Is diet important with a J pouch?
The short answer is YES but first things first, what is a J pouch?
Put simply, a J pouch is a J shaped internal pouch made from the end of the small intestine. This acts as a kind of holding chamber for poo in the absence of the large intestine to do the job! The medical name for it is an ileal pouch anal-anastomosis (IPAA).
When the colon (large intestine) has to be removed due to ulcerative colitis that does not respond to medication (or for other reasons) if the anus and rectum are still intact, there is often an option to have J pouch surgery to reconnect the intestines so the patient does not have to continue living with an ileostomy bag and can poo in a normal way again.
J Pouch surgery works really well for some people but some experience complications. These can include obstructions, narrowings (stricture), diarrhoea. Another common complication is inflammation of the pouch called pouchitis which can occur in up to 50% of patients.
Like the microbiota in the large intestine, the J pouch forms its own microbial colony which helps to keep it healthy. Evidence suggests that its an alteration of these microbes which may trigger an abnormal immune response in the lining of the pouch that leads to acute and/or chronic inflammation. Pouchitis can usually be treated using antibiotics which destroy these microbes but sometimes other treatment is needed if this doesn’t resolve it.
So how can we support a healthy microbial community? Through the food we eat (the microbes in our intestines eat the fibres from foods that we can’t digest)!
What does the research show us about diet and J pouches?
Research published in the European Journal of Nutrition in 2020 reported that following a Mediterranean diet pattern was associated with decreased calprotectin levels (a marker for pouch inflammation) and lower rates of pouchitis over time (1). A Mediterranean dietary pattern encourages the consumption of vegetables, fruits, whole grains, nuts, legumes, and olive oil which contribute to the overall intake of valuable micronutrients.
Interestingly, improved adherence to the Mediterranean diet was associated with a decreased risk for elevated faecal calprotectin. They scored participants diets from low adherence to high adherence to the Mediterranean diet pattern from 0-9 – the higher the number the greater the adherence. They found that just a 1-point increase in score (better adherence) was associated with a 26% reduction in likelihood of someone having increased calprotectin. So even small changes and adaptions to our diets may make a meaningful difference to our pouch health.
In 2013, research was published in the World Journal of Gastroenterology looking at the diet of pouch patients compared to healthy controls, and correlated pouch patients’ diet with disease behaviour (2). They found that the diet of patients who had pouch surgery differed significantly from that of healthy individuals. Patients with pouchitis consumed significantly fewer fruit servings and antioxidants than patients with normal pouches, thus possibly exposing the former to inflammatory and oxidative stress.
This finding was also apparent in another piece of research, published in 2019, which found that fruit consumption correlated with microbial diversity, and relative abundance of beneficial microbial groups such as Faecalibacterium and lower rates of pouchitis (3).
Other research has shown that dietary components influence pouch function via their effect on the speed at which food moves through the small intestine (therefore frequency of bowel movements), water content in the small intestine (therefore diarrhoea), and the structure and fermentative activity of the pouch microbiota (gas and pouch health) (4).
Although we don’t know exactly why these dietary patterns are associated with better pouch health, it is hypothesised that the benefit could relate to their fibre and antioxidant content. This is because fibre has been shown to affect microbiome composition and metabolism in healthy people, especially increased abundance of bifidobacteria and lactobacilli and increased concentrations of immune-regulatory short-chain fatty acids (compounds our gut bugs produce when we feed them fibre). Positive effects of fibre have also been reported in IBD and pouch trials. Excessive oxidative stress from increased inflammation and other contributors in IBD, can damage cell structure. Antioxidants are important in reducing oxidative stress so provide protective mechanisms against cell damage.
It is important to note that these studies have their limitations, mainly that they are observational studies so do not provide cause and effect, only associations, so there isn’t enough evidence yet to say with certainty that a Mediterranean diet pattern or increasing fruit intake will reduce the risk of pouchitis. Luckily there are some trials in progress looking at the causal relationships and I am eagerly awaiting their publication and will share them with you when they are published.
What can we take away from this research?
Whilst we don’t know yet the cause and effect of these, practically we know that following a Mediterranean pattern of eating or increasing fruit intake can have multiple benefits on our health beyond the health of our pouch (e.g. reduce risk of diseases like heart disease and diabetes). In addition, wider research suggests that plant diversity is key when it comes to supporting the health and diversity of the bacterial communities that live in our gut.
But we have to get the balance right with fibre and pouch output – some foods provide fibre that absorbs water and helps to slow down the time food takes to go through the pouch and can help form pouch output properly. On the other hand, some fibres can increase bulk and increase the amount of times someone with a pouch needs to empty it. So, a focus on the types of fibres and foods is important and adapting that for each individuals pouch.
However, as always, its never black and white. There may be reasons, including medical reasons, why it might not be possible or appropriate for someone with a pouch to make these kinds of changes to their diet. Therefore, its really important to get personalised help and support from a nutritionist or dietician who is experienced in working with people with pouches (like me!) before making any changes so we can make sure any changes are right for you.
If you would like help and support with your J-Pouch and what dietary and lifestyle changes would be appropriate for you, please get in touch. You can book a free call, where I can get to know you, your journey, your struggles, your life, and we can chat about the best route forward for you. You can also ask any questions you have about working with me.
I have also written a free e-book to help you find a way forward for your everyday life with Inflammatory Bowel Disease. Whether you are right at the beginning of your journey with IBD or have been living with your condition for years and feel like you have tried almost everything, there are things you can do everyday, beyond the medication you are taking, to help you take back control.
References
Godny L, Reshef L, Pfeffer-Gik T, Goren I, Yanai H, Tulchinsky H, Gophna U, Dotan I. Adherence to the Mediterranean diet is associated with decreased fecal calprotectin in patients with ulcerative colitis after pouch surgery. Eur J Nutr. 2020 Oct;59(7):3183-3190. doi: 10.1007/s00394-019-02158-3. Epub 2019 Dec 7. PMID: 31813010.
Ianco O, Tulchinsky H, Lusthaus M, et al. Diet of patients after pouch surgery may affect pouch inflammation. World J Gastroenterol. 2013;19(38):6458-6464. doi:10.3748/wjg.v19.i38.6458
Godny L, Maharshak N, Reshef L et al (2019) Fruit consumption is associated with alterations in microbial composition and lower rates of pouchitis. J Crohns Colitis. https://doi. org/10.1093/ecco-jcc/jjz053
Ardalan, ZS, Yao, CK, Sparrow, MP, Gibson, PR. Review article: the impact of diet on ileoanal pouch function and on the pathogenesis of pouchitis. Aliment Pharmacol Ther. 2020; 52: 1323– 1340. https://doi.org/10.1111/apt.16085
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We are all wonderfully unique and what works for one person may not work for another so please seek help and advice before changing your diet to work out the right way forward for you.