Crohn s Disease. Naturopathic Treatment Options

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Crohn s Disease Naturopathic Treatment Options by Dr. Gayamali Karunaratna, B.Sc., M.Ed., ND Markham Natural Health Centre 3160 Steeles Avenue East, Suite 204 Markham, Ontario L3R 4G9 http://www.

It is one of two conditions classified as inflammatory bowel diseases (IBD), the other condition being ulcerative colitis (UC).

1 Crohn s Disease Naturopathic Treatment Options by Dr. Gayamali Karunaratna, B.Sc., M.Ed., ND Markham Natural Health Centre 3160 Steeles Avenue East, Suite 204 Markham, Ontario L3R 4G9 Introduction Crohn s disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract. It is one of two conditions classified as inflammatory bowel diseases (IBD), the other condition being ulcerative colitis (UC). UC is limited to the colon, while CD can involve any segment of the gastrointestinal tract, from the mouth to the anus. [1] Symptoms of CD include abdominal pain, distention, bloating, fatigue, diarrhea or constipation, blood in the stool, weight loss, and perianal disease. Abdominal pain can occur anywhere; yet, the right-lower quadrant is most commonly affected region. [1] Weight loss occurs for 65 75% of patients diagnosed with CD. [2] Naturopathic medicine can play an important role in treating CD, by reducing the frequency and severity of inflammatory episodes and by preventing complications such as obstruction and perforation of the small intestine or colon, abscesses, fistulae, intestinal bleeding, and increased intestinal permeability. Diagnosis of CD can be made by endoscopy and radiology tests. It can also extend to include food-allergy testing and stool analysis with parasitology. [1] Naturopathic approaches to treating Crohn s disease involve first a detailed intake or thorough assessment in order to determine which particular factors are involved in any individual case of Crohn s disease. Elimination of the specific factors may then be implemented, followed by treatment utilizing different modalities such as nutritional counselling, traditional Chinese medicine (TCM) and acupuncture, botanical medicine, or homeopathy. This paper will discuss the common causative factors of CD, and naturopathic approaches to treatment.

2 Causative Factors A number of modifiable causative factors have been identified in the development and prognosis of CD. There is a substantial amount of data demonstrating that the Western diet and lifestyle contribute to the increased prevalence of CD among industrialized countries, which is supported by the higher incidence of this disease in these countries, particularly emerging in the 20th century. [1] Diets that are high in refined sugar, less dietary fibre, and considerably less fruit and vegetables have been found to precede and aid in the development of CD. [3] Although CD is considered to be autoimmune in origin, there has been increasing evidence suggesting that it may have an infectious cause. Mycobacterium avium ssp. paratuberculosis (MAP) in particular has been found to be the leading infectious candidate. [4] Lifestyle habits such as cigarette smoking have also been found to be a risk factor for the development of CD, with a higher risk for women than men. [5] Along with cigarette smoking, medical interventions such as the use of the oral contraceptive pill in women has been identified to be a risk factor in the development as well as relapse of CD. [6] An imbalance in the composition of the intestinal flora or gut microbiome has also been found to be a fundamental factor in the development of IBD such as CD, particularly in childhood. The gut microbiome can be thought of as our body s natural defence, as it plays a major role in immune function, aids in digestion, and assists in the production of vitamins. Antibiotics have been found to alter the composition of the microbiota, potentially predisposing one to IBD. Alternatively, prescribing antibiotics to children with intestinal symptoms of as yet undiagnosed CD should also be considered as a possible factor. [7] Familial prevalence or clustering and studies of twins strongly suggest that CD is in fact a genetic disorder. Genome-wide studies for IBD-susceptibility genes have resulted in the identification of several loci and mutations for Crohn s disease and/or ulcerative colitis on chromosome 16. [8]

3 It is important to note that the recurrence of CD has been related to other variables such as age at diagnosis, extent of disease, site of disease, time interval between the onset of symptoms and surgery if required, and the presence of perforating disease. These variables can be confounding or extraneous variables unaccounted for, and associated with each of the aforementioned causative factors. [5] The implication of identifying these modifiable factors is that it enables practitioners to address and aid in altering the course of the disease. Naturopathic Treatment Dietary Modifications A healthy diet is integral to treating any chronic lifestyle disease, hence the saying you are what you eat. As CD is a disease of the gastrointestinal tract, diet is essentially the root of therapeutic management. An elimination diet, in particular, is generally recommended to patients who suffer from CD. This diet involves eliminating common food allergens such as dairy products, wheat, eggs, and corn, to name a few. [1] It can also include increasing the intake of anti-inflammatory foods such as highly essential fatty acid containing salmon, sardines, or mackerel, while reducing intake of inflammatory foods such as red meat, alcohol, caffeine, and sugar. It is important to note that although the elimination diet permits the Brassica family of vegetables and one serving of fruit a day, patients who have CD with symptoms of mild or partial bowel obstruction such as severe pain and vomiting and the inability to pass stools or who have recently undergone gastric surgery are advised to avoid eating these foods, as raw vegetables and fruit may not pass through the strictures and can cause bolus obstruction. [1] Omega 3 Fatty Acids The ingestion of cod liver oil or fish oil first gained popularity in 19th century England as a source of vitamin D for sun-deprived children. Omega 3 fatty acids are considered essential fatty acids (EFAs), as they cannot be produced in the body. They are found in the form of eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA) in large amounts of marine life. EPA, in particular, has anti-inflammatory properties which can help reduce flare-ups and inflammation seen in Crohn s disease. Omega 3 fatty acids act in two ways: by reducing the production of inflammatory prostaglandins (specifically leukotriene B 4 and thromboxane A 2 ) that are found to be elevated in inflamed intestinal mucosa, or by inhibiting the synthesis of cytokines. One study found that taking a specific enteric-coated fish-oil supplement providing 2.7 g of omega 3 fatty acids daily for 12 months can reduce the relapse rate for CD. [9] Food sources of omega 3 fatty acids that is high in EPA include flaxseed; walnuts; and seafood such as wild Alaskan salmon, sardines, anchovies, arctic char, and cod to name a few.

4 Curcumin Curcumin is a natural compound found in the plant Curcuma longa, commonly used in foods as a spice known as turmeric. Curcumin has been found to not only have antioxidant properties, but anti-inflammatory properties as well. [10] It acts by downregulating the inflammatory response by downregulating the activity of inflammatory mediators such as cyclo-oxegenase 2 (COX 2), lipoxygenase, nitric oxide synthase enzymes as well as by inhibiting the production of inflammatory cytokines such as tumour necrosis factor alpha (TNF α) and interleukin factors. [11] Due to the role of inflammation in most chronic diseases, the potential of curcumin has been examined in neoplastic, neurological, cardiovascular, pulmonary, metabolic, and chronic inflammatory bowel diseases. [12] Probiotics As discussed previously, the human body is colonized by a large number of microbes in the gastrointestinal tract, collectively known as the microbiota or microbiome. The microbiota is responsible for the physiological maintenance of general good health through the regulation of metabolic processes, as well as for supporting the immune system. An imbalance of the gut flora is referred to as dysbiosis, which can be due to causes such as prolonged antibiotic use, and can subsequently lead to inflammatory bowel diseases such as CD. [13] Probiotics, on the other hand, are healthy, live bacteria that can replenish the gut microbiome. Providing adequate probiotic support to patients with CD can aid in disease remission and even reduce the need for medications. [1] Glutamine l Glutamine is an amino acid found naturally in the body, particularly in skeletal muscle and lungs. It is responsible for a number of functions in the body, including maintaining acid-base balance, nitrogen supply, formation of nucleotides and amino acids, protein synthesis, and production of other nutrients in the body. [14] The administration of l glutamine, either by intravenous or oral route, has a protective effect that prevents or reduces the intensity of increase in intestinal permeability as seen in leaky gut, which is often a complication of CD. [15] Studies have found that glutamine may be an important dietary component for the maintenance of gut metabolism, structure, and function, particularly when the gut mucosal barrier may become compromised. [16]

5 Vitamin D Vitamin D is a fat-soluble vitamin that our bodies can store. The classic role of vitamin D is to regulate calcium homeostasis, and therefore bone formation and resorption. It is also an important immune system regulator. [2] Patients with IBD such as Crohn s disease should supplement with daily amounts of vitamin D 3 as deficiency is common, and malabsorption and/or long-term corticosteroid therapy can lead to osteopenia and eventually osteoporosis. [1] In addition, vitamin D influences innate immunity, which is believed to be involved in the pathogenesis of CD and UC. [17] A major source of vitamin D is the production through a photolysis action through the skin when it s exposed to the Sun s ultraviolet rays. Conclusion Crohn s disease is an inflammatory bowel disease that is prevalent in North America. Although it is considered to be autoimmune in origin, there are a number of causative factors that have been found to increase the risk of Crohn s disease. Identifying the particular modifiable causative factors that are unique to an individual is crucial in preventing relapse and altering the course of the disease. Naturopathic approaches to treating Crohn s disease begin with proper diagnosis, assessing the risk factors, and implementing the appropriate dietary and lifestyle changes. Modalities such as traditional Chinese medicine (TCM) and acupuncture, botanical medicine, and homeopathy may also be utilized as part of an individual s treatment protocol. The aforementioned natural interventions are not comprehensive in the treatment of Crohn s disease. Always consult with a naturopathic doctor to determine what treatment is appropriate for you. References 1. Prousky, Jonathan. Textbook of integrative clinical nutrition. Toronto, Ontario: CCNM Press Inc., 2012, 506 p, ISBN Cantorna, M.T., et al. Vitamin D status, 1,25 dihydroxyvitamin D 3, and the immune system. The American Journal of Clinical Nutrition. Vol. 80, No. 6 Suppl. (2004): 1717S 1720S. 3. Thornton, J.R., P.M. Emmett, and K.W. Heaton. Diet and Crohn s disease: Characteristics of the pre-illness diet. British Medical Journal. Vol. 2, No (1979): Greenstein, R.J. Is Crohn s disease caused by a mycobacterium? Comparisons with leprosy, tuberculois, and Johne s disease. Infectious Diseases. Vol. 3, No. 8 (2003): Cottone, M., et al. Smoking habits and recurrence in Crohn s disease. Gastroenterology. Vol. 106, No. 3 (1994): Timmer, A., et al. Oral contraceptive use and smoking are risk factors for relapse in Crohn s disease. Gastroenterology. Vol. 114, No. 6 (1998): Hviid, A., H. Svanstrom, and M. Frisch. Antibiotic use and inflammatory bowel diseases in childhood. Gut. Vol. 60, No. 1 (2011): Ogura, Y., et al. A frameshift mutation in NOD2 associated with susceptibility to Crohn s disease. Nature. Vol. 411, No (2001): Belluzzi, A., et al. Effect of an enteric-coated fish-oil preparation on relapses in Crohn s disease. The New England Journal of Medicine. Vol. 334, No. 24 (1996): Holt, P.R., et al. Curcumin therapy in inflammatory bowel disease: A pilot study. Digestive Diseases and Sciences. Vol. 50, No. 11 (2005): Jurenka, J.S. Anti-inflammatory properties of curcumin, a major constituent of Curcuma longa: A review of pre-clinical and clinical research. Alternative Medicine Review. Vol. 14, No. 2 (2009):

6 12. Aggarwal, B.B., and B. Sung. Pharmacologic basis for the role of curcumin in chronic diseases: An age-old spice with modern targets. Trends in Pharmacological Sciences. Vol. 30, No. 2 (2009): Tomasellgo, G., et al. Dysmicrobism, inflammatory bowel disease, and thyroiditis: Analysis of the literature. Journal of Biological Regulators and Homeostatic Agents. Vol. 29, No. 2 (2015): Miller, A.L. Therapeutic considerations of l glutamine: A review of the literature. Alternative Medicine Review. Vol. 4, No. 4 (1999): De-Souza, D., and L.J. Greene. Intestinal permeability and systemic infections in critically ill patients: Effect of glutamine. Critical Care Medicine. Vol. 33, No. 5 (2005): Souba, W.W., et al. The role of glutamine in maintaining healthy gut and supporting the metabolic response to injury and infection. Journal of Surgical Research. Vol. 48, No. 4 (1990): Ananthakrishnan, A.N., et al. Higher predicted vitamin D status is associated with reduced risk of Crohn s disease. Gastroenterology. Vol. 142, No. 3 (2012):

Dietary advice for people with Inflammatory Bowel Disease

Dietary advice for people with Inflammatory Bowel Disease Crohn s disease and Ulcerative colitis Information for patients Name Your Dietitian Dietitian contact number: 0118 322 7116 What is Inflammatory