Understanding and Preventing the Global Increase of Inflammatory Bowel Disease
Section snippets
Epidemiologic Features in 2017
The diagnosis of IBD is made in every inhabitable continent, among all ethnicities and socioeconomic classes. Although IBD is most prevalent among individuals of European descent living in wealthy Western countries, newly industrialized countries in Asia, the Middle East, Africa, and South America have reported rapid increases in incidence.10 As incidence increases, the prevalence of IBD also is increasing in many of these countries. IBD care will be required for an older population in the
Genetic Clues to Pathogenesis
Pathogenesis of Crohn’s disease and ulcerative colitis involves a dysregulated immune response to commensal microbiota in genetically susceptible individuals. The lifetime risk of IBD in first-degree relatives is at least 2-fold higher in Ashkenazi Jews than in non-Jews.39 Twin studies have supported the heritable component of Crohn’s disease and ulcerative colitis.40 Crohn’s disease has 20%–50% concordance between monozygotic twins and 10% concordance in dizygotic twins; concordance values for
Environmental Determinants
The increasing incidence of IBD in newly industrialized countries indicates the influences of a Western lifestyle, urbanization, and industrialization on risk.34, 51 Empiric observations have shown a handful of environmental risk factors for IBD,52 including cigarette smoking (protects against ulcerative colitis in all regions; increases risk for Crohn’s disease in Western, but not in Eastern Asian, countries),51, 53 antibiotic use during childhood (increases risk in Western countries but
The Microbiome and Epidemiology
The intestinal microbiome has an important role in IBD pathogenesis.81, 82 Patients with IBD have broad changes in their intestinal microbiota profile compared with individuals without IBD. In addition, a number of specific changes have been identified, such as a decrease of the butyrate-producing species Roseburia hominis and Faecalibacterium prausnitzii.83 The commensal gut microbiota is ecologically and functionally perturbed in patients with IBD. Treatment-naive patients with new-onset
Future Directions
The combination of the increasing prevalence of IBD and high per-patient cost of care will strain nations and widen the health care gap among individuals of different socioeconomic status.1 Gastroenterologists must unite to support a philosophy of clinical stewardship that balances quality of care to patients with IBD and the increasing societal cost that jeopardizes this care. Gastroenterology clinics therefore should innovate delivery of health care to patients with IBD, to efficiently and
Preventing the Global Increase
To stop the global increase of the incidence of IBD, we should direct our attention to factors associated with protection. Because potentially relevant environmental influences span the spectrum from mode of birth, to early life exposures, to risk factors in adulthood, different populations with different risk factors may require interventions at different time points. Several groups are potentially the most useful to study: pediatric populations, high-risk groups (first-degree relatives and
Acknowledgements
The authors would like to thank Fox Underwood for editing the manuscript and creating the interactive map. The geographic country data were created by the Natural Earth community,105 and the world map was prepared using QGIS106 with the HTML Image Map Plugin.107 The authors would like to thank Whitney Tang and Tiffany daVanzo for their assistance in the development of the figures.
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Conflicts of interest The authors disclose no conflicts.
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Authors share co-first authorship.