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Leveling Up Obesity Management in IBD: How This Bidirectional Relationship Informs IBD Care

Dr. Stephanie L. Gold (Icahn School of Medicine at Mount Sinai): I hope we get to take less time, 10, 15 minutes and talk a little bit about how IBD, obesity and systemic inflammation are all related to each other.

Proposed Etiologic Link Between IBD and Obesity

I think this is a great place to start when we are thinking about that relationship between obesity and IBD. This figure really nicely depicts a conceptual framework linking dietary patterns as you see, obesity, gut microbiome, and chronic inflammatory diseases.

What we know is that the relationship between obesity and chronic diseases such as Crohn's and ulcerative colitis, are likely bidirectional and may be mediated, at least in part, by alterations in the gut microbiome. In addition, we know that dietary patterns, particularly the Western diet, may represent a common upstream driver of both obesity and microbiome disruptions.

Bidirectional Relationship of IBD and Obesity

When we think about this bidirectional relationship of IBD and obesity, we know their current estimates of about 15% to 40% of patients with IBD have concomitant obesity, and about an additional 20% to 40% have overweight. Studies have found that obesity is associated with an increased risk in Crohn's disease. The risk in UC is a little bit less clear.

We know that there are changes in the diversity of the microbiome, the gut microbiome, and altered metabolic signaling of these gut hormones and bile acids in IBD, which may contribute to this bidirectional relationship with obesity.

In addition, there is some question about the interplay of some of our advanced IBD therapies, which we will talk about today and how they may contribute to the picture with overweight and obesity as well.

High-Fat Diet, Obesity, and Inflammation

I really like this figure because it really demonstrates this bidirectional relationship and the connection between gut inflammation as well as obesity. We know that in patients with more of a typical Western diet, it can lead to what we call dysbiosis or changes in the microbiome, and that can lead to shifting in the immune cells, leading to barrier dysfunction and then bacterial translocation against that barrier.

That can lead to the inflammation that we see systemic and transmural inflammation, which is also connected then to obesity. We see these hypertrophic adipocytes, so the cells there, and the adipocytes themselves are not benign. They are also secreting adipokines, proinflammatory cytokines, things we talk so much about in IBD, like TNF, IL-6, leptin, resisting.

All of these are connected in a way that we are now understanding that it is not just two separate diseases, but really a tale of two epidemics together.

Visceral Adipose Tissue as an Immunologic Player

Interestingly, in IBD, we have talked a lot about obesity and a lot about BMI, but what you will see in the data is that the BMI studies, the results are quite heterogeneous. What we have come to understand is that is because BMI may not be a great marker in IBD, but in fact, what is a much better marker is visceral adiposity.

We know that visceral or central adiposity that patients carry around their abdomen is associated with proinflammatory signaling and release from those adipocytes in that mesenteric fat. That is where you are seeing these adipokines and proinflammatory cytokines. We know that visceral fat contains macrophages, and they can secrete tons of inflammatory cytokines as I just said. We are back to those same TNF, IL-6, etc.

These proinflammatory cytokines may then increase gut permeability and the risk for bacterial translocation just furthering that systemic inflammation that we see in inflammatory bowel disease. We know that hypertrophic mesenteric fat, as we said, is secreting these pro-inflammatory cytokines leading to inflammation wrapping around the bowel wall and maybe even contributing to fibrosis.

When we have a target in IBD, we really want to be thinking, yes, absolutely to approaching the weight as a whole, but really thinking about what can we do to reduce visceral adiposity.

Obesity and VAT Affect IBD Treatment

When we think about visceral adiposity, a couple of really NICE studies have been done showing, first and foremost, that increased visceral fat is associated with more severe phenotypes in presentation for Crohn's disease. That means more stricturing disease, more fistulizing disease.

Beautiful studies have been done showing that more visceral adiposity is associated with poor response to anti-TNF therapy. Those patients with higher amounts of visceral fat needed more drug in order to achieve a steroid free remission and to achieve endoscopic remission.

We know in our patients who may need a surgery, that increased visceral adiposity increases the need for surgery, and in those who undergo a surgery, increases those surgical complications that we see, that risk for stoma, other post-op complications like leaks, infection, longer lengths of stay. This is really what we want to be targeting in our IBD patients is trying to reduce that visceral adiposity.

IBD Treatment Considerations

We know that obesity is a risk factor for reduced response, as I just said to biologics and other meds we use for IBD. We will talk about that. There is this question of how are we using weight-based dosing to make sure some of our medications are weight-based, some are not. How are we addressing the obesity there?

NICE studies have been shown looking at a couple of the different medications that we have available, including some of our JAK inhibitors, showing that weight gain may be an unintended side effect in some patients, maybe suggest of some dysregulation in leptin signaling, increasing patients appetites. We really want to be thinking not just about the obesity at presentation, but then the medications we are using, how is that impacting a patient's weight over their disease course?

Skills Building I

Amy Stewart: Thank you so much, Dr. Gold. With that, let us get into some cases and some faculty discussion as we work through this data here.

Patient Case 1: Maya R, 42-Yr-Old Woman With Ileocolonic CD

Our first patient is Maya. She is 42 years old, and she has ileocolonic Crohn's disease. Maya was diagnosed with ileocolonic Crohn's about eight years ago. She reports increased fatigue and intermittent loose stools. She also has hypertension, pre-diabetes, knee pain, and anxiety.

Her current therapy she is on ustekinumab, she is also on amlodipine, vitamin D, and sertraline. Maya has an elevated CRP. Her BMI is 36. A quote from Maya here, “my weight keeps going up and I am worried my IBD medications are failing, but every time I try to eat more vegetables, my gut gets worse”. Dr. Gold, do you hear this in your clinic, and words like this from patients.

Dr. Gold: Every day. Absolutely. Our patients are really struggling because they see what society deems as recommendations for weight loss, but that may not be something that works for our patients. It is incredibly important to talk to our patients about understanding what they can do in terms of lifestyle modifications. I know we are going to talk more about that, but peeling and cooking those vegetables, making soups and smoothies for increased tolerance, and then addressing the obesity as well, especially given the concern that maybe ustekinumab is not working as well.

Amy Stewart: Thank you so much. Quote from Maya, “I am embarrassed to bring this up. I thought Crohn's disease made people lose weight, but I have gained 30 lbs. Does that mean mine is not really active?” I think many of us in GI see this in clinic all the time. It is a common conversation that we have. Here is a good example of a quote of how a healthcare professional could respond to this.

“I am glad you brought it up. Weight changes in Crohn's disease can go in either direction. Increased weight does not mean that your symptoms are not real, and it does not rule out inflammation or nutrient deficiencies. Would it be okay if we talk about how weight, inflammation, treatment and food patterns can interact?”

What I really like about this quote here is that asking for permission, right? Is it okay that we talk about that? Dr. Gold or Dr. Sepulveda, do you have suggestions of how you bring this up to and how you also ask for permission with patients to talk about it?

Dr. Gold: Absolutely. I can just jump in, and I am sure Dr. Sepulveda also can. I love to just keep it as open ended and supportive as possible. I will say to patients, tell me a little bit about your weight history. I find that gives patients a way to take me on a journey. A lot of our IBD patients have had yo-yoing of their weight up and down with flares. They are losing weight. Then when they are feeling better, they are gaining weight. They will take me on this journey, and then usually will let me know if their goals are to gain weight, to lose weight, where they are at in their journey.

Dr. Rafael Sepulveda (Sleep Fit Medical): Like for me, I always try to ask them, what does your current weight mean to you? Or what is your history with weight? It is a good way to have them open up and feel more comfortable. We have to also think that a lot of patients have self-stigma about obesity as a disease process. It is a good way to start the conversation in a good way.

Amy Stewart: Thank you so much. What I also really want to highlight on these slides is that, we talked about patients with obesity and patients with overweight, and that language really matters. We are not describing patients as obese or overweight, but rather they have obesity or overweight.

When we are using that communication and we chart, how we talk to our colleagues, but also how we talk to our patients, really can make a difference in providing that trusting relationship and destigmatizing the conversation as well.

Posttest 1

With that, let us go into some post-test questions before we get back to Maya. Which health care provider response best demonstrates non-stigmatizing, clinically accurate counselling when discussing obesity and Crohn's disease with a patient?

A. “Higher BMI can contribute to GI symptoms, so we should emphasize dietary change before assuming the Crohn’s disease is still active”

B. “Weight loss may improve treatment response, so we should address obesity before deciding whether the current Crohn’s therapy is working”

C. “Weight and IBD can influence each other; higher weight does not rule out active disease, and we should assess inflammation and nutrition”

D. “Because Crohn’s disease often causes weight loss, higher weight may suggest better disease control and less need for additional inflammatory assessment”

Looking at the answers here, about 69% of people chose C, and that is a correct response here. Weight and IBD can influence each other, but higher weight does not rule out active disease and we should assess inflammation and nutrition. This response validates the patient avoids weight stigma, separates body size from disease assessment. Patients with IBD and obesity may still have active inflammation, malnutrition, micronutrient deficiency, or sarcopenia. AGA guidance emphasizes screening for malnutrition symptoms and monitoring iron and vitamin D deficiency in patients with IBD. Anything to add here, Drs. Gold or Sepulveda?

Dr. Gold: I think you hit the nail on the head. These diseases are really – you can see them together and just really want to make sure we are assessing the full patient, that we are assessing for the inflammation, we are targeting the weight, all of these things together.

Patient Case 1: Maya R, 42-Yr-Old Woman With Ileocolonic CD

Amy Stewart: Thank you so much. Let us get back to Maya. She asks, is my weight making the Crohn's disease worse. Before we read the [inaudible] response here, how would you respond to that, Dr. Gold, in your practice?

Dr. Gold: It is a great question. I love that the patient is even asking about this, because that means that the patient is really hearing that these two diseases can coexist together. I always talk to patients a little bit about obesity as well as visceral adiposity, and tell them about the data that we know that patients with increased visceral adiposity can have poor response to biologics, as we reviewed this morning. They can have more severe phenotypes, may need more surgeries and have more surgical complications, and even can have poor quality of life.

We want to make sure we are addressing this. I would encourage the patient to understand that the weight is not just increasing cardiometabolic disease in a patient with IBD, but is also increasing the risks of making it harder for us to treat our underlying Crohn's disease.

Amy Stewart: Thank you so much for that. An example of a response here, and I think practicing these conversations with patients is also really important to make sure that we are comfortable, we are saying the right things, and again, we are building that trusting relationship.

An example of another response. “It might be contributing, but I want to be precise. We know that overweight and obesity are common in people with IBD. Obesity has been linked to lower response for some IBD therapies in our clinical studies. But it is not as simple as weight causes flare ups”. I think being precise about that last point is really key here.

Poll 3

Let us move into a poll. Which counselling message is most accurate?

A. “Obesity may affect IBD through inflammatory pathways, but the relationship is complex and not fully causal”

B. “Obesity may amplify inflammatory signaling, so weight reduction should be considered an initial strategy for controlling IBD activity”

C. “Obesity is mainly relevant to cardiometabolic risk, while its effects on IBD inflammation and treatment outcomes remain clinically limited”

D. “BMI is a practical surrogate for adiposity-related inflammation and can reliably identify patients at higher IBD inflammatory risk”

Here, about 57% of people chose option A, and about 23% of people chose option B, eight and 10 for C and D. What do you think here, Dr. Gold and Dr. Sepulveda? What would you say?

Dr. Gold: Dr. Supulveda, do you want to go ahead?

Dr. Sepulveda: Yes. In general, we have to think that IBD and obesity as disease process are mostly multidimensional. We have to think about adiposity in general and what that means to your microbiome, what that means to your different hormonal pathways. In terms of BMI use as a measure, it is still useful, but we have to think that what we are trying to target is adiposity in general in terms of body composition. Other tools can be used to help assess obesity in this case.

Dr. Gold: Absolutely. I love the part of that statement that says it is complex and not fully causal and not fully understood. I think that is such an important point that I talk to patients about. Patients will come to me and say, I read this one study or I saw this, and the reality is that while we are seeing this relationship, there is so much we still need to learn and to understand, and so I want patients to understand that the relationship here is quite complex and we do not have all the answers yet.

Amy Stewart: I think with that, D not being the most appropriate counselling message, here is that BMI is only one part of the story, and does not account for many of the other things.

Dr. Gold: Absolutely.

Amy Stewart: Patient Case 1: Maya R, 42-Yr-Old Woman With Ileocolonic CD

Back to Maya, our 42-year-old woman, reminder she is got ileocolonic Crohn's disease. She tried salads, beans, and raw vegetables because she heard that anti-inflammatory diets are good, but she had cramping and bloating, so she gave up. Let us talk about some nutrition advice that we might share with our patients here.

Dr. Gold: Absolutely. I hear this every day and I am sure you all do as well. You really want to make sure that we are guiding our patients to make sure that they are able to get as much nutrition as possible, so they are not getting malnourished whether or not they are on an anti-obesity therapy or not on an anti-obesity therapy.

We talk a lot to our patients that if they are not able to tolerate some fruits or vegetables in their raw forms, we do a lot of texture modification strategies. For example, here we would take away the raw veggies and do cooked and peeled vegetables. Really big fans on pureed vegetable soups, as well as other really soft and cooked veggies. Beans can be mashed up into different consistencies. Having things like hummus instead of chickpeas or even baked fruits. We do a lot of like fruit compotes.

All of these are really nice ways for our patient to get in all that good nutrition, the soluble fibers that are in those foods, without causing GI distress, like the bloating and the cramping that a lot of our patients have. This is especially true, I think we will talk a little bit later about stricturing disease, but especially true in those patients who may have an ileostomy or stricturing disease. You really want to – you do not want to be eliminating things from the diet anymore. You just want to be modifying the textures.

Amy Stewart: An appropriate response here too with that is it is common, especially if there is gut sensitivity. The goal is not to find the perfect diet, it is to find the pattern that you can tolerate and sustain. Also remembering this can be individualized based on the patient, but also there can be a lot of fear of food from years of inflammatory bowel disease. How do we also work on that relationship with food and slowly add things back in?

Poll 4

With that, another polling question here for you. Which dietary counselling approach is most appropriate?

A. Recommend limiting high-fiber foods during obstructive symptoms or strictures, then broadly avoid fiber long term to minimize Crohn’s complications.

B. Recommend a structured anti-inflammatory diet to reduce flare risk, emphasizing that dietary modification can replace escalation of IBD therapy

C. Recommend a low-carbohydrate ketogenic diet to prioritize weight reduction, with reassessment if abdominal pain, diarrhea, or intolerance develops

D. Recommend a Mediterranean-style diet, individualized for symptoms or strictures, and coordinate care with a registered dietitian

About 34, a third of people, chose option B, recommending a structured anti-inflammatory diet to reduce risk, emphasizing that dietary modification can replace escalation of IBD therapy. About 56% of people chose option D, recommending a Mediterranean-style diet individualized for symptoms or strictures and coordinating care with a registered dietitian.

How often do each of you recommend patients to see registered dietitians?

Dr. Gold: I can start there. Absolutely, we are so lucky to have amazing registered dietitians in our office who have training in both treatment of inflammatory bowel disease and then also in treatment of obesity as well. It is incredibly important that patients are engaged with the dietitian to make sure that they can get their questions answered, and that they are getting in as much nutrition as possible.

My hesitation would be the concept of that you are going to be replacing IBD therapy with a dietary modification. We do lots of dietary interventions for our patients with IBD, and I think this is just a very specific conversation that should be personalized to the patient. There are some patients who are able to use diet, both for induction and maintenance of remission of their Crohn's or ulcerative colitis, but I would say this should be a one-on-one conversation with the provider, as it is not going to be the right option for many patients.

We want to make sure we are selecting for those individuals the right patient and the right diet to do that. We do not want to be telling patients that we are going to use dietary modifications to replace escalations of IBD therapy.

Amy Stewart: Absolutely. Thinking of diet as an adjunct onto other things that we are doing, right?

Dr. Gold: Wonderful adjunct therapy, absolutely.

Amy Stewart: What I really like about D too, which is the most appropriate counselling approach here, is individualized for symptoms and strictures, which really our registered dietitian colleagues can do. That is their training, particularly obviously if they have IBD and obesity training as well.

Dr. Gold: Absolutely.

Patient Case 1: Maya R, 42-Yr-Old Woman With Ileocolonic CD

Amy Stewart: Back to Maya here, again, our 42-year-old woman with ileocolonic Crohn's disease, her primary care doctor mentioned a GLP-1 medication, but she is worried that it is going to worsen her GI symptoms or interact with Crohn's disease treatment. I would love to get both of your thoughts on how you talk about this with patients.

Dr. Gold: Absolutely. I can start off. I hear this all the time, and I try to get patients to move away from what they have heard. Maybe it is from family or maybe it is from the internet, social media. I try to take a step back and start from a fresh baseline, because I think there is a lot that is been out there, good and bad, about GLP-1s and other therapies.

We really talk about the pathophysiology of obesity and IBD. I talk to them about that. I talk to patients about the reason to actually treat their obesity, why are we doing that, which we have highlighted today? It makes the IBD, it makes it easier to treat the IBD, preventing IBD complications going forward. Then I talked to them about safety and efficacy of the GLP-1s. I think that is a nice transition because you start off by telling patients why this is important, and then go into the fact that we have known from the data that this medication is safe and potentially actually may even benefit some of their GI symptoms, which we can talk about for some of our patients who are having some looser stools like this patient, the antimotility effect of a GLP-1 can actually be quite beneficial and can slow down the stools for them.

I think you just really want to make sure that you are educating the patients as much as possible on what we know.

Dr. Sepulveda: I think from my perspective, I usually ask what they heard, and I just explain a little bit of the inflammatory process that they are going through in terms of their GI symptoms, and how reducing adiposity could benefit the outcome of that condition. A lot of times that conversation is very much multi-dimensional as well, and we get to the root of what is important to the patient. That way, we can find a common ground to move forward.

Amy Stewart: Thank you so much. I think that is incredible advice from both of you. There is also a response here, an example that we could use. It is a reasonable thought, GLP-1 medications can cause nausea, constipation, diarrhea, and abdominal discomfort, which can overlap with IBD symptoms, but early data and IBD are reassuring. Stronger evidence is needed. Really having those one-on-one discussions with our patients about how we are going to monitor throughout.

Poll 5

With that moving into another polling question. Which next step best reflects coordinated, patient-centered care?

A. Start ant obesity medication with symptom monitoring while postponing additional IBD evaluation unless gastrointestinal symptoms worsen

B. Focus on confirming and treating IBD activity first, and avoid weight loss pharmacotherapy until sustained clinical remission is achieved

C. Assess IBD activity, evaluate nutrition and comorbidities, refer to a dietitian, and discuss lifestyle intervention with possible pharmacotherapy and monitoring

D. Establish a 10% weight loss goal before modifying IBD therapy, and use subsequent symptom change to guide further disease assessment

All right. I think all of our talk about individual therapy has really made a difference here. 89% of you chose option C, which is the best next step reflecting coordinated patient-centered care.

Ask, Explain, and Plan

Some tips for talking to patients about this. Ask, Explain, and Plan. Number one, ask permission and assess priorities. Is it okay to discuss your weight as part of your IBD care? Then disease activity using symptoms, biomarkers, diet tolerance, food avoidance, restrictive eating, malnutrition risk, sarcopenia, iron and vitamin D deficiency, current therapy and comorbidities, and also assessing our patients’ goals and prior weight loss experience, as we have talked about throughout this.

Explaining the relationship without adding any blame. IBD and weight can affect one another. Increased weight is linked to inflammation, treatment response, surgical risk, and other health conditions. This is not about blame; weight alone does not tell us if your Crohn's disease is controlled.

Then for Maya specifically, planning one to two realistic next steps. Checking FCP, CRP, therapy adherence and timing, considering optimization if needed. Refer to an IBD-experienced dietitian, shift diet from raw to tolerable healthy foods, address physical activity, keeping in mind that she has knee pain. Coordinate anti-obesity medication initiation access with primary care or obesity medicine, and avoid using weight loss as a prerequisite for appropriate IBD therapy.

Poll 6

Two more quick polling questions here before we move on to our next section. How confident are you in counselling your patients with IBD about weight management?

A. Not confident

B. Somewhat confident

C. Confident

D. Very confident

E. Extremely confident

Poll 7

All right. Moving on to one more here. Write one change that you can make in your practice with regard to counselling patients with IBD about weight management. Go ahead and type in your answer now.

I love seeing all the changes that we are planning to make. With that, Dr. Sepulveda, into your section here.