Lifestyle Medicine in Inflammatory Bowel Disease

Dear Editor,

We enjoyed greatly the article “Lifestyle Medicine: A Brief Review of Its Dramatic Impact on Health and Survival” written by Bodai et al.¹ The article encourages and inspires us.

Following World War II, Japan experienced an economic, nutritional, and epidemiologic transition. Stroke (apoplexy) replaced tuberculosis as the leading cause of death in 1951. Three diseases (cancer, coronary heart diseases, and stroke) became the main causes of death, accounting for about two-thirds of all deaths. Japan’s Ministry of Welfare designated these diseases “adult diseases” in 1956 in an attempt to diagnose and treat the diseases early in persons in their prime. Forty years later, in 1996, the term “adult diseases” was replaced with “lifestyle-related diseases,” considering the importance of lifestyle starting at childhood for prevention of chronic diseases. At that time, diabetes mellitus and hypertension were added to the three diseases above to form the five major lifestyle-related diseases. Consequently, “lifestyle disease” is a familiar term to the Japanese people.² It is obvious that the majority of diseases we face are chronic diseases (lifestyle diseases) caused by an unhealthy lifestyle.^1,3 Therefore, incorporation of a healthy lifestyle in medicine, namely lifestyle medicine, is fundamental for prevention and treatment of chronic diseases.^1,3 Bodai et al described the effect of lifestyle medicine in obesity, diabetes, cardiovascular disease, and cancer.¹ We want to comment on our experience of lifestyle medicine in inflammatory bowel disease (IBD): Crohn disease (CD) and ulcerative colitis (UC).

We regard IBD as a lifestyle disease mainly mediated by westernized diets, which tend to cause reduced gut microbial diversity.^4,5 We have provided a primarily plant-based diet (PBD) (lacto-ovo-vegetarian diet) for all IBD inpatients since 2003.⁴ Meat and fish are served once every 2 weeks and once a week, respectively. Sweets are not served. Fruits, vegetables, legumes, potatoes, and yogurt are served daily. We also provide information on healthy lifestyle habits: No smoking, regular physical activity, moderate or no use of alcohol, regularity of meals, and not eating between meals.⁶ We give each patient a dietary and lifestyle recommendation on discharge. We recommend a PBD for meals, active exercise, and maintenance of healthy lifestyle. We have 15 years of experience of such lifestyle medicine involving more than 159 patients with UC and 70 patients with CD.⁷ In CD, infliximab combined with PBD induced remission in 44 consecutive cases without fail.⁸ This remission rate is excellent considering that around 30% of sufferers are primary nonresponders to infliximab. PBD is effective in the maintenance of remission in CD: 100% and 90% at 1- and 2-year follow-up, respectively.⁴ This remission rate is achieved without scheduled maintenance therapy with infliximab. We recommend a short period of educational hospitalization for patients with mild UC to replace their omnivorous diet with a PBD. The cumulative relapse rates after educational hospitalization at 1 and 5 years of follow-up were 2% and 19%, respectively.⁹ Although our patients were mild cases, these relapse rates are far better than those reported in the literature (28% to 50% at 1 year and 57% to 78% at 5 years). PBD score,⁷ which evaluates adherence to the PBD, was significantly better relative to baseline both at short-term (14 months) and long-term (47 months) follow-up.⁹ We now treat mild cases of UC with PBD first, not medication.^9,10 PBD without medication can induce remission in a subset of patients with mild UC.^9,10 Our success with lifestyle medicine in IBD was greater than we expected and as dramatic as that described by Bodai et al¹ in representative chronic diseases. It is regrettable that the PBD menu and dietary guidance for PBD by a registered nutritionist are not currently covered by health insurance.