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Inflammatory bowel disease (IBD) has traditionally beenconsidered a Western disease. However, the last 2 decadeshave seen an increase in the reports of both ulcerative colitis(UC) and Crohn’s disease (CD) from Asian countries [1].Most of these reported series have been hospital-based withonly one population-based survey by Sood et al. [ 2]. Time-trend data from Japan and China indicate a dramatic increasein the incidence of UC and a more gradual increase in that ofCD [1]. In addition, a higher incidence of UC has been notedamongst second-generation Asian migrants in the UnitedKingdom [3]. This increase in the incidence and prevalenceof IBD in Asia mirrors the epidemiological trend in theWestern world that occurred 50 years ago Though increasedawareness of IBD, better diagnostic facilities, and the growthof the specialty appear to have played a major factor for thisincrease in reported incidence, there is probably also agenuine increase in the incidence of both UC and CD [1].The role of the changing environment in the pathogen-esis of IBD is likely to be a major contributory factor forthe increase in this condition in Asian countries. Improve-ment in sanitation and public health, while inevitablyleading to a decrease in the burden of infectious diseases,have been shown to be associated with an increase inautoimmune and chronic inflammatory diseases [4]. Theenvironmentalfactorswhicharewell-recognisedasassociatedwith IBD include smoking, diet, stress, microbial agents,appendicectomy, social status and intestinal permeability tofermentable oligo-, di- and mono-saccharides and polyols(FODMAPs).In this issue of the Journal, Pugazhendhi et al. [5]fromatertiary referral hospital in southern India report a case–control study that looked at the association of surrogatemarkers of environmental hygiene in patients with CDcompared to age-linked healthy controls. They found thaturban residence, safe drinking water and availability of pipedwater (all indicators of better hygiene) were positivelyassociated with CD whereas consumption of fish (a sourceof ω-3 polyunsaturated fatty acids) and exposure to cattle (anindicator of poor hygiene) were negatively associated withCD. The message of the study is clear—improved hygienewas associated with a higher prevalence of CD in this area.The ‘hygiene hypothesis’ [6] of IBD is based on theobservation that incidence of IBD has increased in bothdeveloping and developed countries with improvements inhygiene during the 20th century. It claims that raisingchildren in extremely hygienic environments negativelyaffects immune development and tolerance to a variety ofantigenic challenges, which in later life predisposes them todevelop chronic inflammatory diseases such as IBD.However, the evidence for the contribution of severalfactors included in this hypothesis has never been analyzedin a systematic manner. In the present study too, except fordiet (fish oil), all the other factors found to be correlatedwith the development of CD, can be linked to gutmicrobiota and immune tolerance.The mucosal surface of the human gastrointestinal tractis approximately 200–300 m

Environmental factors associated with Crohn’s disease in India—there’s more to it than meets the eye