Trend Watch

GI Nutrition Conference Highlights Latest in Diet Therapies, Microbiome, Telemedicine

William D. Chey, MD
William D. Chey

Last month, dieticians, gastroenterologists, and other health care providers from across the world gathered in Ann Arbor, Michigan, for a 3-day program focused on the role of nutrition and lifestyle interventions in the management of patients with digestive and liver diseases.

The conference, called Food: The Main Course to Digestive Health, was developed by the University of Michigan Digestive Disorders Nutrition and Lifestyle Program and the Department of Nutritional Sciences in the School of Public Health, and sponsored by the American College of Gastroenterology. It featured a series of lectures and panel discussions on topics ranging from diet therapies for GI conditions like irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and non-alcoholic fatty liver disease (NAFLD), as well as the latest developments in gut microbiome science and telemedicine.

The course director, William D. Chey, MD, Nostrant Professor of Gastroenterology & Nutrition Sciences at Michigan Medicine, Ann Arbor, recently spoke with Healio Gastroenterology and Liver Disease to discuss the highlights from the conference, and the importance of multidisciplinary collaboration between gastroenterologists and dieticians.

Healio: What prompted you and the ACG to develop this program?

Chey: It was a growing recognition of the importance of diet and nutrition in the pathogenesis and treatment of a whole range of different GI conditions.

In my many discussions with gastroenterologists all over the U.S., it’s clear that they’re incredibly interested in how we can manipulate diet and nutrition in a way that benefits patients with conditions like GERD, IBS, IBD, as well as with tried-and-true diet-related conditions like celiac disease or eosinophilic esophagitis (EoE). It was also clear from my own experience and discussions with colleagues that it’s very hard for physicians, who are so constrained for time in the office nowadays, to be able to expend the time and, also have the expertise to provide adequate, medically responsible nutrition counseling to their patients.

Physicians are increasingly recognizing the tremendous benefits and value of collaboration with registered dieticians who are properly trained in the care of patients with digestive and liver disorders.

While that may seem obvious, the problem is that most dieticians across the U.S. have not received specific training regarding digestive and liver disorders. So, as we’ve developed this Digestive Disorders Nutrition and Lifestyle Program at Michigan Medicine, we’ve not only built a robust clinical service in both nutrition and behavioral medicine, but we’ve also worked hard to develop training programs to amplify what we’ve built here, and the expertise that we bring to the table in these disciplines.

This course is really one of our initial efforts in that regard, to not only deliver excellent clinical care, but to provide training to a cohort of dieticians who are experts in caring for patients with digestive and liver disorders around the country and indeed, around the world. In that way we hope to increase the likelihood that diet and nutrition are implemented in a medically responsible way as part of a treatment plan for patients with digestive and liver disorders.

Healio: Why is it so important for gastroenterologists and dieticians to work together in a multidisciplinary way?

Chey: The traditional model has always been that gastroenterologists and dieticians work in a very siloed type of environment, in which the gastroenterologist and the dietician do their own thing but don’t work as a team. We did it that way for many years here and we found that the recommendations of the gastroenterologist were often not aligned with the recommendations of the dietician, so patients were often receiving conflicting information.

We came to realize two things: First, that the dietician did not necessarily receive their training from gastroenterologists, but rather from other dieticians that had established thoughts about what to do for problems with digestive and liver disorders. Second, the lack of communication between gastroenterologists and dieticians missed the opportunity to advance care and innovate through collaboration.

The conclusion we came to when we started our program in 2007 was that we could improve the quality of the information we’re providing to patients by sharing respective best practices from the nutrition world and the GI world, and, also create direct lines of communication between providers and dieticians with the overall goal of providing coordinated, high-quality care that incorporates diet and nutrition for our patients with digestive and liver disorders.

And this model works great. In fact, it’s clear to me from talking with the attendees from the course that this model is widely rolling out across the country. Many other programs are adopting this model and incorporating dieticians trained in GI nutrition into their practices, either having them embedded in the practice or working in a collaborative manner with dieticians in the community.

The idea of aligning the scientific knowledge with the expectations of a consultation, and then creating lines of communication that allow providers to approach the care of these patients in a team-based approach, has been a remarkable advance in the care of patients with digestive and liver disorders.

Healio: What were some key points from the discussions about the low FODMAP diet in IBS?

Chey: There are four key take-aways on the low FODMAP diet from the meeting.

One, there’s an increasing body of evidence to suggest that the low FODMAP diet provides benefits for patients with IBS, particularly pain and bloating.

Two, while the low FODMAP diet clearly exerts effects on fermentation that can reduce GI symptoms in patients with IBS, there’s fascinating and provocative recent work to suggest that the low FODMAP diet might also have effects on immune activation in the GI tract, which could also contribute to its symptom benefit for patients with IBS.

Three, the low FODMAP diet is far more than just eliminating certain carbohydrates from the diet. It’s a three-step process that includes elimination, reintroduction and maintenance. Right now, I think many practices are only focusing on that first step, and we need to move providers that are utilizing low FODMAP diet toward that three-step process and not just elimination.

Finally, that the low FODMAP diet plan is best administered through a coordinated effort between the gastroenterologist and a GI dietician. Digital tools like the low FODMAP mobile app created by Monash University and our website, www.myginutrition.com, can also be very helpful for patients interested in the low FODMAP diet.

Healio: Did Stephen Vanner, MD, of University of Toronto, share any new or particularly impactful data on the role of the gut microbiome during his presentation?

Chey: Dr. Vanner delivered a fantastic talk. He did a really good job of highlighting the latest data on alterations in the gut microbiome between patients with IBS and healthy controls, showing how that might impact upon a variety of parameters that we think are relevant to the pathogenesis of the disorder, not the least of which is the luminal microenvironment — for example, the way that the microbiome interacts with food, how those interactions could influence things like bile acid concentrations in the intestinal lumen, and how the luminal microenvironment, in turn could affect intestinal permeability and immune activation, with signaling through the enteric nervous system to the central nervous system.

Dr. Vanner also emphasized that while alterations to the microbiome in IBS patients are interesting, what may be most important are the metabolomic consequences of those changes in the microbiome. Just looking at changes in certain strains of bacteria may not really help us to understand what’s most important, which is likely those interactions between bacteria within communities that reside within the GI tract and the resultant downstream effects on the metabolome.

What was clear to me after the discussion was that we’re really at the beginning of this journey and we have a long way to go, but the exciting thing to speculate about is the notion that understanding alterations in the microbiome and metabolome might provide us with attractive targets to develop biomarkers to parse patients into subgroups, and in that way, choose the right microbiome-based therapy for the right patient. Whether you’re talking about antibiotics, prebiotics, probiotics, or diet, thinking about leveraging the microbiome or the metabolome in a way to pursue a personalized medicine approach is very exciting.

Healio: Can you recap some highlights from the talk given by Ryan W. Stidham, MD, of University of Michigan, on nutrition counseling via telemedicine or digital apps?

Chey: Frankly, I was blown away by Dr. Stidham’s talk. He has been at the tip of the spear for our GI program in terms of developing a telemedicine footprint, and he’s been doing a lot of work behind the scenes to allow our telemedicine program to move forward.

I learned so much about the different aspects of telemedicine that all of us are going to face in the near future. There are many issues we have to confront as we develop telemedicine programs, from the equipment and infrastructure needed to deliver the service, to issues involving scheduling and managing patient expectations, to financial and medicolegal/liability issues.

This is clearly the way of the future. If you look at the data that Dr. Stidham and his team collected on patient acceptance, and their willingness to engage in telemedicine, especially those with IBD, it’s overwhelming. The patients actually prefer this way of interacting with their health care providers, so it’s a no-brainer on the patient preference side. There is a small proportion of patients that prefer face-to-face visits, but most patients really like this idea of being able to do a visit over the internet at their convenience, for so many of the obvious reasons: convenience, missed time from work, child care, parking, to name a few.

There are many attractive things about telemedicine from a provider standpoint, as well: being able to do a clinic visit from your office or another designated space, not having to worry about the patient being late because they can’t find a parking spot or there’s an accident on the highway. Importantly, it could significantly reduce no show rates. People no-show for a variety of reasons related to life getting in the way, and you’re likely to minimize that by having patients do their visit at home during a time that’s convenient for them. So that’s a potentially very important benefit for the doctor and the health care system.

However, there are counterbalancing forces that are really holding this in check right now. The federal government seems to be very supportive of this notion of telemedicine, but the problem is that stakeholders are currently struggling with figuring out the parameters around which the government or an insurance company would provide payment, and the standards that define an adequate telemedicine visit. Right now, most providers are utilizing the same standard they apply to an office visit, but the struggle on the payer side is that this is such a new concept, they’re still finding their sea legs in regards to what they’ll pay for, and what level of service and documentation are necessarily to justify payment for a telemedicine visit.

The reason why I inserted this lecture into the program this year, and it was incredibly popular, is because I believe nutrition counseling and behavioral health, things like hypnosis and cognitive behavioral therapy administered by a GI psychologist, are perfect for telemedicine, because they benefit from face-to-face interaction, but they don’t require a hands-on physical examination. – by Adam Leitenberger

Reference:

Food: The Main Course to Digestive Health. September 22-24, 2017; Ann Arbor, Michigan.

Disclosures: Chey is the director of Food: The Main Course to Digestive Health, and director of the Digestive Disorders Nutrition & Lifestyle Program at Michigan Medicine. He reports consulting for Nestle Health Sciences and Ritter Pharmaceuticals, research grant funding from Nestle Health Sciences and True Self Foods, and is a patent holder of My Nutrition Health.

William D. Chey, MD
William D. Chey

Last month, dieticians, gastroenterologists, and other health care providers from across the world gathered in Ann Arbor, Michigan, for a 3-day program focused on the role of nutrition and lifestyle interventions in the management of patients with digestive and liver diseases.

The conference, called Food: The Main Course to Digestive Health, was developed by the University of Michigan Digestive Disorders Nutrition and Lifestyle Program and the Department of Nutritional Sciences in the School of Public Health, and sponsored by the American College of Gastroenterology. It featured a series of lectures and panel discussions on topics ranging from diet therapies for GI conditions like irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and non-alcoholic fatty liver disease (NAFLD), as well as the latest developments in gut microbiome science and telemedicine.

The course director, William D. Chey, MD, Nostrant Professor of Gastroenterology & Nutrition Sciences at Michigan Medicine, Ann Arbor, recently spoke with Healio Gastroenterology and Liver Disease to discuss the highlights from the conference, and the importance of multidisciplinary collaboration between gastroenterologists and dieticians.

Healio: What prompted you and the ACG to develop this program?

Chey: It was a growing recognition of the importance of diet and nutrition in the pathogenesis and treatment of a whole range of different GI conditions.

In my many discussions with gastroenterologists all over the U.S., it’s clear that they’re incredibly interested in how we can manipulate diet and nutrition in a way that benefits patients with conditions like GERD, IBS, IBD, as well as with tried-and-true diet-related conditions like celiac disease or eosinophilic esophagitis (EoE). It was also clear from my own experience and discussions with colleagues that it’s very hard for physicians, who are so constrained for time in the office nowadays, to be able to expend the time and, also have the expertise to provide adequate, medically responsible nutrition counseling to their patients.

Physicians are increasingly recognizing the tremendous benefits and value of collaboration with registered dieticians who are properly trained in the care of patients with digestive and liver disorders.

While that may seem obvious, the problem is that most dieticians across the U.S. have not received specific training regarding digestive and liver disorders. So, as we’ve developed this Digestive Disorders Nutrition and Lifestyle Program at Michigan Medicine, we’ve not only built a robust clinical service in both nutrition and behavioral medicine, but we’ve also worked hard to develop training programs to amplify what we’ve built here, and the expertise that we bring to the table in these disciplines.

PAGE BREAK

This course is really one of our initial efforts in that regard, to not only deliver excellent clinical care, but to provide training to a cohort of dieticians who are experts in caring for patients with digestive and liver disorders around the country and indeed, around the world. In that way we hope to increase the likelihood that diet and nutrition are implemented in a medically responsible way as part of a treatment plan for patients with digestive and liver disorders.

Healio: Why is it so important for gastroenterologists and dieticians to work together in a multidisciplinary way?

Chey: The traditional model has always been that gastroenterologists and dieticians work in a very siloed type of environment, in which the gastroenterologist and the dietician do their own thing but don’t work as a team. We did it that way for many years here and we found that the recommendations of the gastroenterologist were often not aligned with the recommendations of the dietician, so patients were often receiving conflicting information.

We came to realize two things: First, that the dietician did not necessarily receive their training from gastroenterologists, but rather from other dieticians that had established thoughts about what to do for problems with digestive and liver disorders. Second, the lack of communication between gastroenterologists and dieticians missed the opportunity to advance care and innovate through collaboration.

The conclusion we came to when we started our program in 2007 was that we could improve the quality of the information we’re providing to patients by sharing respective best practices from the nutrition world and the GI world, and, also create direct lines of communication between providers and dieticians with the overall goal of providing coordinated, high-quality care that incorporates diet and nutrition for our patients with digestive and liver disorders.

And this model works great. In fact, it’s clear to me from talking with the attendees from the course that this model is widely rolling out across the country. Many other programs are adopting this model and incorporating dieticians trained in GI nutrition into their practices, either having them embedded in the practice or working in a collaborative manner with dieticians in the community.

The idea of aligning the scientific knowledge with the expectations of a consultation, and then creating lines of communication that allow providers to approach the care of these patients in a team-based approach, has been a remarkable advance in the care of patients with digestive and liver disorders.

PAGE BREAK

Healio: What were some key points from the discussions about the low FODMAP diet in IBS?

Chey: There are four key take-aways on the low FODMAP diet from the meeting.

One, there’s an increasing body of evidence to suggest that the low FODMAP diet provides benefits for patients with IBS, particularly pain and bloating.

Two, while the low FODMAP diet clearly exerts effects on fermentation that can reduce GI symptoms in patients with IBS, there’s fascinating and provocative recent work to suggest that the low FODMAP diet might also have effects on immune activation in the GI tract, which could also contribute to its symptom benefit for patients with IBS.

Three, the low FODMAP diet is far more than just eliminating certain carbohydrates from the diet. It’s a three-step process that includes elimination, reintroduction and maintenance. Right now, I think many practices are only focusing on that first step, and we need to move providers that are utilizing low FODMAP diet toward that three-step process and not just elimination.

Finally, that the low FODMAP diet plan is best administered through a coordinated effort between the gastroenterologist and a GI dietician. Digital tools like the low FODMAP mobile app created by Monash University and our website, www.myginutrition.com, can also be very helpful for patients interested in the low FODMAP diet.

Healio: Did Stephen Vanner, MD, of University of Toronto, share any new or particularly impactful data on the role of the gut microbiome during his presentation?

Chey: Dr. Vanner delivered a fantastic talk. He did a really good job of highlighting the latest data on alterations in the gut microbiome between patients with IBS and healthy controls, showing how that might impact upon a variety of parameters that we think are relevant to the pathogenesis of the disorder, not the least of which is the luminal microenvironment — for example, the way that the microbiome interacts with food, how those interactions could influence things like bile acid concentrations in the intestinal lumen, and how the luminal microenvironment, in turn could affect intestinal permeability and immune activation, with signaling through the enteric nervous system to the central nervous system.

Dr. Vanner also emphasized that while alterations to the microbiome in IBS patients are interesting, what may be most important are the metabolomic consequences of those changes in the microbiome. Just looking at changes in certain strains of bacteria may not really help us to understand what’s most important, which is likely those interactions between bacteria within communities that reside within the GI tract and the resultant downstream effects on the metabolome.

PAGE BREAK

What was clear to me after the discussion was that we’re really at the beginning of this journey and we have a long way to go, but the exciting thing to speculate about is the notion that understanding alterations in the microbiome and metabolome might provide us with attractive targets to develop biomarkers to parse patients into subgroups, and in that way, choose the right microbiome-based therapy for the right patient. Whether you’re talking about antibiotics, prebiotics, probiotics, or diet, thinking about leveraging the microbiome or the metabolome in a way to pursue a personalized medicine approach is very exciting.

Healio: Can you recap some highlights from the talk given by Ryan W. Stidham, MD, of University of Michigan, on nutrition counseling via telemedicine or digital apps?

Chey: Frankly, I was blown away by Dr. Stidham’s talk. He has been at the tip of the spear for our GI program in terms of developing a telemedicine footprint, and he’s been doing a lot of work behind the scenes to allow our telemedicine program to move forward.

I learned so much about the different aspects of telemedicine that all of us are going to face in the near future. There are many issues we have to confront as we develop telemedicine programs, from the equipment and infrastructure needed to deliver the service, to issues involving scheduling and managing patient expectations, to financial and medicolegal/liability issues.

This is clearly the way of the future. If you look at the data that Dr. Stidham and his team collected on patient acceptance, and their willingness to engage in telemedicine, especially those with IBD, it’s overwhelming. The patients actually prefer this way of interacting with their health care providers, so it’s a no-brainer on the patient preference side. There is a small proportion of patients that prefer face-to-face visits, but most patients really like this idea of being able to do a visit over the internet at their convenience, for so many of the obvious reasons: convenience, missed time from work, child care, parking, to name a few.

There are many attractive things about telemedicine from a provider standpoint, as well: being able to do a clinic visit from your office or another designated space, not having to worry about the patient being late because they can’t find a parking spot or there’s an accident on the highway. Importantly, it could significantly reduce no show rates. People no-show for a variety of reasons related to life getting in the way, and you’re likely to minimize that by having patients do their visit at home during a time that’s convenient for them. So that’s a potentially very important benefit for the doctor and the health care system.

PAGE BREAK

However, there are counterbalancing forces that are really holding this in check right now. The federal government seems to be very supportive of this notion of telemedicine, but the problem is that stakeholders are currently struggling with figuring out the parameters around which the government or an insurance company would provide payment, and the standards that define an adequate telemedicine visit. Right now, most providers are utilizing the same standard they apply to an office visit, but the struggle on the payer side is that this is such a new concept, they’re still finding their sea legs in regards to what they’ll pay for, and what level of service and documentation are necessarily to justify payment for a telemedicine visit.

The reason why I inserted this lecture into the program this year, and it was incredibly popular, is because I believe nutrition counseling and behavioral health, things like hypnosis and cognitive behavioral therapy administered by a GI psychologist, are perfect for telemedicine, because they benefit from face-to-face interaction, but they don’t require a hands-on physical examination. – by Adam Leitenberger

Reference:

Food: The Main Course to Digestive Health. September 22-24, 2017; Ann Arbor, Michigan.

Disclosures: Chey is the director of Food: The Main Course to Digestive Health, and director of the Digestive Disorders Nutrition & Lifestyle Program at Michigan Medicine. He reports consulting for Nestle Health Sciences and Ritter Pharmaceuticals, research grant funding from Nestle Health Sciences and True Self Foods, and is a patent holder of My Nutrition Health.