Recent studies reveal enlightening insights into the interaction between gut health and systemic inflammatory conditions. Researchers at the Centro Nacional de Investigaciones Cardiovasculares (CNIC) in Madrid, Spain have discovered how disruptions to the intestinal barrier allow gut bacteria to trigger epigenetic changes in immune stem cells, resulting in both enhanced infection resistance and exacerbation of inflammatory diseases (Robles-Vera, et al., 2025).1 These findings significantly improve our understanding of the gut-immune system axis and its implications for health. The researchers found that:
Mincle (also known as Clec4e or Clecsf9), is a type of receptor protein found on the surface of immune cells such as macrophages and dendritic cells, for example. It's a C-type lectin receptor, meaning that it binds to carbohydrates. Mincle is an innate immune receptor on myeloid cells (immature white blood cells that originate in the bone marrow). It senses molecular patterns associated with pathogens, and molecular patterns associated with damage, (molecules associated with pathogens or damaged cells). Mincle's activation triggers the release of cytokines and other immune molecules that help mediate the immune response. But they also found that: While trained immunity enhances protection against bacterial, viral, and fungal infections, it also exacerbates inflammatory conditions such as:
It's well-known that: Poor diet, chronic stress, alcohol consumption, and certain medications can weaken the gut barrier, promoting bacterial translocation and systemic inflammation. And other research shows that: A healthy diet can maintain a healthy gut microbiota, reducing inflammation and mitigating chronic disease risks. The implications of this discovery suggest that: Blocking Mincle could be a promising strategy to prevent or reduce inflammation in diseases associated with gut permeability, such as colitis and cardiovascular conditions. The discovery that innate immunity can be trained redefines its role in health and disease. This finding opens avenues for novel treatments that utilize trained immunity, and underscores the far-reaching influence of gut health on systemic diseases, emphasizing the importance of a holistic approach to managing chronic conditions. In the meantime, our best strategy for maintaining gut health primarily depends on maintaining gut barrier integrity, and this can be achieved by:
Conclusions: This research highlights the delicate balance of the gut-immune axis. While trained immunity provides robust protection against infections, it comes at the cost of heightened inflammatory responses. Understanding this duality could lead to innovative treatments for inflammatory diseases, with lifestyle modifications playing a critical role in prevention. These findings emphasize the importance of gut health as a cornerstone of systemic well-being. Reference: 1. Robles-Vera, I., Jarit-Cabanillas, A., Brandi, P., Martínez-López, M.,Martínez-Cano, S., Rodrigo-Tapias, M., . . . Sancho, D. (2025). Microbiota translocation following intestinal barrier disruption promotes Mincle-mediated training of myeloid progenitors in the bone marrow. Cell Immunity, Retrieved from https://www.cell.com/immunity/fulltext/S1074-7613(24)00577-6
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Many microscopic colitis (MC) patients put their disease into remission by following an elimination diet. And most of us find that following a meticulous elimination diet is not much fun, to say the least. But persevering can bring remission of the clinical symptoms of the disease without a need for any prescription drugs. And although no one enjoys the process, once accomplished, it can bring a powerful sense of self-satisfaction and self-reliance. And most importantly, it allows the symptoms of the disease to be completely controlled without any need for powerful and expensive medications. Recently, as reported in an online article on the Gastroenterology & Endoscopic News website, a panel of gastroenterology experts speaking at the 2025 ASPEN Nutrition Science & Practice Conference issued strong cautions about the broad use of elimination diets across gastrointestinal (GI) disorders — a perspective that may affect how physicians approach dietary therapy in MC in the future (Starr, 2025, June 2).1 The panel acknowledged the clinical value of elimination diets in certain GI conditions such as eosinophilic esophagitis (EoE) and irritable bowel syndrome (IBS). But they focused on numerous caveats regarding the use of elimination diets when treating IBD. They pointed out that while these diets have demonstrated "high rates of histologic and symptomatic response", especially when closely monitored and tailored to individual needs, they also emphasized that:
This perspective is highly relevant to MC, where patients often adopt elimination diets to identify triggers such as gluten, dairy, soy, eggs, supplements and even certain medications. Many of us have not only seen dramatic symptom improvement when the responsible triggers are removed from our diet, but we've been able to keep our symptoms in remission by continuing to follow diet restrictions. And although this medical advisory should prove to be helpful in future treatments, that's not guaranteed, because of all the caveats mentioned, and the fact that IBD treatments involving diet changes typically lack validation through controlled trials. Without such evidence, most clinicians are skeptical. While MC was not specifically mentioned during the ASPEN panel, the medical community’s general cautionary stance on elimination diets carries indirect but important implications for how such diets are perceived and prescribed in the care of MC patients. The panel acknowledged that elimination diets, including elemental and multi-food elimination regimens, can be highly effective, but they also pointed out that patient adherence over time tends to be poor. As we are well aware, many MC patients report long-term adherence due to symptom relief, but most of us also struggle with the emotional, social, and nutritional challenges of maintaining a restricted diet. Unlike EoE or IBS, where elimination diet outcomes are supported by growing bodies of research, MC continues to be underrepresented in dietary studies. The absence of randomized controlled trials or guidelines specifically validating elimination diets for MC may cause clinicians to hesitate in recommending them, despite patient-reported success stories. The panel urged clinicians to screen for avoidant/restrictive food intake disorder (ARFID) and other “disordered eating behaviors” before initiating restrictive diets. This is particularly relevant in MC, where prolonged gastrointestinal distress can relatively quickly disrupt our eating habits. But a growing trend is developing. Gastroenterologists seem to be increasingly trying to label the use of self developed elimination diets by IBD patients as "eating disorders" that should be treated by psychologists. This is an issue I've written about previously, where gastroenterologists try to blame diet changes by IBD patients (without medical guidance) on psychological issues, when the changes are actually made in order to prevent (or at least minimize) clinical symptoms of IBD (Persky, 2025, April 1).2 Gastroenterologists are increasingly expected to collaborate with dietitians and pharmacists to ensure that elimination diets are nutritionally sound and psychologically safe. For MC patients, many of whom self-direct dietary interventions due to limited clinical guidance, this means a growing need for formalized support from GI nutrition teams, rather than relying solely on trial-and-error. But although most clinicians are actually concerned about patient welfare, from the patient's point of view, policies such as this typically result in increased medical expenses, because it adds a need to see additional specialists, and a need to schedule additional healthcare appointments. Celiacs went through a similar cycle a decade or so ago. Such cautionary advisories are reminiscent of "warnings" that gastroenterologists have issued in the past regarding the proliferation of celiac patients treating themselves by following a gluten-free diet, rather than seeking an official celiac diagnosis. Most of us can remember what happened a couple of decades ago when the medical profession noticed that many celiac patients were "self treating" by adopting a gluten-free diet without an official medical celiac diagnosis. As the trend became increasingly popular, gastroenterologists began to issue more frequent advisories in an attempt to discourage the trend. Gastroenterologists began formally and consistently warning against self-treating celiac disease without a medical diagnosis around the late 2000s to early 2010s, with a significant increase in published warnings and clinical guidance between 2012 and 2015. Why did this trend (to self-treat) develop? Despite advances in awareness and diagnostics, a search of the literature shows that multiple studies have concluded that a realistic and evidence-backed estimate is that only 15% to 30% of people with celiac disease have been correctly diagnosed by the medical profession. This widespread underdiagnosis has led many individuals to self-identify through dietary trials — a fact that helps explain both the popularity of gluten-free diets, and the resistance from medical authorities who are taught to only recognize evidence validated by official medical tests, or official medical trials. The sad truth is, many of the warnings from gastroenterologists and medical organizations about not adopting a gluten-free diet without an official celiac diagnosis, while rooted in legitimate clinical concerns, can often impose unreasonable hardships on patients. Patients seek relief, not a label. Most people who adopt a gluten-free diet do so because they feel better, not because they’re chasing a diagnosis. For individuals suffering from chronic diarrhea, fatigue, joint pain, brain fog, or other inflammatory symptoms, the relief that comes from eliminating gluten can be profound and life-changing. And from the patient’s perspective, why should they continue eating something that clearly makes them sick, just so they can be told officially that it’s the thing making them sick? Of course this undermines the medical argument that testing must precede dietary change, especially when that testing requires ongoing gluten exposure, which may be intolerable or debilitating. After all, an official celiac diagnosis doesn't change the treatment. Celiac disease is treated exclusively through diet. There is no medication or surgical cure. Whether a person has celiac disease, non-celiac gluten sensitivity (NCGS), or undiagnosed microscopic colitis that improves when gluten is totally avoided, the clinical advice is the same: avoid gluten. So, from the patient’s standpoint, the expensive and invasive diagnostic process can seem like an unnecessary formality that doesn’t alter their course of action. A gluten challenge is a rather barbaric diagnostic procedure. Medical guidelines often require a patient to consume gluten daily for weeks before testing to avoid false negatives. However, for patients who already know gluten causes severe symptoms (neurological, gastrointestinal, or autoimmune flares), this can feel ethically and physically unreasonable. And unfortunately, many gluten challenges don't allow sufficient time for an adequate level of damage to develop to qualify for a celiac diagnosis, due to the relatively strict celiac diagnostic criteria (a minimum of a Marsh 3 level of damage). Patients rightly ask: “Why should I make myself sick for six weeks just to prove what I already know?” “Would a doctor ask a peanut-allergic person to eat peanuts just to confirm it in a lab?” This creates a dilemma for medical professionals. Many of the warnings against self-diagnosis carry undertones of professional gatekeeping. Doctors, particularly in gastroenterology, may feel that widespread self-diagnosis undermines their role in managing chronic GI conditions. Some see this as part of a broader pattern in which the medical community resists patient-driven health solutions unless they flow through institutional channels. Furthermore, celiac disease diagnosis typically leads to long-term specialist follow-ups, which generates revenue streams for lab testing, procedures (like endoscopy), and monitoring services, thereby aligning with financial incentives in the medical system. To add insult to injury, the diagnostic testing is often inadequate. Currently available celiac disease tests are far from perfect. Many patients with early-stage or patchy intestinal damage test negative on biopsy or have borderline antibody levels, especially if they've already begun reducing gluten. Serological tests (like anti-tTG or EMA) can be unreliable in patients with IgA deficiency, other autoimmune diseases, or mild mucosal damage. This means patients who do pursue testing may still be told “everything looks normal,” despite obvious gluten-related symptoms, and then they're discouraged from continuing a diet that helps them. And while clinicians don't seem to be concerned about counterproductive mistakes such as this, to patients in such a situation, this is nothing less than disastrous. Same song, second verse: This new advisory (warning) regarding the use of elimination diets for treating various gastrointestinal issues appears to have only slightly more merit than the previous warnings about adopting a gluten-free diet without an official celiac diagnosis. True, elimination diets can eventually lead to vitamin or mineral deficiencies, or some unforeseen consequence, but in reality, that possibility is almost surely no worse than allowing the gastrointestinal symptoms to continue without making the diet changes. After all, despite the often misguided attempts by gastroenterologists to disguise diet changes made to reduce clinical symptoms as eating disorders, most people probably understand the clinical symptoms of their digestive disorders better than their gastroenterologists. And most people certainly have adequate intelligence to take countermeasures with their diet (by eating alternate nutrient rich foods) or taking supplemental vitamins and minerals in order to make up for any vitamin or mineral deficiencies that might develop. Unfortunately, most practitioners don't seem to test often enough (if ever) for the most vital minerals and vitamins needed by IBD patients, anyway. So what can we conclude from all this? The continued issuance of medical advisories from the medical community, against patient initiated diet changes, may be evidence of a basic problem with the system — the healthcare system appears to primarily focus on the needs of the healthcare system, when it should be primarily focusing on the needs of patients. And additionally, a troubling side effect of advisories such as this can be seen in the bias displayed against using dietary changes to treat disease, and a continuing failure by researchers to produce the research data needed to validate elimination diets. Clinicians are generally discouraged from prescribing diet changes in general, unless they take all sorts of precautions first, despite the fact that diet changes are probably the safest way to treat any digestive disorder (compared with typical conventional medical interventions). A major hang up in this entire process is the fact that no one wants to finance the needed research to prove the value of elimination diets. Most research is funded by big Pharma, but they're certainly not going to finance research that doesn't require the use of expensive drugs. And with the recent cuts in government funding, there doesn't appear to be much hope that this research will be done anytime soon. References: 1. Starr, M. (2025, June 2). Elimination Diets Call for Caution and Adaptation. Gastroenterology & Endoscopic News, Retrieved from https://www.gastroendonews.com/PRN/Article/05-25/Elimination-diets-GI-disorders/77083 2. Persky, W. (2025, April 1) My Doctor Says I Have an Eating Disorder. Do I? Microscopic Colitis Foundation Newsletter, Retrieved from https://www.microscopiccolitisfoundation.org/uploads/5/8/3/2/58327395/newsletter_april_2025.pdf
A search of the Internet shows that there has been a significant amount of research published regarding the prevalence of white coat syndrome (WCS), also known as white coat hypertension. This condition refers to the phenomenon where patients exhibit elevated blood pressure readings in a clinical setting, such as a doctor's office, but have normal blood pressure readings in other settings, such as at home. It's likely that many patients are misdiagnosed with hypertension. Clinicians typically would rather treat hypertension than not, since hypertension is known to lead to many health problems. They probably view it as a "safe" diagnosis, even if incorrect, since they consider the treatment to be safe, even if the patient doesn't actually have hypertension. Therefore many clinicians usually don't make any attempt to rule out white coat syndrome. But white coat syndrome is a common issue. Research indicates that the prevalence of white coat syndrome can vary widely, with estimates ranging from 15% to 40% of patients with elevated blood pressure readings in clinical settings (Mancia, Facchetti, Bombelli, Cuspidi, and Grassi, 2021).1 Factors contributing to the prevalence of WCS include anxiety, the patient's medical history, and the specific context of the medical visit. White coat syndrome tends to be more prevalent in younger individuals and those with higher levels of anxiety. It's also observed across various demographics, but the specific prevalence can vary based on factors such as age, sex, and overall health. Alternate methods can be used for monitoring blood pressure. Several studies have utilized ambulatory blood pressure monitoring (ABPM) to assess blood pressure variations in patients and have found that a notable percentage of individuals diagnosed with hypertension in a clinical setting may actually have normal blood pressure when measured outside of medical offices. When suspected, white coat syndrome should be ruled out by further testing. White coat syndrome can obviously complicate the diagnosis of hypertension, as it may lead to misclassification of individuals as hypertensive when they are not, and that never looks good on a patient's health record. Accurate diagnosis often requires repeated measurements or alternative monitoring methods. This condition highlights the impact of psychological factors on physical health, emphasizing the need for healthcare providers to consider patients' mental states (with regard to anxiety) during assessments. While it's suspected that white coat syndrome may be associated with cardiovascular issues, there are currently no research data to verify any cause/effect relationship. It's likely that if there is an association, is primarily due to the stressful effects of anxiety, since chronic stress is known to cause inflammation. And published research shows that inflammation (especially IL:-6) is associated with systolic blood pressure (Chae, Lee, Rifai, and Ridker, 2001).2 References: 1, Mancia, G., Facchetti, R., Bombelli, M., Cuspidi, C., and Grassi, G. (2021). White-Coat Hypertension: Pathophysiological and Clinical Aspects: Excellence Award for Hypertension Research 2020. Hypertension, 78(6), 1677–1688. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC9634724/ 2. Chae, C. U., Lee, R. T., Rifai, N., and Ridker, P. M. (2001). Blood Pressure and Inflammation in Apparently Healthy Men. Hypertension, 38(3). Retrieved from https://www.ahajournals.org/doi/10.1161/01.HYP.38.3.399
As more adults age with chronic conditions such as inflammatory bowel diseases, the 2025 American Geriatrics Society (AGS) Annual Scientific Meeting has revealed a new tool to help clinicians take safer, smarter, steps when it comes to prescribing medications for older patients. This was developed as a companion to the AGS Beers Criteria. The Beers Criteria Alternatives List highlights safer pharmacologic and non-drug alternatives to medications considered high-risk in older adults, as discussed in an online Medscape article (Salahi, 2025, May 15).1 Most MC patients are older. For seniors with microscopic colitis (MC), this development offers much-needed support, since MC is often treated with medications. Older adults are more vulnerable to side effects and drug interactions, and many commonly prescribed drugs are now flagged as inappropriate. According to Dr. Michael Steinman, a geriatrician, and professor of medicine at UCSF, who helped lead the initiative, the goal of the list is to improve both function and safety, not just to reduce pills. Older adults process drugs differently due to changes in metabolism, kidney function, and body composition—making adverse effects more common. We definitely need to avoid certain medications. For MC patients, chronic diarrhea already puts patients at risk for electrolyte imbalance and nutrient deficiencies. Commonly prescribed medications (like NSAIDs, PPIs, and SSRIs) can worsen MC symptoms or trigger flares. Polypharmacy (taking multiple medications) is common in seniors and further complicates management. The Beers Criteria flags many medications that may be dangerous for seniors, especially when safer alternatives are available. Some are particularly relevant to MC:
The Alternatives List developed by Steinman and colleagues goes beyond warning labels. It provides step-by-step substitutions, including:
For instance, instead of continuing long-term PPIs for acid reflux (often overprescribed in older adults), the list recommends:
Does that sound familiar? It should, because it's what we've been recommending for many years. Care should be personalized. Importantly, Steinman emphasized that this isn't a call to automatically stop medications, but rather to create individualized plans that involve the patient. That’s especially important for MC patients, who may be juggling:
The recommended changes won't happen overnight. Dr. Judith Beizer, a clinical professor of pharmacology at St. John’s University, underscored that implementation takes time, and requires team-based care:
For primary care physicians with limited time, the list is designed to be quickly referenced, and it will soon be published in:
MC patients should work with their providers.
Conclusion: The AGS Beers Criteria Alternatives List brings a much-needed update to the way clinicians approach medication safety for older adults — especially those managing an autoimmune disease such as MC. With targeted recommendations, safer substitutes, and a greater emphasis on individualized care, these long overdue recommendations for changes in treatment policies should reduce the risks of overmedication while preserving quality of life. Reference 1. Salahi, L. (2025, May 15). The New Playbook for Ditching Dangerous Senior Meds. Medscape. Retrieved from https://www.medscape.com/viewarticle/new-playbook-ditching-dangerous-senior-meds-2025a1000c0r
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December 2025
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