Framework Matters: Study Links for Safe & Effective Crohn’s Strategies

This post is really a reference guide that includes an outline and framework for thinking about Crohn’s strategies in a differnent way, along with links to a series of studies that go into depth about each area. This is a good place to start research, and a good resource to share with your doctor.

 
“Nothing in biology (nutrition or medicine) makes sense except in the light of evolution”. Dr. Loren Cordain

Intestinal Barrier Function & Leaky Gut:

These studies provide the framework for all the rest. Essentially all modern diseases of inflammation can be linked to a series of mismatches between our genes and environmental factors. The origin of this inflammation starts in the gut with a breakdown in intestinal barrier function.

• The Western diet and lifestyle and diseases of civilization: Cordain, Research Reports in Clinical Cardiology: 2011 March
• Mechanisms of disease: the role of intestinal barrier function in the pathogenesis of gastrointestinal autoimmune diseases. Fasano Nat Clin Pract Gastroenterol Hepatol. 2005 Sep
  Zonulin and Its Regulation of Intestinal Barrier Function: The Biological Door to Inflammation, Autoimmunity, and Cancer Alessio Fasano Physiol Rev 2011 Jan
• Leaky Gut and Autoimmune Diseases Fasano Clinic Rev Allerg Immunol 2011 Nov. 

  

Below is a simple chart that list the stressors/environmental factors that either increase intestinal permeability directly or damage the balance of the gut flora, all leading to inflammation.

Increasing Intestestinal Permeability

Gluten/Prolamines	Casein	HBC	Stress
Lectins & Saponins	Low Vitamin D	PPI	Sleep Deprivation
Omega 6 Fats	Antibiotics	Alcohol	Endurance Exercise
FODMAPs	NSAIDs	Capsaicin

 

Below is a simple chart that list the environmental factors that either decrease intestinal permeability directly or improve the balance of the gut flora, all leading to reduced inflammation and healing.

Improving Intestestinal Permeability

IBD Diet	Krill Oil	Probiotics & Fermented Food	Colostrum
Proline (Broth & Gelatin)	Curcumin — BCM95	Mutaflor, VSL#3, Lactobacillus paracasei	LDN
CLA (Bones & Butter)	Boswellia — 5Loxin	S. Boulardii,  B. Coagulans	Cannaboids (CBD)
D3 & K2	L. Glutamine & Arginine	Sleep, Meditation/Yoga, Acupuncture	IF & HIIT = Growth Hormone

Diet:

• SCD — Pilot Testing a Novel Treatment for Inflammatory Bowel Disease Clinical and Translational Science Research Retreat. 2011 May.
• Does gluten cause gastrointestinal symptoms in subjects without coeliac disease? J Gastroenterol Hepatol. 2011 Apr
• Dietary Lectins as Disease Causing Toxicants Pakistan Journal of Nutrition 2009
• Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. J Gastroenterol Hepatol. 2010 Feb
• Dietary fructooligosaccharides increase intestinal permeability in rats. J Nutr. 2005
• Indigestible disaccharides open tight junctions. Dig Dis Sci. 2004 Jan
• GAPS – www.gaps.me, SCD – www.scdlifestyle.com Paleo – www.robbwolf.com

  

 Fat Balance:

• Linoleic Acid, a Dietary N-6 Polyunsaturated Fatty Acid, and the Aetiology of Ulcerative Colitis – A European Prospective Cohort Study. Gut 2009 July
• The Type of Dietary Fat Modulates Intestinal Tight Junction Integrity, Gut Permeability, and Hepatic Toll-Like Receptor Expression. Alcohol Clin Exp Res. 2011
• Conjugated linoleic acid modulates immune responses in patients with Mild to Moderately active Crohn’s disease. Clinical Nutrition 2012 March.
• Lipid based therapy for ulcerative colitis-modulation of intestinal mucus membrane phospholipids as a tool to influence inflammation. Int J Mol Sci. 2010 Oct
• Butyrate enhances the intestinal barrier by facilitating tight junction assembly via activation of AMP-activated protein kinase in Caco-2 cell monolayers. J Nutr. 2009

   

Microbiota & Probiotics:

• Gut Microbiota and Pediatric Disease Dig Dis 2011
• Association between the use of antibiotics and new diagnoses of Crohn’s disease and ulcerative colitis. Am J Gastroenterol. 2011 Dec
• Association of Repeated Exposure to Antibiotics With the Development of Pediatric Crohn’s Disease–A Nationwide, Register-based Finnish Case-Control Study. Am J Epidemiol. 2012 Apr
• Influence of Saccharomyces boulardii (Florastor) on the intestinal permeability of patients with Crohn’s disease in remission. Scand J Gastroenterol. 2008
• Anti-inflammatory effects of Saccharomyces boulardii mediated by myeloid dendritic cells from patients with Crohn’s disease and ulcerative colitis. Am J Physiol Gastrointest Liver Physiol. 2011 Dec
• The probiotic Escherichia coli Nissle 1917 (Mutaflor) reduces pathogen invasion and modulates cytokine expression in Caco-2 cells infected with Crohn’s disease-associated E. coli LF82. Trop Med Int Health. 2011 May
• Probiotic Bacteria Produce Conjugated Linoleic Acid Locally in the Gut That Targets Macrophage PPAR γ to Suppress Colitis. PLoS One. 2012
• Lactocepin Secreted By Lactobacillus Exerts Anti-Inflammatory Effects By Selectively Degrading Proinflammatory Chemokines Cell Host & Microbe 2012 April
• Helminthic therapy: improving mucosal barrier function. Trends Parasitol. 2012 Mar 

Supplements:

• Vitamin D and gastrointestinal diseases: inflammatory bowel disease and colorectal cancer.Therap Adv Gastroenterol. 2011 Jan 

Target Vitamin D Levels 25(OH)D – 10,000 iu/day
Dr. Jaquelyn McCandless	65 – 90
Robb Wolf	60 – 80
www.VitaminDCouncil.org	50 – 80
www.GrassRootsHealth.net	40 – 60
Vitamin D IBD Study	30 – 60

• Curcumin Ameliorates Hydrogen Peroxide-Induced Epithelial Barrier Disruption. Dig Dis Sci. 2012 March.
• Therapy of active Crohn disease with Boswellia. Z Gastroenterol. 2001 Jan
• Dietary supplementation of krill oil attenuates inflammation and oxidative stress in experimental ulcerative colitis. Scand J Gastroenterol. 2012 Jan
• Glutamine and Whey Protein Improve Intestinal Permeability and Morphology in Patients with Crohn’s Disease: A Randomized Controlled Trial. Dig Dis Sci. 2011 Oct
• Combined Glutamine and Arginine Decrease Proinflammatory Cytokine Production by Biopsies from Crohn’s Patients J Nutrition 2008
• Zinc supplementation tightens “leaky gut” in Crohn’s. Inflamm Bowel Dis. 2001 May
• Intestinal immune system influenced by cocoa-enriched diet. J Nutr Biochem. 2008 Aug 

Drugs:

• Therapy with the opioid antagonist naltrexone promotes mucosal healing in active Crohn’s disease: a randomized placebo-controlled trial. Dig Dis Sci. Smith & Zagon 2011 Jul 

  

• Rifaximin-extended intestinal release induces remission in patients with moderately active Crohn’s disease. Gastroenterology. 2012 May
• Cannabinoid-induced apoptosis in immune cells as a pathway to immunosuppression. Immunobiology. 2010 Aug
• Cannabinoids mediate opposing effects on inflammation-induced intestinal permeability British Journal of Pharmacology 2011
• Linaclotide in the management of gastrointestinal tract disorders. Drugs Today (Barc). 2012 Mar
• 5-aminosalicylate is not chemoprophylactic for colorectal cancer in IBD: a population based study. Am J Gastroenterol. 2011 Apr
• Efficacy of 5-aminosalicylates in Crohn’s disease: systematic review and meta-analysis. Am J Gastroenterol. 2011 Apr

The Crohn’s and Colitis Foundation of Canada Endorses LDN?

In an article on their website entitled Opioid boost may ease Crohn’s symptoms, the CCFC gives Low Dose Naltrexone (LDN) a positive review. Of course they are cautious and don’t really endorse LDN, but this is at least a step in the right direction.

Dr. Keith Sharkey – the Crohn’s and Colitis Foundation of Canada Chair in IBD Research – believes it is worthwhile for patients interested in LDN to consider and discuss this treatment option with their doctors. “Talk to your doctor and ask whether it’s safe and appropriate for you,” he said. And he goes on to suggest that “further clinical trials are absolutely warranted and low-dose naltrexone has to be tested in a multi-centre study.”

LDN acts as a powerful anti-inflammatory and we’ve seen direct results of improved ESR and CRP with LDN.  The clinical trial showed that it improved symptoms for 88% of those in the study, but 33% saw complete remission with endoscopic confirmation of mucosal healing within 12 weeks. All with no dietary changes.

It is important to note that the CCFC may never have paid any attention to LDN if it were not for the tireless efforts of Sara Craig who manages a support page on Facebook. Sara made the effort to collect LDN success stories from people like me and she presented them to the CCFC at a conference in October of 2011. It appears that her efforts were fruitful as she got Dr. Sharkey to do some research.

Since Naltrexone is an FDA approved drug, LDN can be prescribed “off-label” by your doctor right now, there is no reason to wait to begin using LDN. You can learn more about LDN, and find doctors that will prescribe it at http://www.ldnscience.org and http://www.lowdosenaltrexone.org If you are set on working with your current doctor, you could bring them the published results from the small clinical trial that was done at Penn State by Dr. Jill Smith. In fact, Dr. Smith will consult with your doctor if they call her office – 800-243-1455.

If your doctor still won’t cooperate, you can email Crystal Nason – angelindisguiseldn@yahoo.com with where you live, and she will give you a list of LDN prescribing doctors. Of course, you can always get Naltrexone yourself without a prescription via a number of online pharmacies – http://www.alldaychemist.com & http://www.unitedpharmacies.com have the cheapest prices. You can get a years supply of LDN for about $100.

LDN is not a magic cure for Crohn’s but combined with other safe strategies it can make a huge difference. LDN, along with the SCD, GAPS or Paleo diet should be the first line of treatment. Maybe with exposure like this we’ll see some progress.

Thanks Sara!

Does it work?

The short answer is – Yes!

Although it’s an experiment of 1 and admittedly not at all scientific, I thought it would make sense to report on the recent results from my daughters blood work. It turns out that the strategy we are following – borrowed heavily from the Core Strategy I outline in this blog –  is working.  While no plan is perfect, its nice to know that this one is safe and effective.  We set a goal about 18 months ago…to find a way to provide some diet flexibility beyond the strict SCD program that we had successfully implemented in the past. It does appear that the addition of LDN and key supplements has made some diet flexibility possible. I’m sure we’ll have to make adjustments over time, but we’re pretty pleased with the results!

Here is the plan:

• Wheat/Gluten grain and mostly dairy free diet – potato & rice are well tolerated. (I’m sure there is some cheating going on, but not that much.)
• LDN – 4.5mg capsules each night
• Monthly B12 injections
• Daily supplements: Vitamin D3 10,000 iu, Boswellia/5Loxin 150mg, Curcumin/BCM95 500mg, Krill Oil 1,000mg & Bacillus Coagulans (DuraFlora – 2 capsules)

Here are the blood results:

• Vitamin D level – 25(OH)D = 79 (I think we are in “theraputic level” territory)
• C-reactive protein (CRP) = .56 (is a protein found in the blood, the levels of which rise in response to inflammation) anything under 1 is considered a low level of inflammation.
• The erythrocyte sedimentation rate (ESR), = 18 also called a sedimentation rate (SED) , is a common blood test  that is a non-specific measure of inflammation.  For women, anything under 20 is considered in the normal range.

IBD Pilot Study Using Diet based on SCD shows 100% Success Rate

It looks like the mainstream medical community may be finally realizing that diet is central to the cause and healing of IBD.  Last May, the folks at UMass led by Barbara Olendzki published a pilot test using a diet largely based on SCD to treat IBD. Here is a link to a pdf showing the study results, and I’ve copied the abstract below. I’m sure it will take alot more to completely turn things around, but this is a major step forward. Even though this study is small, I’d say a 100% success rate is pretty good!

And here is a link to the most recent SCD Lifestyle post and podcast interview of one of the researchers that conducted the study http://scdlifestyle.com/2012/02/umass-ibd-diet-study-sees-success/ Kudos to Steve Wright for putting this together!

Abstract

Background: Inflammatory Bowel Disease (IBD), which includes Crohn’s disease (CD) and ulcerative colitis (UC), are chronic non specific inflammatory conditions. Standard IBD treatment typically employs a combination of anti-inflammatory and immune suppressive medications; however, the pharmacological approach is not by itself curative. The Anti-Inflammatory Diet for IBD (IBD-AID), which is derived and augmented from The Specific Carbohydrate Diet (SCD), is a nutritional regimen that restricts the intake of complex carbohydrates such as refined sugar, gluten-based grains, and certain starches from the diet. These carbohydrates are thought to provide a substrate for pro-inflammatory bacteria. The second component of the diet involves the ingestion of pre- and probiotics to help restore an anti inflammatory environment.

Study Objective: To assess the efficacy and feasibility of the Anti –Inflammatory Diet (IBD-AID) intervention for the treatment of IBD.

Intervention: Patients were recruited from the UMMHC gastroenterology clinic upon referral from their gastroenterologist. They received individual instruction of the diet and its restrictions through 5 individual nutrition sessions over approximately a 6-10 month period. Support materials were provided. Cooking classes were also available to the patients.

Conclusion: This case series indicates the potential for the IBD-AID to be used as an adjunctive or alternative therapy for the treatment of IBD. Notably, 9 out of 11 patients were able to be managed without anti-TNF therapy, and 100% of the patients had their symptoms reduced. To make clear recommendations for its use in clinical practice, randomized trials are needed alongside strategies to improve acceptability and compliance with the IBD-AID.

Citation: Barbara C. Olendzki, Gioia Persuitte, Taryn Silverstein, Katherine Baldwin, David Cave, John K. Zawacki, Kanishka Bhattacharya, and Yunsheng Ma. “Pilot Testing a Novel Treatment for Inflammatory Bowel Disease” Clinical and Translational Science Research Retreat.. May. 2011. Available at: http://works.bepress.com/barbara_olendzki/46

The Core Strategy

My approach to dealing with autoimmune disease in general and Crohn’s specifically is very eclectic. There is no cure but there certainly are safe, effective and affordable strategies that will let most people live normal lives.

There is finally science that explains what is going on with these diseases. The core problem is in the functioning of the gut lining or leaky-gut where the gut lining is actually leaking undigested proteins into the bloodstream, kicking off an inflammatory response. The two key factors that create leaky-gut are the direct action of prolamines/gluten/lectins in grains & legumes, as well as the omega 6 fats in seed/grain oils — along with dysbiosis in the gut, where complex carbohydrates & fructans are poorly digested, ferment, and feed the growth of pathogenic bacteria.

So now we have a mess that needs to be unraveled. Here is the basic strategy:

• Stop eating the foods that cause leaky-gut
• Stop eating the foods that feed pathogenic bacteria
• Supplement to kill pathogenic bacteria and replenish good bacteria
• Supplement to reduce inflammation and heal leaky-gut

And here are the tactics:

• Diet – The most important component – 75% – is diet.  Eliminate all processed sugar, grains, legumes, and dairy. Although grains are the enemy, it’s also important to reduce high omega 6 fats and fructose. So what do you eat? Meats (hopefully grass-fed/pastured animals and wild caught seafood), Vegetables, Fruits and Nuts (and Tubers after some healing). Great diets for this include: SCD or Specific Carbohydrate Diet, GAPS or Gut and Psychology Syndrome Diet, and Paleo. Both SCD and GAPS are specifically designed for autoimmune disease and offer an intro phase and process for healing. Paleo doesn’t offer a process, but I’m partial to their evlolutionary biology approach to the world.  Here is a PDF that outlines a solid approach. It combines the best of SCD/GAP with its low FODMAP strategy, all within a Paleo foundation.
• LDN – For many, diet is enough, but for most diet needs to be combined with LDN and key supplements.The only drug that makes sense to me is LDN or Low Dose Naltrexone. LDN is safe, effective and affordable. Naltrexone has been around for over 30 years and is FDA approved, but LDN for Crohn’s would need to be prescribed “off-label” or purchased directly from an online pharmacy. LDN works by tricking your body into producing 3 times the amount of endorphins it normally would. Endorphins perform a critical function that is profoundly important for the proper functioning of the immune system. The result is reduced inflammation, and demonstrated healing of the gut lining. LDN works best when combined with a gluten, soy, casein restricted diet because these foods actually compete for the opioid receptors that LDN works on.
• Supplements– Athough you can go crazy with supplements, there are a core that have been shown to be effective. Few of them do much without the foundation of the right diet, but when combined, they can be very helpful:

–D3 Make sure your blood levels are between 60 – 80. For most, this might require supplementing with 5,000 or 10,000 iu’s per day. There are clinical trials going on right now at Penn State for vitamin D and Crohn’s. Here is a great resource for vitamin D.

–B12 Shots are critical for anyone with a damaged ileum. They are great for dealing with fatigue.

–Boswellia & Curcumin are both great, natural anti inflammatories with small clinical trials that show that they are as effective as mesalamine without any of the side effects. Take boswellia in 5Loxin form and take curcumin in BCM-95 form.

–Probiotics – There are some great probiotics that can help crowd out pathogenic bacteria and re-populate the gut with beneficial bacteria. One of the best ways is to ferment your own yogurt or vegetables. Or you can buy probiotics. The 3 strains that have some clinical trials to back them are S. Boulardii, VSL#3 and Mutaflor. S. Boulardii is affordable, available and works great for diarrhea, candida and c. diff. I’m partial to Mutaflor, but it is expensive, and unavailable in the US.

–Leaky-Gut Healers – There are a number of interesting supplements that either aid digestion or directly help with the healing of the gut lining: GAPS bone broth or gelatin,  Betaine hcl with pepsin has multiple benefits with GERD, CRP/homocysteine, and killing pathogenic bacteria. L. Glutamine,  Zinc Carnosine, Colostrum/Proline Rich Polypeptides (PRP) and Coconut Oil.

There are other strategies, but this is a great start. Follow the links, do some research. Share this with your doctor. And get started. You can get your life back. Let me know how it goes!

Alan