Treatment by diet changes
Anti-inflammatory medications may be ineffective against drug-induced MC. In fact, in some cases just stopping the use of the medication that causes the inflammation may be sufficient to bring remission without any need for further intervention. Similarly, in some cases anti-inflammatory medications may be unable to overcome the inflammation generated with each meal by inflammatory foods as long as major food sensitivities remain in the diet.
Many microscopic colitis patients have been able to control their symptoms and get their life back by modifying their diet. This can be done by removing from their diet all foods that cause their immune system to produce antibodies that can be detected by IgA-based stool tests, avoiding raw fruits and vegetables, and by restricting their intake of fiber, sugar, artificial sweeteners, acidic foods, and spicy foods. The most common foods that cause the immune system to produce antibodies are gluten, casein (the primary protein in all dairy products), soy, and eggs, usually in that order. Not all MC patients are sensitive to all of those foods, but many are, and some are sensitive to additional foods. Unprocessed whole foods, such as those on the plate shown here, will not only allow healing, but they are much healthier choices in most cases.
For decades, many gastroenterologists have claimed that diet has no effect on microscopic colitis, and presumably this mistaken claim is based on an unfortunate lack of definitive research data. But just because no researchers have developed a valid research program to investigate the concept of diet control for MC certainly does not mean that treatment by diet changes is not practical. No researchers have ever proven that MC cannot be controlled by diet changes, either. But because GI specialists have no data on which to dispute dietary treatments, fewer of them are still clinging to that outdated viewpoint today. More and more gastroenterological departments at major hospitals are beginning to accept the gluten-free diet as a part of their recommended treatment program for microscopic colitis patients, according to the information posted on their websites. Even the Mayo Clinic website now recommends the gluten-free diet as part of their self-management treatment program for microscopic colitis.
While some patients are able to tolerate the use of certain probiotic products, most MC patients find that probiotic or prebiotic products in general either do not help to bring remission or they make the situation worse by actually contributing to the reaction. Therefore as a general rule, most MC patients are better off without them, at least in the early stages of treatment. Whether or not they are useful at a later stage in the treatment is open to debate.
Microscopic colitis is associated with increased intestinal permeability (aka leaky gut syndrome).
Researchers have shown that gluten causes increased intestinal permeability for everyone, not just for celiacs (Drago, et al., 2006).1 Over time, with continued regular exposure to gluten, intestinal permeability worsens. At some point the condition may become significant enough that certain peptides are able to pass through the tight junctions into the bloodstream. Peptides are short to medium-length amino acid chains resulting from the incomplete digestion of certain protein molecules, such as gluten and casein. This happens because the tight junctions are open wider than normal and they remain open longer than normal.. Normally the tight junctions only open wide enough to allow nutrients in the form of individual amino acids to pass through and then they close after the opportunity to absorb nutrients has passed.
But when peptides are able to pass through the tight junctions into the bloodstream, the immune system immediately recognizes that those peptides shouldn't be there, so it marks them as foreign invaders and begins to produce antibodies against them. This primes the immune system so that the next time those peptides appear in the blood, antibody production will be stepped up and an assortment of inflammatory agents will be released in an attempt to destroy the invaders. With repeated exposures, this leads to a condition where anytime that particular protein is identified within the digestive system, an immune system reaction against it is triggered.
This is part of the adaptive immune system, the same system that provides immunity to a disease in response to a vaccine. A vaccine prompts the immune system to begin producing antibodies against a specific pathogen so that in the future, any exposure to that pathogen will result in a flood of antibodies that promote the release of additional immune system defense mechanisms designed to destroy the pathogen before it can become well established.
The lymphocytes (white blood cells) that infiltrate the mucosal lining of the colon as lymphocytic (microscopic) colitis develops are one example of an immune system response to the production of antibodies. Ingestion of a food that prompts the production of IgA antibodies in the intestines leads to increased lymphocyte infiltration into the mucosal lining of the intestines. The lymphocytes are sent to destroy the perceived threat created by the peptides that are leaking into the bloodstream. But since these white cells are designed to kill pathogens, they are inneffective at destroying the peptides (which are not actually pathogens and are not alive) and unable to prevent them from entering the bloodstream.
Lymphocytes cause inflammation, but normally this is only a temporary condition because after the pathogens that were the target of the attack have been destroyed, the inflammation fades away as the populations of T cells, cytokines, macrophages, and various other immune system defenses decline and return to normal levels. But when the attack has been triggered because of food sensitivities, it can never end, unless diet changes are made to stop the production of antibodies by avoiding the foods that trigger the antibody production. Without diet changes, microscopic colitis tends to be self-perpetuating. A similar situation exists with drug-induced MC. As long as a drug that promotes the production of antibodies continues to be used, the resulting inflammation will continue to be produced and the clinical symptoms will be perpetuated.
This is the reason why foods that a patient has been eating for many years without any issues can suddenly begin to cause major digestive system problems. And unfortunately, the type of gluten sensitivity that typically occurs with MC is not normally detected by the blood tests used by physicians to detect celiac disease. The mainstream medical community has no officially-approved medical tests available for detecting non-celiac gluten sensitivity. Therefore, unless they are willing to order the stool tests from EnteroLab, physicians have no way to detect the type of gluten sensitivity that MC patients typically have, nor any of the other food sensitivities, for that matter, unless the patients happen to be allergic to those foods (which is an entirely different type of reaction).
Treating the disease by making diet changes can be done with or without the use of medications.
While some MC patients are lucky enough to respond promptly to diet changes, it can take weeks or months in some cases for the intestines to heal enough to bring significant improvement. Kids tend to heal quickly, but adults take much longer, because increasing age slows down the healing process. Consequently, some patients take a medication to help mask their symptoms while the diet changes heal the gut. Unfortunately the medications most commonly used to treat the disease do not actually heal the intestines. In fact, research shows that the corticosteroids for example, actually retard healing. Medications only treat the symptoms, so soon after treatment with a medication is discontinued, symptoms typically return. By making appropriate diet changes, it's possible to prevent the inflammation from being produced in the first place, and this allows the gut to heal. It should also be noted that because anti-inflammatory medications tend to mask food sensitivities, their use can make identifying food sensitivities more difficult. Therefore, when an anti-inflammatory medication is used concurrently with diet changes, it may be necessary to make diet adjustments as the medication dosage is tapered.
It takes a long time for inflammation-damaged intestines to heal.
Kids heal relatively quickly, and they often heal in a year or less, but it typically takes adults much longer to heal, usually in the range of 2–3 years for complete healing, and in some cases it can take longer. After remission is achieved, and a significant amount of intestinal healing has occurred, depending on age, amount of damage, and immune system health, more normal levels of fiber and sugar, and raw fruits and vegetables may be slowly reintroduced into the diet. This is best done by reintroducing 1 food at a time, for 3 days, starting with a small serving, and increasing the serving size each day. If no reaction is apparent after 3 days, then the food can usually be assumed to be safe, and can remain in the diet.
Reliable stool testing can save a lot of trial and error testing to discover food sensitivities.
Currently, the only laboratory in the world that seems to offer accurate and reliable stool testing for food sensitivities is EnteroLab, located in Dallas, TX. While numerous labs offer blood tests or other testing methods for the detection of food sensitivities, the combined experience of many, many MC patients shows that in general, those tests are typically less sensitive and less reliable than the stool tests offered by EnteroLab. The antibodies are produced in the intestines, and therefore they are concentrated in the stool, rather than in the blood, or any other medium used for testing purposes. Only a relatively small fraction of the antibodies end up in the blood, making their detection there more difficult.
1. Drago, S., El Asmar, R., Di Pierro, M., Grazia, C. M., Tripathi, A., Sapone, A., . . . Fasano, A. (2006). Gliadin, zonulin and gut permeability: Effects on celiac and non-celiac intestinal mucosa and intestinal cell lines. Scandinavian Journal of Gastroenterology, 41(4), 408–19. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16635908
Many microscopic colitis patients have been able to control their symptoms and get their life back by modifying their diet. This can be done by removing from their diet all foods that cause their immune system to produce antibodies that can be detected by IgA-based stool tests, avoiding raw fruits and vegetables, and by restricting their intake of fiber, sugar, artificial sweeteners, acidic foods, and spicy foods. The most common foods that cause the immune system to produce antibodies are gluten, casein (the primary protein in all dairy products), soy, and eggs, usually in that order. Not all MC patients are sensitive to all of those foods, but many are, and some are sensitive to additional foods. Unprocessed whole foods, such as those on the plate shown here, will not only allow healing, but they are much healthier choices in most cases.
For decades, many gastroenterologists have claimed that diet has no effect on microscopic colitis, and presumably this mistaken claim is based on an unfortunate lack of definitive research data. But just because no researchers have developed a valid research program to investigate the concept of diet control for MC certainly does not mean that treatment by diet changes is not practical. No researchers have ever proven that MC cannot be controlled by diet changes, either. But because GI specialists have no data on which to dispute dietary treatments, fewer of them are still clinging to that outdated viewpoint today. More and more gastroenterological departments at major hospitals are beginning to accept the gluten-free diet as a part of their recommended treatment program for microscopic colitis patients, according to the information posted on their websites. Even the Mayo Clinic website now recommends the gluten-free diet as part of their self-management treatment program for microscopic colitis.
While some patients are able to tolerate the use of certain probiotic products, most MC patients find that probiotic or prebiotic products in general either do not help to bring remission or they make the situation worse by actually contributing to the reaction. Therefore as a general rule, most MC patients are better off without them, at least in the early stages of treatment. Whether or not they are useful at a later stage in the treatment is open to debate.
Microscopic colitis is associated with increased intestinal permeability (aka leaky gut syndrome).
Researchers have shown that gluten causes increased intestinal permeability for everyone, not just for celiacs (Drago, et al., 2006).1 Over time, with continued regular exposure to gluten, intestinal permeability worsens. At some point the condition may become significant enough that certain peptides are able to pass through the tight junctions into the bloodstream. Peptides are short to medium-length amino acid chains resulting from the incomplete digestion of certain protein molecules, such as gluten and casein. This happens because the tight junctions are open wider than normal and they remain open longer than normal.. Normally the tight junctions only open wide enough to allow nutrients in the form of individual amino acids to pass through and then they close after the opportunity to absorb nutrients has passed.
But when peptides are able to pass through the tight junctions into the bloodstream, the immune system immediately recognizes that those peptides shouldn't be there, so it marks them as foreign invaders and begins to produce antibodies against them. This primes the immune system so that the next time those peptides appear in the blood, antibody production will be stepped up and an assortment of inflammatory agents will be released in an attempt to destroy the invaders. With repeated exposures, this leads to a condition where anytime that particular protein is identified within the digestive system, an immune system reaction against it is triggered.
This is part of the adaptive immune system, the same system that provides immunity to a disease in response to a vaccine. A vaccine prompts the immune system to begin producing antibodies against a specific pathogen so that in the future, any exposure to that pathogen will result in a flood of antibodies that promote the release of additional immune system defense mechanisms designed to destroy the pathogen before it can become well established.
The lymphocytes (white blood cells) that infiltrate the mucosal lining of the colon as lymphocytic (microscopic) colitis develops are one example of an immune system response to the production of antibodies. Ingestion of a food that prompts the production of IgA antibodies in the intestines leads to increased lymphocyte infiltration into the mucosal lining of the intestines. The lymphocytes are sent to destroy the perceived threat created by the peptides that are leaking into the bloodstream. But since these white cells are designed to kill pathogens, they are inneffective at destroying the peptides (which are not actually pathogens and are not alive) and unable to prevent them from entering the bloodstream.
Lymphocytes cause inflammation, but normally this is only a temporary condition because after the pathogens that were the target of the attack have been destroyed, the inflammation fades away as the populations of T cells, cytokines, macrophages, and various other immune system defenses decline and return to normal levels. But when the attack has been triggered because of food sensitivities, it can never end, unless diet changes are made to stop the production of antibodies by avoiding the foods that trigger the antibody production. Without diet changes, microscopic colitis tends to be self-perpetuating. A similar situation exists with drug-induced MC. As long as a drug that promotes the production of antibodies continues to be used, the resulting inflammation will continue to be produced and the clinical symptoms will be perpetuated.
This is the reason why foods that a patient has been eating for many years without any issues can suddenly begin to cause major digestive system problems. And unfortunately, the type of gluten sensitivity that typically occurs with MC is not normally detected by the blood tests used by physicians to detect celiac disease. The mainstream medical community has no officially-approved medical tests available for detecting non-celiac gluten sensitivity. Therefore, unless they are willing to order the stool tests from EnteroLab, physicians have no way to detect the type of gluten sensitivity that MC patients typically have, nor any of the other food sensitivities, for that matter, unless the patients happen to be allergic to those foods (which is an entirely different type of reaction).
Treating the disease by making diet changes can be done with or without the use of medications.
While some MC patients are lucky enough to respond promptly to diet changes, it can take weeks or months in some cases for the intestines to heal enough to bring significant improvement. Kids tend to heal quickly, but adults take much longer, because increasing age slows down the healing process. Consequently, some patients take a medication to help mask their symptoms while the diet changes heal the gut. Unfortunately the medications most commonly used to treat the disease do not actually heal the intestines. In fact, research shows that the corticosteroids for example, actually retard healing. Medications only treat the symptoms, so soon after treatment with a medication is discontinued, symptoms typically return. By making appropriate diet changes, it's possible to prevent the inflammation from being produced in the first place, and this allows the gut to heal. It should also be noted that because anti-inflammatory medications tend to mask food sensitivities, their use can make identifying food sensitivities more difficult. Therefore, when an anti-inflammatory medication is used concurrently with diet changes, it may be necessary to make diet adjustments as the medication dosage is tapered.
It takes a long time for inflammation-damaged intestines to heal.
Kids heal relatively quickly, and they often heal in a year or less, but it typically takes adults much longer to heal, usually in the range of 2–3 years for complete healing, and in some cases it can take longer. After remission is achieved, and a significant amount of intestinal healing has occurred, depending on age, amount of damage, and immune system health, more normal levels of fiber and sugar, and raw fruits and vegetables may be slowly reintroduced into the diet. This is best done by reintroducing 1 food at a time, for 3 days, starting with a small serving, and increasing the serving size each day. If no reaction is apparent after 3 days, then the food can usually be assumed to be safe, and can remain in the diet.
Reliable stool testing can save a lot of trial and error testing to discover food sensitivities.
Currently, the only laboratory in the world that seems to offer accurate and reliable stool testing for food sensitivities is EnteroLab, located in Dallas, TX. While numerous labs offer blood tests or other testing methods for the detection of food sensitivities, the combined experience of many, many MC patients shows that in general, those tests are typically less sensitive and less reliable than the stool tests offered by EnteroLab. The antibodies are produced in the intestines, and therefore they are concentrated in the stool, rather than in the blood, or any other medium used for testing purposes. Only a relatively small fraction of the antibodies end up in the blood, making their detection there more difficult.
1. Drago, S., El Asmar, R., Di Pierro, M., Grazia, C. M., Tripathi, A., Sapone, A., . . . Fasano, A. (2006). Gliadin, zonulin and gut permeability: Effects on celiac and non-celiac intestinal mucosa and intestinal cell lines. Scandinavian Journal of Gastroenterology, 41(4), 408–19. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16635908
WHY WE RECOMMEND AGAINST EATING OUT WHEN TRYING TO RECOVER FROM A FLARE
When the American College of Gastroenterology held their Annual Scientific Meeting on Monday (10/08/2018), a research paper was presented that showed that when foods at restaurants that were claimed to be gluten-free were tested, almost a third of them actually contain more than the legally allowed limit of gluten.1 According to the data, the problem is much worse at dinner than at breakfast. The problem progressively increases during the day, suggesting that contamination levels possibly continue to accumulate on utensils and facilities over time.
Although the staff at most restaurants surely have good intentions, they apparently lack the knowledge or understanding, and the expertise required to be able to consistently and reliably prepare meals that are actually gluten-free.2 The worst culprits seem to be pizza and pasta. About half of the "gluten-free" pizza and pasta dishes failed the test.
It's pretty obvious that if you're serious about recovering, eating out is not a safe policy to follow. The risk of being served food contaminated with gluten is way too high to be acceptable. But an important point here that is rarely even considered by most people is the fact that even if the levels of gluten contamination are slightly below the legal limit, that's enough gluten to keep almost anyone's immune system active enough to perpetually maintain a state of low-level background inflammation. The existence of that background inflammation means that the immune system will remain at a "ready" or "high-alert" condition at all times, and the intestines will not be able to completely heal. In that state, an exposure to even a small to moderate dose of gluten might trigger a surprisingly severe flare — much worse than if the intestines were allowed to heal first.
1. 8 - Gluten contamination of restaurant food: Analysis of crowd-sourced data
Lerner, B. A., Phan Vo, L., Shireen Yates, S., Rundle, A.G., Green, P.H.R., & Lebwohl, B. (2018, October 8). ACG 2018, Retrieved from https://www.eventscribe.com/2018/ACG/fsPopup.asp?Mode=presInfo&PresentationID=442112
2. One-third of 'gluten-free' restaurant dishes actually contain gluten, study finds
Pawlowski, A. (2018, October 8). Retrieved from https://www.today.com/health/are-gluten-free-restaurant-dishes-really-gluten-free-study-results-t138963
Although the staff at most restaurants surely have good intentions, they apparently lack the knowledge or understanding, and the expertise required to be able to consistently and reliably prepare meals that are actually gluten-free.2 The worst culprits seem to be pizza and pasta. About half of the "gluten-free" pizza and pasta dishes failed the test.
It's pretty obvious that if you're serious about recovering, eating out is not a safe policy to follow. The risk of being served food contaminated with gluten is way too high to be acceptable. But an important point here that is rarely even considered by most people is the fact that even if the levels of gluten contamination are slightly below the legal limit, that's enough gluten to keep almost anyone's immune system active enough to perpetually maintain a state of low-level background inflammation. The existence of that background inflammation means that the immune system will remain at a "ready" or "high-alert" condition at all times, and the intestines will not be able to completely heal. In that state, an exposure to even a small to moderate dose of gluten might trigger a surprisingly severe flare — much worse than if the intestines were allowed to heal first.
1. 8 - Gluten contamination of restaurant food: Analysis of crowd-sourced data
Lerner, B. A., Phan Vo, L., Shireen Yates, S., Rundle, A.G., Green, P.H.R., & Lebwohl, B. (2018, October 8). ACG 2018, Retrieved from https://www.eventscribe.com/2018/ACG/fsPopup.asp?Mode=presInfo&PresentationID=442112
2. One-third of 'gluten-free' restaurant dishes actually contain gluten, study finds
Pawlowski, A. (2018, October 8). Retrieved from https://www.today.com/health/are-gluten-free-restaurant-dishes-really-gluten-free-study-results-t138963
ARTIFICIAL SWEETENERS ARE TOXIC TO GUT BACTERIA
Our policy has always been to avoid artificial sweeteners, not only when treating microscopic colitis, but at all times. Now we have published medical proof that at least six artificial sweeteners (aspartame, sucralose, saccharine, neotame, advantame, and acesulfame potassium-k) showed toxic effects toward normal gut bacteria when mixed in sports drinks at a concentration of as little as one mg/ml of the artificial sweeteners.1 This is strong evidence that using these artificial sweeteners is likely to lead to adverse health consequences. And in the case of microscopic colitis patients, we know from experience that most artificial sweeteners can cause flares and prevent remission. Artificial sweeteners may be an even greater threat than we realize because they have been identified as environmental pollutants. They can often be found in drinking water, lakes, rivers, and underground aquifers, making them difficult to avoid completely.2
1. Measuring artificial sweeteners toxicity using a bioluminescent bacterial panel
Harpazm D., Yeo, L. P., Cecchini, F., Koon, T. H. P., Kushmaro, A., Tok, A. I. Y., & Eltzov, E. (2018). Molecules, 23(10), 2454. Retrieved from https://www.mdpi.com/1420-3049/23/10/2454
2. Artificial sweeteners have toxic effects on gut microbes
American Associates, Ben-Gurion University of the Negev. (2018, October 1). [Web log message]. Retrieved from https://www.sciencedaily.com/releases/2018/10/181001101932.htm
1. Measuring artificial sweeteners toxicity using a bioluminescent bacterial panel
Harpazm D., Yeo, L. P., Cecchini, F., Koon, T. H. P., Kushmaro, A., Tok, A. I. Y., & Eltzov, E. (2018). Molecules, 23(10), 2454. Retrieved from https://www.mdpi.com/1420-3049/23/10/2454
2. Artificial sweeteners have toxic effects on gut microbes
American Associates, Ben-Gurion University of the Negev. (2018, October 1). [Web log message]. Retrieved from https://www.sciencedaily.com/releases/2018/10/181001101932.htm
