm /d GLA (6 borage oil and 7 sunflower oil capsules /d); or 7 fish oil and 6 borage oil capsules daily (combination therapy). Discussion: Rheumatoid Arthritis (RA) is a chronic systemic inflammatory disease. Mediators of inflammation and prothrombotic factors contribute to endothelial dysfunction and development of cardiovascular disease in RA patients. Marine and botanical oils represent an excellent primary or secondary therapy for improvement of the cardiovascular risk management in RA. Patients taking these oils exhibit significant additional reductions in total and LDL-cholesterol, triglycerides, the TC/HDL ratio, and in the atherogenic index, and experience a significant increase in HDL-cholesterol. All of these improvements in the lipid profile were seen after 9 months of therapy, and increased after 18 months of oils administration. The overall dropout rate was 51%, and was similar across groups: 25 in the borage oil group, 28 in the fish oil group, and 22 in the combination group. Reasons for dropout were mainly gastrointestinal distress (belching, bloating, diarrhea, nausea, cramping), or an inability to swallow the large number of rather sizable capsules. This can be ameliorated by freezing the capsules and reducing their size. Among those evaluated for this study, compliance was 100%, assessed by pill counts. Learning Outcome: All treatments were safe, thus treatment of RA patients with one or a combination of these or similar oils should prove useful for reduction of cardiovascular risk in RA patients

Healthy Food Accessibility in Grocery Stores in Central Massachusetts

BACKGROUND. Accessibility to healthy food is one of the most influential community-level factors affecting obesity and chronic disease. The Community Nutrition Environment Evaluation Data System (C-NEEDS) is a set of instruments for objectively assessing availability and quality of 61 major healthy and unhealthy food items in foods stores in the Northeast region. METHODS. The C-NEEDS was developed considering seasonal variations, cultural relevance and utility to cardiovascular health research. Both inter- and intra-rater reliability tests showed a high degree of agreement. Using the instruments, we conducted four rounds of longitudinal surveys of 107 grocery stores in Worcester County, Massachusetts between 2007 and 2010. A healthy food availability index (HFAI, 0-37 points) was calculated for each store, a higher score indicating a greater availability and better quality of healthy foods. Using linear regression models, we examined variations in HFAI in relation to community household income and housing density. RESULTS. Store-level HFAI did not vary significantly by tertile of community median income, but did vary by housing density. High-density communities (upper tertile) had the greatest percentage of stores in the top HFAI tertile (34-37 points). Middle-density communities had the greatest percentage of stores in the low HFAI tertile (0-17 points). A majority of the stores located in low-density communities had middle range of HFAI (18-33 points). The mean HFAI increased with each successive round of grocery store surveys (β=2.02/round [95% confidence interval 0.74-3.31]). CONCLUSION. Access to healthy foods improved slightly over time, however, notable disparities still existed in Central Massachusetts during the study period. Better access was associated with community housing density but not median household income. Further studies on the causes of the disparities may inform public health organizations about necessary community actions to reduce these disparities

An anti-inflammatory diet as treatment for inflammatory bowel disease: a case series report

BACKGROUND: The Anti-Inflammatory Diet (IBD-AID) is a nutritional regimen for inflammatory bowel disease (IBD) that restricts the intake of certain carbohydrates, includes the ingestion of pre- and probiotic foods, and modifies dietary fatty acids to demonstrate the potential of an adjunct dietary therapy for the treatment of IBD. METHODS: Forty patients with IBD were consecutively offered the IBD-AID to help treat their disease, and were retrospectively reviewed. Medical records of 11 of those patients underwent further review to determine changes in the Harvey Bradshaw Index (HBI) or Modified Truelove and Witts Severity Index (MTLWSI), before and after the diet. RESULTS: Of the 40 patients with IBD, 13 patients chose not to attempt the diet (33%). Twenty-four patients had either a good or very good response after reaching compliance (60%), and 3 patients\u27 results were mixed (7%). Of those 11 adult patients who underwent further medical record review, 8 with CD, and 3 with UC, the age range was 19-70 years, and they followed the diet for 4 or more weeks. After following the IBD-AID, all (100%) patients were able to discontinue at least one of their prior IBD medications, and all patients had symptom reduction including bowel frequency. The mean baseline HBI was 11 (range 1-20), and the mean follow-up score was 1.5 (range 0-3). The mean baseline MTLWSI was 7 (range 6-8), and the mean follow-up score was 0. The average decrease in the HBI was 9.5 and the average decrease in the MTLWSI was 7. CONCLUSION: This case series indicates potential for the IBD-AID as an adjunct dietary therapy for the treatment of IBD. A randomized clinical trial is warranted