Thriving with Sjogren's: Nurturing Your Gut for Optimal Health
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Kara Wada, MD: Welcome back to this episode of Becoming Immune Confident. Hi, I'm Dr. Kara Wada and we are continuing our conversation today with Cristina Montoya about Sjogren's and gut health. Not only is Cristina an expert in helping women with autoimmune conditions like Sjogren's and rheumatoid arthritis, but she helps them navigate the often confusing world of gut health.
She also lives with both of these conditions herself. In this episode, we'll dive into the specific actionable strategies you can use to nourish your gut and to feel your best when living with Sjogren's. We'll cover everything from dietary adjustments to lifestyle changes that can make a real difference.
Get ready to take notes.
Understanding Sjogren's Impact on the Body: Beyond Dry Eyes and Mouth
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Cristina Montoya: When you go and you go see the doctor, and you say you have sjogren's, what's the first thing that they say to you?
Kara Wada, MD: Dry eyes and dry mouth.
Cristina Montoya: And what are the recommendations?
Kara Wada, MD: I mean, eat more veggies. Drink more water.
Cristina Montoya: Just drink water. And, uh, yeah, that's fine. Well, it is not. Okay. cheers, right? We do need the water. Yeah, for sure.
Neurological Manifestations and Gut Health: The Gut-Brain Connection
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Cristina Montoya: But this is what's so fascinating about understanding the impact of sjogren's on gut health, starting from your mouth. Because for many years we thought, Oh yeah, so sjogren's causes dryness because there's an infiltration, lymphocytic infiltration, right? And the salivary glands and the tear glands, mainly. But then when you think about the glandular function, if you think about someone with diabetes, you're still able to produce insulin even if you're functioning at like a 50%.
So there were questions, why isn't that happening with someone with Sjogren's? They still have a 50% function, but they are not producing enough saliva. So this is where they're starting to say, Hey, wait a minute. There is another manifestation here, which is the neurological manifestation affecting the autonomic nervous system and there is not enough, there is a disconnect and helping stimulate saliva. So when someone is a healthy person, they grab maybe a slice of lemon.
They immediately, just a thought, just a look at the lemon, they salivate. They haven't even tried it. You have someone with Sjogren's and try that and see if there's any saliva coming down, especially if they are pretty advanced in their condition. Nothing. And in that case, it's probably more that there was an impairment of the autonomic nervous system, specifically the parasympathetic nervous system that is not really active enough to activate that sensation and send the signals to the brain, "Hey, I need to produce saliva because this person is going to eat. I need to get it ready so that the digestion process starts."
And it all trickles down from that. So then you go down to the esophagus and again, they will blame it to the dryness. But we also, there's secretory glands in the esophagus. So if they're not triggered to, like, to release those secretions, then it causes more dryness and difficulty swallowing. And again, there's also could be dysregulation and motility. So you're not only, like, going down with the dryness, but the esophagus is not propelling all the food down. On top of that, and there has been quite a few studies showing that the patients with Sjogren's also have like a low pressure of the esophageal, the lower esophageal sphincter, meaning that it just doesn't contract enough. Then what happens then? Gastroesophageal reflux disorder. And it just, it continues. It's like a rollercoaster, like, it just, like a snowball I will say that basically starts in your mouth.
Kara Wada, MD: I think that, you know, the important points to really like emphasize there is that not only is it dryness, but also neurologic implications from that contributing to the decrease in saliva production and excretion, but also motility issues from gum to bum, as you put it.
Gastrointestinal Manifestations and Research: The Latest on Sjogren's and the Gut
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Kara Wada, MD: And, to complicate matters to kind of learning more about how, you know, some of these changes in our microbiome and the permeability of the gut lining, you know, how that may be stoking the fire of some of these inflammatory changes from the get go, which I think, you know, kind of thinking back in my story of the first symptoms I experienced, or I recall experiencing were chalked up to IBS type symptoms, you know, back in college of just lots of tummy distress all the time. And with particular foods that would definitely add lighter fluid to that situation.
Cristina Montoya: That's correct. But for many years, like I've been with the Sjogren's Society of Canada, or involved in some of the education, almost since 2016, at some capacity, and I remember my first presentation with them was about Sjogren's and Irritable Bowel Syndrome. And back then I also wrote an article for the Sjogren's Foundation, even then, for me it's like a, "Yeah, maybe that's just what it is, it's Irritable Bowel Syndrome." But then I think two years ago in 2022, that's when I challenged the rheumatologist here in Canada. And I said, Hey, let's just do a workshop. And it was approved. And I think about the gastrointestinal manifestations in Sjogren's and I was so happy with my own rheumatologist attended the workshop. And it's like, "Wow, I had no idea." And because of that, I started asking more questions to my patients. So even if I can make a difference, it's just that one rheumatologist and somehow it will go down. I think I'm doing my job. I know it's taking a lot of time.
Challenges in the Medical Field and Nutrition: Navigating Misinformation
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Kara Wada, MD: Uh, I was talking with someone this morning just about how slow sometimes things evolve within the medical field. Um, I think, I don't know if it's physicians were just stubborn or we get like locked into thinking that everything's the same as what we learned through our training. Even though we are actively, you know, we all have to keep up with our continuing education, like within allergy, our example is like, we've known that flu vaccine and egg allergy are not related for over 20 years, but we still will be asked that question, you know, a little less than I used to, but it was some regularity because I think sometimes misinformation just keeps getting perpetuated. It's really frustrating.
Cristina Montoya: It is, I mean, you know, in the field of nutrition, now everybody has an opinion on it. And we know that nutritional science is a fairly young. And it's a young science field and it's evolving. But because food is the one thing that everyone has control over. That's the one thing that we know, we put in our mouths. Uh, but I find it very responsible for moderate peoples without understanding what a individual person is going through, what is their medical condition, but they just feel so like strong about their message and they're actually causing harm. And so many times when I get a chance to be on Instagram or, you know, or programs like this one, I try to maybe break down those myths that it's not just about the food, it's just one piece. And remember, it's like when you eat an orange, you're not just eating like vitamin C, it's a combination of vital nutrients, fiber. And then depending, like you say, like the gut microbiota, what is the composition of the gut microbiota and how that gut microbiota is going to interpret those message.
How is it going to take those phytonutrients? And I also find it interesting that it's not only just food that influences the gut microbiota.
There is some research done, especially in rheumatoid arthritis patients, that prior to being diagnosed with rheumatoid arthritis, they do find that they have dysbiosis. So yeah, there's like, there's an alteration in the gut diversity.
But once they're started on methotrexate, that concentration, like the harmful bacteria, it starts to diminish. And so it's also maybe the fact that you're immunomodulators, you an immunologist that is not just about the food that we eat, but all the environmental factors around it.
Kara Wada, MD: We've seen similar findings with eczema too. And I think, you know, it's this idea that the barrier is broken and along with a broken barrier, you see changes in maybe the types of bacteria, the amounts or how they behave. And we don't know what is the initial insult. Is it the barrier becoming leaky? Is it the microbiome? But when you see the barrier healed using medications or what have you, like the microbiome also changes along with that. And so, in order to see sustained improvement, at least in the skin barrier too, they're looking at how can we help support those healthy microbes to kind of reinforce that.
And, you know, we're literally just scratching the surface. And I think, you know, as you think about the logistics of researching this, it's a lot easier to look at a rash on our skin and study that and biopsy it and swab it and do all these things, you know, certainly compared to being much more invasive with our GI tract. And so I'm excited about what we'll learn in the next, you know, 10 years even, but also a little bit impatient too.
Cristina Montoya: And it's still, and it's still, but I have to see, I have to say that I've seen advances in therapy, development therapies, like for like rheumatoid arthritis, I always say as bad as it looks, like it looks, you know, my hands are twisted. But nowadays, I'm not saying that being diagnosed with rheumatoid arthritis, for instance, it's a great thing. No, it is not. But in terms of treatments and options, this is perhaps a better time than when I was diagnosed. When I was diagnosed, the only options were methods, but just maybe a few. It's maybe three therapies and that's it. Whereas here, I have gone through like maybe four different biologics and thankfully, I have reached clinical remission for rheumatoid arthritis for the past year and I'm like knock on wood. And so that's why I continue focusing on my Sjogren's because we still don't have an approved like FDA treatment for Sjogren's and unfortunately it is still an autoimmune disease that is highly underdiagnosed, under treated, under recognized. It's still considered like a nuisance to dryness disease, which we know it is not, and I still experience many of the symptoms that I know for a fact they're related to Sjogren's and not to rheumatoid arthritis. Because over the years you learn to identify what comes from one, or most of the time what comes from one disease and what comes from the other.
Dietary Adjustments for Sjogren's: Gastroparesis and Beyond
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Kara Wada, MD: Another aspect of Sjogren's and its impact on the gut that I've learned a lot from you to recognize in my patients, especially, or to look for in my patients to know to look for is gastroparesis, which essentially is slow emptying of the stomach. And, you know, when we come back to that idea of some of the things that we hear and see all over the internet, there's a lot of stuff out there that maybe it's going to be a lot less helpful for those with gastroparesis. So maybe we can kind of dig in a little bit about that.
Cristina Montoya: Oh, that one is an interesting one because I also recently was watching one of the webinars on the latest treatment of guidelines for gastroparesis. And they still don't have a lot of answers for it. One, it is quite complex to diagnose in terms of having access to gastro motility clinics, is that one. Especially here in Toronto, I think we only have one. And it's, yeah, it is very booked. It's very difficult to get into the gastro motility clinic unless you're like basically, you know, pooping or not able to swallow anything at all. So then you get a referral there. That diagnosis process can be lengthy.
Um, in terms of nutrition, we need to modify it quite a bit, right, because the idea, in a way, is we also want to somehow continue stimulating that peristalsis along the gastrointestinal tract. So, the small meals are still recommended very soft because we want to make sure that they're also trying to pass through the gastrointestinal tract a little bit faster than you would want. And here's in a situation when it gets sticky because you know, gastroparesis almost kind of goes to constipation, right? Because there's that lack of movement. So then people tend to saturate themselves on fiber supplements. And take like, "Oh no, just take Metamucil." I love Metamucil. But it's not the best option for someone who is suffering gastroparesis. I feel that in that situation, we need to see like case by case. What are their routines? Right? So what is their lifestyle routine? So what time do they get up? What do they consume throughout the day? Are there any medications or is there any possibility of switch those medications to maybe liquid medications? You want to try to come down that like gastrointestinal tract like as much as you can. So it's just fascinating. I don't know, but it's painful.
Kara Wada, MD: Yeah. Oh yeah. And I mean, it's hard because everything you see out and a lot of the advice that we generally give, you know, eat a higher fiber diet, eat lots of veggie, you know, eat, you know maybe end up kind of being the worst advice for someone with gastroparesis.
And so as you, you know, going back to what you said, it really is so important to know what's going on, be mindful of how you respond to food and realize that, you know, a lot of these kind of protocols or, you know, have kind of the, everything spelled out what you need to do aren't necessarily, you know, one size fits all doesn't fit all.
Cristina Montoya: It doesn't, and I learned especially for Sjogren's, it's like I can see the differential between, let's say rheumatoid arthritis and Sjogren's. So rheumatoid arthritis generally, you know, you see like how the Mediterranean diet way of eating is still, you know, the primary anti inflammatory eating pattern. And I believe in that, I think, and I try to practice it as much as I can. But when it comes to Sjogren's, especially those with gastrointestinal manifestations, sometimes that high fiber load of the Mediterranean diet is a no no and it can cause pain and frustration and disbelief like, "This is not an anti inflammatory diet at all. Why is this causing me so much pain?" And so that's when we get, you know, health care professionals who care about what you're saying, who are knowledgeable, who are interested in this, and maybe for us, like, who actually live with the condition, we can really help those at times to understand what is going on with their bodies, and try to get their best shape, I think, and we can get that.
Practical Tips for Gut Health: Plant-Based Foods, Hydration, and Meal Timing
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Kara Wada, MD: Any advice, you know, if someone has a recent diagnosis of Sjogren's or RA, or maybe they just suspect their gut health is not where it needs to be, what's like your best first step that you might recommend for someone who's just kind of starting off on exploring this?
Cristina Montoya: To me, I always, my first thing when it comes to gut health in general, that we know plant foods are the first thing to go to, right? So in a way, I don't like to use this word like detoxification. Like we know our liver, if it's working, like it's doing its job. And if we're pooping and we know that we're detoxifying and we're sweating, but that maybe we're not doing that. But, uh, what I mean is more about like shifting. How are we eating? And now I mentioned to you that I'm doing like a kitchen clean out and you start looking into your pantry and I said, what isn't there that is supporting your gut health? So are you maybe filling your pantry with more legumes, right? That are like, um, you know, that are high fiber, high protein, and you are adding more whole grains.
Are you adding more like quinoa or brown rice type of thing? Note that I'm not against white rice because I love my white rice. I'm sorry, but I'm Latina and I love it. So I just want to make that clear that even white rice can be a very supportive food for gut health, right? You cook it, you cool it, you reheat it the next day and we have resistant starch, which is great for gut health. So I feel that the first thing that you want to see, at least, is to start adding more plant foods into your diet. You want to aim, let's say, like the rule is like 30 different plants, plant foods a week and it may seem that is way that's too much and it's not. Like if you take your typical oatmeal in the morning, if it just instead of having just the plain oatmeal with butter then you want to add like seasonal fruits or even frozen fruits. You want to add some seeds, you want to add some nuts, right? You want to add some spices, cinnamon, right? Like nutmeg. And in there you could even have just six plants in one meal. But on the other hand, you don't want to be like go overhead and like smoothies, especially people with Sjogren's. We really, our go to are smoothies. Where smoothies can be a bomb. If you're suffering from gastrointestinal disease, especially if you don't tolerate like high FODMAP foods. If for some reason you start adding all the, oh let's add apples and bananas in that concentration of fructose in that smoothie, I'll tell you half an hour later, it's a bomb.
Kara Wada, MD: Yeah. I've certainly I have had some patients say I look seven months pregnant or I'm running to the bathroom or I'm just like doubled over from the fiber bomb and fructose bomb. Yeah.
Cristina Montoya: That's true. I do not feel that it, I know it's like so common and as Sjogren's we tend to, oh, just hydration. You know what I noticed? Some things with Sjogren's have learned, actually no, don't drink a lot of fluids. They drink sips. They don't take the time to actually, you know, go up and drink a full glass of water. So they might sip throughout the day, then they might maybe reach maybe two cups of water, but it's, "Oh yeah, I'm drinking water. I'm just sipping on it." But to actually, you are going to, you know, that you're having a high fiber a meal or high fiber snack. You want to accompany that with a full glass of water, not just sips. Just a full glass of water to make sure that you get that fiber moving and you also activate the peristalsis. That's why you also want to think about it. I don't need for, especially for gut health. I've like intermittent fasting. I have my doubts because during the day, even though we find that like counterproductive, but actually one way to help to stimulate our gastrointestinal tract is by eating, right? So if you eat, you're going to stimulate the peristalsis. What you want to make sure is that you want to keep the timings of the, like the physiological timings. So you don't want to keep your stomach full constantly. So let the stomach rest for two or three hours after you eat. But then make sure that you always have your snack and you like power up the snack with like your protein, grain and fruit or veggie.
That's like kind of my, my one, two, three go for a snack. And, but the one thing you can do is instead of the fasting is like giving an overnight rest to the gut. So let's be like your last meal to be at 7 PM and maybe your first meal or beverage to be at 7 AM. And if you want to stimulate more even your gastrointestinal tract, make sure that that first drink is something warm. If you enjoy your coffee first thing in the morning, go ahead. If it doesn't make you, it doesn't stimulate, doesn't always stimulate your gastrointestinal tract, but something warm. And if you have especially constipation, that's probably one of the best things you can do. Something warm, and especially coffee.
Kara Wada, MD: Oh, gosh.
Now I know we're gonna be best friends forever.
Upcoming Events and Resources: Cristina's Blog, Webinars, and the Virtual Sjogren's Summit
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Kara Wada, MD: For listeners who want to continue their journey and want to continue learning from you, where can they find you? Can you share about some of the exciting things that you have going on. Um, we're going to make sure to link to all these. So if you are listening or on YouTube, we'll have all those links in the show notes, but tell us too.
Cristina Montoya: Yeah, you can find me on arthritisdietitian.com. So I recently reactivated my blog. It was lost like for almost two years, but it's reactivated. So yay. Uh, since, uh, January this year, I started running a sjogren's and gut care series webinar. My first one was on a low FODMAP diet for Sjogren's. Last month I did one that it was very well received on digestive enzymes for Sjogren's.
And the one coming up is on the dietitian tips and tricks for managing constipation in Sjogren's. And the one that I'm really working on, I'm excited, is the virtual uh, Sjogren's and gut care event on July 20th. That is in celebration of the Canadian Sjogren's Awareness Month, World Sjogren's Day on July 23rd. And I already have like, five exciting speakers, so we will be talking about, again, from gum to bum, so all the oral health. I have a speech language pathologist, I will have a dietitian speaking about digestive enzymes, and I will be focusing on gastroparesis, and so it's, uh, it's going to be exciting, um, just to spray! I have the energy to keep on going!
Kara Wada, MD: Oh, this is good. I can't wait. Um, I already have it on my calendar and excited to continue to share. Thank you so much. I always learn so much from you and just the energy that you bring to this space I think, it's contagious in the best way. Thank you.
Cristina Montoya: Thank you so much.
Kara Wada, MD: Thank you for tuning in to this empowering episode of Becoming Immune Confident. We hope you've gained valuable insights and practical tools for thriving with Sjogren's. Be sure to visit Cristina's website, arthritisdietitian.com, for even more information and support. And don't forget to join both Cristina and I at the 3rd Annual Virtual Sjogren's Summit, Gut Instincts for Sjogren's.
Registration is open now at sjogren's summit.com. Come and connect with a community of people who understand your journey and learn the latest strategies for improving your gut health and overall wellbeing. We can't wait to see you there and intent till then. We'll see you on our next episode of becoming Immune Confident. Hey there, amazing listeners. Before we wrap up today's episode, I want to take a quick moment to ask for your support. If you're enjoying the content of the Becoming Immune Confident Podcast, we're bringing you week after week, there's a simple, but incredibly impactful way you can show your appreciation.
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