Sunday, December 2, 2012

Exercise and IBD


Crohn's, Ulcerative Colitis, and Calisthenics 


Exercise is generally one of the pillars of a healthy lifestyle.  By doing both cardio and weight training, an individual can increase their overall fitness level, lower their risk of heart issues, improve their mood, increase their overall energy, and improve their ability to stave off illness.  Additionally, exercise is fun – you can find an activity that fits your interests and lifestyle, from walks in the park to parkour, and it is a chance to be social.  There are concerns with exercise and its impact on IBD, though, ranging from the short-term issues from the exercise itself to the long term impact due to exercise-related inflammation. 

Inflammation


Inflammation is the general response of the body’s tissue to an unwanted stimulus.  Chronic inflammation is a serious concern with IBD sufferers.  IBD itself causes both local inflammation (in the digestive system) and remote inflammation (in the case of co-morbid diseases like Rheumatoid Arthritis and Psoriasis).  Overall inflammation is measured indirectly by looking at specific markers.  The three most common markers are:

IL-6.  Interleukin-6 is a cytokine (a molecule that sends signals to cells) that is released during muscle contraction.  IL-6 can cause inflammation, but also inhibits another inflammatory marker, TNF-alpha.

CRP.  C-Reactive Protein is the most common marker tested for in IBD.  It is an indirect measure of overall body inflammation, and a low CRP number is always desirable.

TNF-alpha.  Tumor necrosis factor alpha is another cytokine associated with all of the signs of inflammation.  TNF-alpha inhibitors such as Humira, Remicade, and Cimzia are now the cornerstones of IBD treatment.

Exercise is linked to inflammation in two ways – acute and chronic.  Acute inflammation occurs immediately after exercising (at least intense exercising).  Chronic inflammation is the overall level of inflammatory markers present while not exercising.  Because inflammation is also associated with obesity, smoking, poor diet, and other factors that are correlated with people that don’t exercise, it can be difficult to determine the impact of just exercise on inflammation.  That said, there have been a few studies that have isolated the impact of exercise.

The easiest effects for IBD sufferers to recognize and associate with are the acute effects of exercise.  Light (briskly walking a couple of miles) to moderate (swimming for 30 minutes) exercise tends to have minimal effect.  Strenuous exercise (running a marathon) does tend to have an effect – namely the provocation of heartburn, fecal incontinence and diarrhea.  Individuals running triathlons, even those without underlying IBD, have experienced GI symptoms (between 30 and 81% have reported this).  This is believed to be due to reduced blood flow to the GI tract, the mechanical impact of bouncing, and the overall acute inflammatory increase.  CRP, IL-6, and TNF-alpha markers tend to elevated immediately following a period of intense exercise(1,2)  At the most intense side, ischemic colitis, the lack of adequate blood flow to the large intestine can occur in endurance athletes.  Ischemic colitis is a serious, acute condition that requires immediate medical intervention, and is the result of numerous emergency room visits following marathons each year.  (3)

The long term impact of exercise is exactly the opposite.  Increased bone density, reduced stress levels, and overall lower at-rest levels of all three major inflammatory markers are present.  The impact was found to happen after even light exercise over a 12-week period, and is proportional (though with diminishing returns) to the intensity of the exercise.  Because the overall health impact of both muscle-building anaerobic exercise and aerobic conditioning are both important, two times a week each for strength training and aerobic workouts have been proven beneficial.  As a side benefit, regular exercise has been correlated with a 50% reduction in the risk for developing colon cancer.  (2,4,5)

Special Cases

IBD sufferers have special needs, depending on where they are with their disease.  Anyone who has had a recent IBD surgery (within the past 8 weeks) needs to discuss any psychical activity beyond walking or similar light impact activities with their physician.  Additionally, when flaring, the overall level of activity may need to be toned down – the impact of the flare on general body fatigue and the acute impact on already inflamed tissue may be detrimental.  This is an area where the research is spotty, and additional data is needed.

While fatigue is a general issue for those with IBD, individuals that have had extensive bowel resectioning  (30%+) have an even greater level of fatigue.  Because of this, most cannot tolerate the energy requirements of rigorous exercise.  (6)  

Bottom Line

·         Light to moderate exercise to the level tolerated is excellent for those with IBD that have not had recent surgery.
·         2-3 times a week of aerobic exercise (walking, jogging, swimming, biking) and twice a week of strength training have overall positive impacts on inflammation and quality of life, with generally no negative impact on the underlying disease.
·         Strenuous endurance exercise should be discussed with your doctor before starting a regime.

(1)    H P F Peters, W R De Vries.  Potential benefits and hazards of physical activity and exercise on the gastrointestinal tract.  Gut, 2001.
(2)    Neeraj Narula, BSc and Richard N Fedorak, MD.  Exercise and inflammatory bowel disease.  Canadian Journal of Gastroenterology, 2008.
(3)    I Leon D. Sanchez, MD, MPH , Jason A. Tracy, MD, David Berkoff, MD, Ivan Pedrosa, MD.  Ischemiccolitis in marathon runners: A case-based review.  Emergency Medicine, 2006.
(4)    Christos Kasapis, MD, Paul D. Thompson, MD (FACC).   The Effects of Physical Activity on Serum C-Reactive Protein and Inflammatory Markers: A Systematic Review.  Journal of the American College of Cardiology, 2005.
(5)    Ford, Earl S.  Does Exercise Reduce Inflammation? Physical Activity and C-Reactive Protein Among U.S. Adults.  Epidemiology, 2002.
(6)    Brevinge H, Berglund B, Bosaeus I, Tolli J, Nordgren S, Lundholm K. Exercise capacity in patients undergoing proctocolectomy and small bowel resection for Crohn’s disease. British Journal of Surgery. 1995;

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