Conscientious Consumption: News in IBD Nutrition | Jill Roberts Center for Inflammatory Bowel Disease

Sleep on This: What IBD Patients Can Do to Improve Sleep

Sleep on This: What IBD Patients Can Do Right Now to Improve Their Sleep Quality

May 25, 2021

Another topic that seems to generate a lot of buzz among the IBD community is sleep. Much like almost 1/3 of adults in the U.S., patients with IBD often struggle with sleep issues - some may be related to insomnia, while others may be a function of nocturnal symptoms. There may, however, be something more going on here. In 2019, a group of researchers at Weill Cornell published a paper revealing some interesting findings regarding circadian rhythms (which control the sleeping and feeding cycles) and IBD. Their results indicated a potentially "dysfunctional" relationship between circadian rhythms and specific lymphoid cells (group 3 innate lymphoid cells, aka ILC3s) that are involved in gene expression of proteins that influence the circadian clock. The homeostasis (e.g., balance) of these ILC3s is somehow compromised in IBD patients, suggesting that an inflamed gut may interfere with sleep cycles. Teasing this idea out a bit further, one of my dietetic interns from the Bronx VA's internship program was especially interested in this relationship between sleep cycles and IBD, and thus decided to write a post to describe her research. Let's take a look at what Stefanie was able to uncover on this complex topic! - Ryan Warren, M.S., R.D.N., C.D.N.

By Stefanie Rodriguez, Dietetic Intern

While the exact mechanisms that cause and aggravate IBD are still being researched, we know that environmental factors, such as food intake and stress impact our immune systems. Similarly, sleep is beginning to gain more attention as an important factor in IBD management. New research is uncovering the intricate relationship between sleep, IBD, and the trillions of bacteria that populate the gut. Most IBD patients describe their sleeping patterns as disturbed, fragmented, and insufficient. In fact, a study found that 73% of patients with quiescent IBD, and 100% of patients with active IBD describe having poor sleep quality (1.) Another study found that sleep disturbance was independently associated with up to two times higher risk of flares in patients with Crohn’s disease. If you have IBD, how does this affect you? Simply put, your sleep pattern may be influencing your disease severity more than you think.

Your Gut Has a Sleep Pattern Too

Circadian rhythm refers to the body’s internal clock, which regulates cycles throughout the body based on a 24-hour period.2 We usually associate circadian rhythm with our sleeping patters, which typically follow light and dark cues. But did you know that circadian rhythms also significantly influence the ~100 trillion bacteria in the gut? The microbiome follows a sleep cycle much like our own by responding to stimuli including our body’s fasting and feeding cycle. Research using mouse models uncovered that about 60% of the total composition of the microbiome changes throughout the day according to the rhythm set by light and darkness (3.) The method by which gut bacteria follow this pattern is related to natural fluctuations that occur in the gut microbiota in a 24-hour period. However, new studies are finding that factors such as food intake and fractured sleeping patterns may disassociate these peripheral circadian rhythms from the master clock in the brain (4.)

The dysregulation of the gut circadian rhythms through fractured sleep may have a more significant impact than we previously believed. For example, we now know that some lactobacillus and clostridium species of gut bacteria regulate the production of the neurotransmitter serotonin by colonic cells (4.) Serotonin is then converted to melatonin, a sleep hormone that tells the body when it’s time to sleep. This mechanism speaks to the cyclic nature of the issue, stemming from a fractured sleep pattern that could alter gut processes and consequently, further exacerbate insomnia.

Melatonin and Inflammation

In recent studies, melatonin has been found to be positively associated with anti-inflammatory cytokines (e.g., a group of protein molecules released by immune cells that communicate with other cells in the body) (4.) This means that a reduction in melatonin will be reflected by a reduction in these immunomodulators. Conversely, reduced melatonin has been associated with an increase in pro-inflammatory cytokines. In summary, low melatonin, which may be triggered by changes in gut bacteria composition, may trigger inflammation.

A Cascade That Leads to “Leaky Gut”

So far, we have discussed the effect of sleep dysregulation on the gut and how this leads to an increase in inflammatory markers. To add insult to injury, short sleep will also cause a release of glucocorticoids and other substances that lead to a cascade of events. These events ultimately lead to the breakdown of the tight junctions between intestinal cells, resulting in increased intestinal permeability or what we know familiarly as “leaky gut”. Now microbiota, food particles, and chemicals in your gut can infiltrate the circulation and cause even more inflammation.

What Does All of This Mean?

If you retain nothing more from this article, remember this: maintaining a robust sleeping cycle will help manage your IBD symptoms. Sleep deprivation and IBD are deeply interconnected in a cycle where lack of sleep may be worsening IBD symptoms and flares. Meanwhile IBD itself continues to perpetuate sleep insufficiency and fatigue through the internal dysregulation of your sleep cycle, and symptoms that persist throughout the night. It is possible, however, to take action to break the cycle between sleep deprivation and inflammation.

Where to begin?

Talk to your doctor, dietitian, and/or integrative healthcare providers to discuss methods to track and improve your sleep quality. In the meantime, here are some methods for improving sleep quality to get you started:

1. Address any underlying issues: What is keeping you up? Work with your healthcare team and support system to address these triggers.

2. Keep a sleep journal: Spend some time understanding your sleep pattern. Use a digital sleep tracker and document your sleeplessness as well as what is triggering it.

3. Mindful eating: Chew your food well and eat small, frequent meals to reduce discomfort due to roughage and overloading. Focus on keeping track of your trigger foods and build in a 4-hour window between your last meal of the day and your bedtime to prevent nighttime urgency and discomfort. Finally, speak to a dietitian who can help you create a tailored plan for you.

4. Take ownership over your medical intervention: Follow and take charge of your prescribed IBD treatment. Talk with your doctor to make sure that you understand your regimen. Provide feedback if your regimen is not working for you.

5. Manage stress: Stress impacts our sleep and has been found to be strongly associated with IBD. Develop stress management strategies such as meditation, yoga, or bubble baths that allow you to relax before going to sleep.

6. Turn the screens off: Leave your phone out of reach when you go to bed, take that tv out of your room, and put down your iPad at least 30 minutes before going to sleep.

7. Listen to relaxing sounds: There are many applications that provide sleep meditations, bedtime stories, and pleasant sounds that may facilitate your sleep.

8. Incorporate aromatherapy: Use an oil diffuser with calming scents such as lavender, peppermint, and eucalyptus.

9. Adjust your environment: Use blackout curtains or a sleep mask if you are unable to keep your room dark.

10. Create a habitual sleep schedule: Establish a sleep plan that builds in 8-10 hours of sleep and fits into your schedule.

References:

1. Rozich JJ, Holmer A, Singh S. Effect of Lifestyle Factors on Outcomes in Patients With Inflammatory Bowel Diseases. Am J Gastroenterol. 2020 Jun;115(6):832-840. doi: 10.14309/ajg.0000000000000608. PMID: 32224703; PMCID: PMC7274876. https://pubmed.ncbi.nlm.nih.gov/32224703/

2. Suni E. Circadian rhythm. https://www.sleepfoundation.org/circadian-rhythm. Updated 2020.

3. Matenchuk BA, Mandhane PJ, Kozyrskyj AL. Sleep, circadian rhythm, and gut microbiota. Sleep Med Rev. 2020 Oct;53:101340. doi: 10.1016/j.smrv.2020.101340. Epub 2020 May 13. PMID: 32668369. https://pubmed.ncbi.nlm.nih.gov/32668369/

4. Gombert M, Carrasco-Luna J, Pin-Arboledas G, Codoñer-Franch P. The connection of circadian rhythm to inflammatory bowel disease. Transl Res. 2019 Apr;206:107-118. doi: 10.1016/j.trsl.2018.12.001. Epub 2018 Dec 19. PMID: 30615844. https://pubmed.ncbi.nlm.nih.gov/30615844/

Oral Thiamine Combats Fatigue in IBD Patients

Oral Thiamine Combats Fatigue in Quiescent IBD Patients

February 17, 2021

By Ryan Warren, M.S., R.D.N., C.D.N.

Fatigue in patients with inflammatory bowel disease (IBD) is not only a hot topic, but one that is inherently challenging to overcome for both patients and their clinicians. As a clinical nutritionist, I am looking for clues and answers to this complex issue day in and day out. Recently, however, the possibility of thiamine (vitamin B1) supplementation, has come onto my radar screen. Let me walk you through what I’ve learned so far...

When I’m consulting with my patients, I typically like to start our conversations by getting a sense of their current IBD symptoms. We discuss bowel habits, abdominal pain, gas, bloating, and nausea - just to name a few. Across the board, however, one of the most common complaints in my IBD patient population is fatigue, also sometimes described by patients as “very low energy” or “lethargy.” This observation is not all that surprising; in fact, research shows that nearly 80% of patients with active IBD, and 50% of patients in remission, report fatigue as a symptom!

How do we tackle fatigue? It requires quite a few considerations. From a nutritional perspective, there are a few things we'll discuss in order to address low energy levels. First and foremost, I try to ensure that the patient’s diet is as nutritionally adequate as possible and as tolerable for the patient - i.e., the diet is replete with an appropriate balance of carbohydrates, fats, proteins, vitamins and minerals.

In some cases, however, patients struggle to absorb certain nutrients regardless of the adequacy of the overall diet. This will often depend on their disease status, extent of inflammation, disease location, surgical history, etc. Bloodwork and relevant nutrition-related labs can give us a good serological picture of what a patient may be lacking, such as iron, vitamin B12, and electrolytes just to name some popular ones. Oftentimes, patients are advised to supplement with readily absorbable vitamins and minerals that can help to replete important nutrients, many of which are associated with energy generation.

Additionally, hydration status, sleep hygiene, and physical activity can be important clues to discern in trying to piece together why patients may be dealing with low energy levels. Drinking plenty of water, often with electrolyte replenishment, can help to stave off the lethargy that can sometimes be associated with dehydration. Ensuring a good night’s sleep and appropriate levels of physical activity are also important to consider when working to optimize a patient’s overall energy level.

But what if the aforementioned are not enough? Wouldn’t it be great if there was just a “magic pill” that IBD patients could take for boosting energy? And I’m not talking about caffeine! Interestingly enough, we may be getting closer to another key aspect of the low energy “solution,” if you will. Studies indicate a potentially promising finding that thiamine (aka, vitamin B1) may be one answer we’ve been seeking all along.

In one particular study, the researchers’ objective was to determine if intracellular thiamine deficiencies were potentially contributing to chronic fatigue symptoms in a group of twelve IBD patients, and secondarily, if treatment with high dose oral thiamine would sufficiently replenish thiamine levels in all cells of the body in order to enhance the efficacy of glucose metabolism. The study population was comprised of eight UC patients and four Crohn’s patients, all of whom had normal blood levels of both thiamine and thiamine pyrophosphate. The study intervention of daily supplementation with thiamine ranged from 600 mg to 1500 milligrams, depending on the patients’ weight status.

After 20 days of supplementation, the researchers assessed the patients’ chronic fatigue syndrome scale scores and blood thiamine levels. Ten out of twelve patients showed complete fatigue regression; the remaining two patients showed “nearly” complete fatigue regression. The study results therefore suggest that high dose thiamine supplementation may support passive transport of thiamine into the body cells in IBD patients whose active transport mechanisms may be compromised. In other words, many IBD patients may struggle with thiamine deficiencies at the cellular level, making supplemental thiamine a viable option for supporting the movement of thiamine from the blood into the cells. I’ll give you a moment to digest that idea...

Now, let’s address the bottom line here: despite serological values for vitamin B1 (thiamine), which may appear normal in most IBD patients, supplementation with vitamin B1 may help to improve energy levels in IBD patients by boosting intracellular transport of this important vitamin involved in metabolism and energy production.

So what does this mean clinically for healthcare professionals and patients? Should every IBD patient be supplementing with thiamine? Not necessarily. Fatigue is certainly multi-factorial as previously discussed, and other potential triggering factors should absolutely be addressed. There may, however, be certain patients who could benefit from experimental vitamin B1 supplementation to boost energy levels. As always, this is determined on a case-by-case basis. Remember to consult with your doctor and/or registered dietitian before initiating a new supplement. And, hopefully in the near future, there will be more exciting news to share about fighting fatigue!"

References:

Bager, P., et al. (2021). Randomised clinical trial: high-dose oral thiamine versus placebo for chronic fatigue in patients with quiescent inflammatory bowel disease. Aliment Pharmacol Ther, 53(1), 79-86. https://doi.org/10.1111/apt.16166

Costantini, A., & Pala, M. I. (2013). Thiamine and Fatigue in Inflammatory Bowel Diseases: An Open-label Pilot Study. The Journal of Alternative and Complementary Medicine, 19(8), 704–708. https://doi.org/10.1089/acm.2011.0840