IBD: Part 1
In this article Dr. Weiner explains the 8 obstacles to cure and foundational effective treatments for Inflammatory Bowel Diseases (IBD) offering a deeper understanding of this condition.
This original article was published on January 15, 2014 at ndnr.com. It is the first part of our new series of posts on IBS, IBD, and SIBO that are very relevant in 2019.
Look forward to additional articles in this series on The IBS within the IBD, Use of Elemental Diets in IBS and IBD, and additional videos and summary articles including posts related to Chinese Medicine and Acupuncture as effective treatments for managing symptoms of IBS, IBD, and SIBO.
Read the full text of the original article here:
Gary Weiner, ND, LAc
With a plethora of IBD cases in our clinic, we find effective treatment requires a strategic approach integrating conventional use of medications such as corticosteroids, anti-inflammatories, immunosuppressants, and biologic medications with the therapies that stimulate the vital force, treat assumed causes, and remove the obstacles preventing remission.Inflammatory bowel disease (IBD), comprised of ulcerative colitis (UC) and Crohn’s disease (CD), is one of the 5 most prevalent gastrointestinal diseases in the United States. It is without a medical cure, often requires a lifetime of care,1 and can be difficult to manage with either conventional or unconventional treatment.
The naturopathic physician’s contribution to an integrative paradigm can be visualized like a wheel or “tire,” with the center hub being a dietary strategy. The dietary strategy gets the wheel of treatment rolling. The spokes point to obstacles that need to be removed as the dietary strategy is implemented. Outside of the wheel are some guiding sign posts that reinforce a successful clinical journey through a waxing and waning disease with large bumps in the road. With each bump, the naturopathic physician keeps the patient moving forward lest he head for more aggressive interventions without good integrative care.
THE CENTER OF THE HUB: IMPLEMENTING THE DIETARY STRATEGY
A dietary strategy remains the center of treatment in our clinic. This is rarely as simple as cleaning up a “Standard American Diet” or as easy as eliminating food allergies and intolerances, attempting a “Paleolithic diet,” or using the “anti-inflammatory” diet with its grains, fiber and seeds that are abrasive to an acute gut. Instead, we often implement the Specific Carbohydrate Diet™ (SCD) as the principal dietary strategy. With full support (hours of counseling and weekly follow-up for the first 6-8 weeks), we frequently see satisfactory management of acute symptoms and mucosal healing over time. The diet was developed based on the principle that specifically-selected carbohydrates, requiring minimal digestive processes, are absorbed and leave virtually none to be used for furthering microbial growth in the intestine.2 The SCD has not been studied sufficiently for integration into conventional care; however, one case series from the University of Massachusetts shows clinical correlation with the positive outcomes3observed in our clinic, where over 80% of the cases respond with improvement. Additionally, a 2013 retrospective study from the University of Washington and Seattle Children’s Hospital shows promising outcomes with SCD in pediatric CD patients, and invites further prospective studies to validate efficacy.4
We begin an introductory phase of the SCD, as outlined by Elaine Gottschall in Breaking the Vicious Cycle,2and expand it over time, adding foods to develop a unique “safe list” for the patient that will support intestinal healing. This phase typically begins with little fiber, and choices such as broiled fish, dry cottage cheese, eggs, apple cider, gelatin, chicken soup and pureed carrots. Over time, and only with careful supervision, we add vegetables and fruits that are well-cooked and deseeded, while meats are simply prepared. With tolerance and emerging remission, we add greater variety, including more complex cooking styles, and raw fruits and vegetables. Legumes are withheld until later phases. Particular cultured dairy products are included; however, we complete ELISA food allergy and cytotoxic testing to modify the diet, eliminating foods for improved outcomes. There is reason to believe allergy and intolerance are factors in the IBD gut, though it has not been proven as a cause.5 We interpret tests as potentially useful information, noting no evidence in research to validate reliability.6,7
Studies conclude that diet is relevant to the manifestations of the IBD, perhaps related to etiology but rarely supporting any particular dietary treatment approach.8 A particular dietary etiopathogenesis has never been defined,9 although data suggests that short-chain carbohydrates (FODMAPS) appear to play a role in the induction of functional gut symptoms,10 and excess intake of refined carbohydrates, low intake of fruits and vegetables, and overconsumption of polyunsaturated and monounsaturated fatty acids, compared to omega-3 fatty acids in the diets of industrialized nations, appear to be associated with increased risk of the disease.11
In my experience, gastroenterologists and dieticians are unprepared to support patients through dietary trials necessary to contribute to healing this condition nutritionally. Correct counseling and support is painstaking and it may take months to see progress with the evolution of the “safe” list that will contribute to mucosal healing.
When our dietary strategy does not take us on a direct route to remission of IBD, that is, when the correct dietary strategy plateaus, we consider the obstacles that have to be removed, or at least addressed, in order to make progress.
OBSTACLE 1: DYSBIOSIS
It is widely agreed that the main cause of IBD is a disruption of the normal microbiota,12 which consists of at least 1000 species of bacteria. The delicate symbiotic relationship between microbiota and host appears lost in IBD. Suspected pathogens are many, including Mycobacterium aviumsubspeciesparatuberculosis, Yersinia, Pseudomonas, Salmonella, Campylobacter jejuni, Clostridumdifficile, Adenovirus, Mycoplasma, Ruminococus gnavus, Fusobacterium varium, Escherichia coli,13 fungal flora such as Candida spp, Penicillium spp, Saccharomyces spp,14 and other organisms. However, any specific patterns of disturbance elude firm conclusions. The lack of clarity in defining the best probiotic therapy is equally as inconclusive as defining a pathogen, although it seems clear that an increased propensity of obligatory aerobic bacteria is seen displacing the anaerobic species, with both bifidobacteria (in CD) and Lactobacilli(in UC) being deficient in the IBD microbiota.15 On the other hand, different types of disturbances in microbiota may be responsible for UC and CD, with absence of butyrate-producing species being deficient in UC.16 In our practice, butyrate enemas can be ameliorative in UC with some validating research showing efficacy.17 While patients often respond to simple introduction of antibiotic or probiotic agents, we find it rare to see clear remission with single-agent, antimicrobial or probiotic therapy. In fact, patients can be aggravated by these therapies.
The following are our guidelines for treating IBD:
- Have faith in a well-chosen dietary strategy such as the SCD and the “safe list” to address dysbiosis.
- Address suspected pathogenic organisms and dysbiotic overgrowth with additional therapies.
- Use laboratory testing, however imperfect, to gather information; send stool samples to at least 2 different labs with different methods of organism recovery, assess small intestinal bacterial overgrowth (SIBO) with breath testing, look “under the carpets” with antibody testing offered by various labs, and consider methods such as organic acid testing.
- Review medical records to determine organisms treated previously.
- Use accumulated data to treat, based on findings.
Assume dysbiosis in spite of the normal lab findings, and select strategies depending on circumstances, findings, strength of patient, and pattern of dysbiosis.
Select the most effective agents that will be tolerated, including pharmaceuticals, Chinese and western herbs, selective antimicrobial, antifungal, or symbiotic agents; given the sensitivity of these patients to many encapsulated supplements and some well-indicated decoctions at full strength, we find biotherapeutic drainage strategies employing diluted botanicals to be useful.
Implement probiotics and prebiotics strategically, often starting with single organisms like Lactobacillus acidophilus and Saccharomyces boulardii, and progress in complexity, watching responses. VSL #3 remains the most researched probiotic for IBD showing efficacy,18 and we have had a few cases where it has been extremely effective in stimulating remission; however, we usually avoid the B bifidus contained within it, due to more frequent aggravations.
Consider recent advances in fecal microbiota transplantation (FMT)19,20 and helminthic therapy,21 both showing considerable promise as a therapy to effectively restore gut ecology.
OBSTACLE 2: IMMUNE DYSREGULATION
Dysbiosis is thought to trigger immune dysregulation with related microbial host-antigen reactivity.22 The obstacle of an upregulated immune system appears best removed through implementation of the dietary strategy, repairing gut permeability, addressing dysbiosis, assuring adequate nutritional support, and removing the other obstacles discussed herein. We consider adding specific agents to impact dysregulation, including guggulsterone, Boswellia, psyllium, bromelain, Curcuma longa (turmeric), Potentilla erecta (tormentil), Ulmus fulva (slippery elm), Glycyrrhiza glabra (licorice), butyrate, aloe vera, and others.23Low-dose naltrexone (LDN) has been helpful in many of our cases for maintaining remission. Some limited studies validate its use.24
OBSTACLE 3: INTESTINAL PERMEABILITY
Increased intestinal permeability is present in a large number of IBD cases.25 Intestinal permeability is usually greater in CD than in UC.26 In our view, effective dietary and dysbiosis strategies can repair intestinal permeability; however, employing other supplemental support is helpful in removing this obstacle. We use probiotics, lactoferrin, glutamine, digestive enzymes, betaine hydrochloride (HCl), antioxidants, and hydrolyzed fish protein, among other agents. Performing a urinary lactulose/mannitol test at the beginning of a treatment will often (but not predictably) demonstrate permeability, and as cases resolve, the test will typically show improved or normal permeability.
OBSTACLE 4: NUTRITIONAL INSUFFICIENCIES
IBD patients are at risk for nutrient deficiencies as a consequence of long-term gut inflammation and decreased oral intake, and malnutrition is a significant risk, especially in CD.27 In our clinic, we see frequent nutritional deficiencies in CD, while UC appears more stable, except during flares. We screen specifically for vitamin B12 (using the methylmalonic acid test), vitamin D, folic acid (especially if patients are on methotrexate), iron (usually low with chronic GI bleeding), zinc, selenium, and all essential and non-essential amino acids. As many IBD patients cannot tolerate oral iron, we consider IM or IV injections, or compounded transdermal iron as ferric ammonium chloride when iron deficiency anemia is present. Studies have concluded that correcting nutritional deficiencies in IBD patients through enteral and parenteral nutrition can induce remissions.28 Given absorption problems and gross micronutrient deficiencies and insufficiencies, we start most IBD patients on IV drips for 4-6 weeks, to provide baseline micronutrients in an environment of intestinal distress as we implement a dietary strategy and attempt to stimulate remission.
Continue to Part 2 of this article.
Gary Weiner, ND, LAc practices at Pearl Natural Health in Portland, Oregon, where he has developed an alternative and complementary care program for inflammatory bowel disease. He graduated from NCNM in 1997 and completed a 1-year residency in family medicine. He has served as adjunct faculty and clinical supervisor at NCNM, and is on the medical advisory board of the Northwest Crohn’s and Colitis Foundation of America. He was recently invited and presented continuing education in complementary care for IBD to 50+ gastroenterologists at the 2013 meeting of the Oregon Gut Club, accredited by Providence Portland Medical Center. Dr Weiner lives with his wife and daughter.
full reference list available at the original source