Abstract
Robynne Chutkan, MD, FASGE, Assistant Professor of Medicine, Department of Gastroentrology, Georgetown MedStar Hospital, Washington DC, and Founder of the Digestive Center for Wellness, Washington DC, is passionate about the need for an integrative approach to digestive care. In this column, Dr. Chutkan explains the gut-immune connection and the fact that many clinicians are unaware of how treatment choices for patients may have adverse effects on a person's gut—increasing the risk for illness and disease. An expert in inflammatory bowel disease treatment, she describes the importance of lifestyle behaviors and how they significantly affect gut health.
Medications can significantly affect GI health. A large national health survey in 2020, involving 53,000 participants demonstrated that people taking proton pump inhibitors once daily had double the risk of developing COVID and an increased risk in severity of disease. 1 Despite important data like this, many clinicians are not aware of the connections. We have to understand all the various factors that make us more susceptible to COVID and other infections.
As clinicians, we have to connect the dots between the gut and the rest of the body so that we can adequately address a person's health issues. What's going on in the gut may not be the only cause but it is often an important contributor. An integrative approach takes into account this interconnectedness between the gut and the immune system, the brain, the cardiovascular system, and other bodily processes.
When things in the gut are disrupted and the microbiome becomes imbalanced, we have to examine the repercussions in other areas of the body. Increasing evidence demonstrates a connection between overuse of antibiotics in childhood and development of autoimmune disease. If a rheumatologist doesn't fully understand the role of excessive antibiotic use and poor diet on autoimmune diseases when seeing patients, a critical opportunity to help people is missed. A pharmaceutical only approach is not always enough to get people to the finish line.
In addition, patients often want to know what else they can do to improve their health besides take prescription medications, and many are demanding a more integrative approach.
I enjoyed my almost 10 years as full-time faculty at Georgetown. I had great colleagues and helped to grow the IBD clinic and services for patients. But I also became very interested in nutrition and the impact of diet and lifestyle on GI diseases.
Academic centers often take a more conventional approach to GI disorders, with a strong focus on procedures and medications. In addition, clinic visits tend to be short, and there wasn't much capacity for discussing the things I wanted to explore with my patients such as the impact of diet and lifestyle. There was an overwhelming interest from patients, but I wasn't able to create those resources for patients within the confines of an academic GI practice at the time. So, in 2004, I opened my private practice, the DCW.
I opened DCW with the goal of creating a more innovative and integrative approach to digestive health that would incorporate these elements of diet and lifestyle that I had seen firsthand were so important and that patients were expressing a strong desire for. Starting out, I had a biofeedback practitioner who worked with my patients, and I had nutritionists and health coaches on staff and a massage therapist. With this team, I really felt like we were able to cover some important areas for GI care. The practice has continued to evolve to address habits that we now know can be important for people with acute and chronic symptoms. In addition to nutrition, we pay attention to things like sleep and stress management, exercise, and exposure to nature—all factors that have been shown to affect the immune system and are especially important in people struggling with autoimmune diseases. This approach has been very well-received by patients. I've continued some involvement in academic life, teaching fellows and having medical students rotate with me, however, I'm grateful to be able to practice gastroenterology in a model that aligns with my beliefs.
There is a strong connection between gut health and sleep hygiene. Vaccines are less efficacious if people are sleep deprived two days before receiving the hepatitis, influenza, and COVID vaccines and we know from a British Medical Journal article published in 2021 that people with chronic sleep problems have a significantly increased risk of COVID. 2
It is common practice for clinicians to give an antipyretic when a person has a fever, but fever is both a signal from your body to alert you that it's fighting something, and part of its protective mechanism. Most viruses stop replicating at high temperatures, so fever is an important way for one's body to prevent further attack and damage. The replication rate of poliovirus at normal body temperatures is 250 times higher than at an elevated temperature of 104°F—a clear example of host defenses working to stop the spread of the virus within the body. The reality is that when one battles a virus and reaches for a pharmaceutical agent to lower one's temperature, he or she is actually sabotaging one of the most important—and most potent—anti-viral weapons. I'm not suggesting that one should never treat a fever, but I am suggesting that we think carefully before reaching for some of these pharmaceuticals aids that can sometimes end up being more hindrance than help.
I try to balance patient expectations and tell them that sometimes in order to be well you have to be a little sick. It is important to understand how these defenses work and counsel patients about how what they might be doing could be sabotaging those defenses and making them more susceptible.
Diet also really matters, and the statistics for what Americans are eating are pretty disturbing. We know that on a weekly basis 3 out of 4 people don't eat a single piece of fruit a day, 9 out of 10 people don't reach the minimum intake of vegetables, and only 1% consume the recommended amount of unprocessed whole grains. We are eating in a way that makes us more susceptible to disease.
The 2018 American Gut Project data showed that the most important predictor of a healthy microbiome was the number of different plant foods people ate. Consumption of 30 or more different plants per week was associated with a healthier microbiome compared to eating less than 10. And although 30 may sound like a lot, that includes vegetables, fruits, nuts, seeds, legumes, whole grains, herbs, and spices, so there's a lot to choose from.
To Contact Dr. Robynne Chutkan
Robynne Chutkan, MD, FASGE
Assistant Professor of Medicine, Department of Gastroentrology, Georgetown MedStar Hospital, Washington DC
Founder, Digestive Center for Wellness, Washington DC
Website:
I have a 1, 2, 3 rule that I recommend to patients: 1 vegetable at breakfast, 2 vegetables at lunch, 3 vegetables at dinner, so that by the end of the day you've consumed six servings of vegetables.
I have helped patients with complicated Crohn's disease and UC get off biologics and steroids and into remission through my integrative approach. These drugs are fraught with undesirable side effects; steroids independently have a higher risk of death than the disease itself. So being able to help my patients in this way makes me feel like I'm doing something meaningful.