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.
As a large number of IBD patients fail conventional treatment, do not tolerate medications o their side effects, suffer refractory illness and steroid-dependance, or have troubling relapses, 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. As Naturopathic Physicians trained as primary care physicians, in both the pharmacologic management of disease and natural therapeutics, we are well suited to provide the necessary integration to address the these integrative needs of the IBD patient.
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. For most patients, dietary change is not easy, and it is important to obtain considerable support and counseling to assure success. When this dietary strategy is correctly implemented, 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, there is ample empirical evidence amongst experienced naturopathic physicians and patients world-wide to point to this particular strategy as central to a plan with potential to heal inflammatory bowel disease naturally. While there are no controlled trials validating SCD, one case series from the University of Massachusetts shows clinical correlation with the positive outcomes3 observed 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,2 and 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 the cause of the diseae, but rarely supporting any particular dietary treatment approach.8 A particular dietary cause 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 rarely 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. If you seek a dietary solution to your IBD, you must work through levels of dietary change that will support mucosal healing and a remission of your symptoms.
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 One: Dysbiosis
It is widely agreed that the main cause of IBD is a disruption of our normal intestinal bacteria, also known as our microbiome, or 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 avium subspecies paratuberculosis, Yersinia, Pseudomonas, Salmonella, Campylobacter jejuni, Clostridum difficile, 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 Some practitioners recommend butyrate enemas as 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 real issue at hand is that almost all IBD research focuses on the disturbance of the microbiome of the IBD gut as the central factor that has caused the immune dysregulation that spells ulceration or fibrosis (with genetics and environmental triggers also contributing). When a dietary strategy such as SCD does not adequately address the dysbiosis, another strategy needs to be added.
The following are our guidelines for treating the presumed dysbiosis of IBD
- First, we have faith in a well-chosen dietary strategy such as the SCD and the “safe list” to address dysbiosis. You will work with your natuopathic physician to develop this list.
- We address suspected pathogenic organisms and dysbiotic overgrowth with additional therapies.
- We 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
- We examine medical records to determine organisms treated previously or coordinate with your gastroenterologist to explore antibiotic or probiotic strategies.
- We use accumulated data to treat, based on findings
- We assume dysbiosis in spite of the normal lab findings, and select strategies depending on circumstances, findings, strength of patient, and pattern of dysbiosis
- We 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 patients to many encapsulated supplements and some well-indicated decoctions at full strength, we find herbal strategies employing diluted botanicals to be useful
- We 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 bifidus contained within it, due to more frequent aggravations
- We are increasingly interested in 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. Many of us are exploring options to be able to recommend FMT and facilitate trials after an appropriate donor screening.
Obstacle Two: 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 (the so-called “leaky gut syndrome,” addressing dysbiosis, assuring adequate nutritional support, and removing the other obstacles discussed herein. We also 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.23 Low-dose naltrexone (LDN), an experimental compounded medication prescribed by many naturopathic physicians, has been helpful in many cases for maintaining remission. Some limited studies validate its use.24
Obstacle Three: Intestinal Permeability
Tiny, microscopic holes in the intestinal lining caused by immune-system overactivity are characterized by the term “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 Four: 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 Maintaining optimal nutrition is a vital part of maintaining remission in IBD. 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 mesalamine and 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 often start 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.
Obstacle Five: Suboptimal Digestion
We pay attention to the entire GI tract, which means addressing possible functional hypochlorhydria, pancreatic insufficiency (PI), bile acid insufficiency, and also bile acid malabsorption, which is a common feature of CD.29 PI is often associated with IBD with frequent bowel movements. There is little data to support HCL supplementation in IBD; however, we have seen profound improvement using this and even have one case where HCL supplementation has been responsible for sustained symptom remission. It is helpful to use laboratory testing to assess functional digestion and absorption problems, and then treat accordingly with tolerated agents and strategies.
Obstacle Six: Stressors and Psycho-Emotional Issues
Stress appears to be a trigger and perhaps an antecedent of IBD, though data on interventions are poorly documented.30 The possible mechanisms by which stress could be translated into IBD symptoms include changes in motor, sensory and secretory gastrointestinal function, increased intestinal permeability, and changes in the immune system.31 Likewise, the relationships between the hypothalamic-pituitary-adrenal (HPA) axis activity, hypocorticism, and glucocorticoid receptor dysfunction have been tied to inflammatory and autoimmune diseases.32 Depression and anxiety are prevalent in patients with IBD and may influence disease expression.31 One study showed that a significant number of IBD patients felt that antidepressant treatment positively influenced their IBD.33
In our clinic we integrate classical acupuncture, homeopathy, counseling, and neural therapy, either through treatment in the clinic, or referral. If anxiety and depression are present, remedies (natural or pharmacologic) must be incorporated into the plan. We teach mindfulness-based stress reduction (MBSR) in our clinic in 8-week cycles, as outlined by Jon Kabat-Zinn.34 MBSR has been shown in several studies to impact inflammation in a variety of health conditions,35,36 and has been shown in one study to decrease C-reactive protein (CRP).37 Psycho-emotional imbalance and stress must be addressed in treatment for successful outcomes. Increasingly there is evidence that the stress, and mental and emotional states, directly influence the bacteria of the gut, and a mechanism by which the mid contributes to dysbiosis has been articulated by researchers.
Obstacle Seven: Low or subtimal adrenal function.
One obstacle in managing some IBD cases is low hormone output from the gland of stress—the adrenal gland. The central hormone produced by adrenal gland, cortisol, functions as the bodies natural anti-inflammatory required in adequate amounts to maintain a balanced state. This problem, referred to as functional adrenocortical insufficiency was described at length in the text, The Safe Uses of Cortisol, by Jeffries.38 It is surprising how little data exists on this phenomenon despite widespread agreement that the HPA axis is relevant to the mechanism of IBD.39 We screen IBD patients to find significant numbers with low salivary cortisols, 24-hour urinary cortisols, and, in some cases, morning serum cortisols. When adrenal salivary testing reveals a low cortisol concentration, low DHEA-S, and low 17-OH-progesterone, we maintain a high confidence level that low-dose hydrocortisone will contribute to symptomatic, if not endoscopic remission. One fatigue study published in The Lancet demonstrated that low-dose hydrocortisone (10 mg or less) is not suppressive of adrenal function.40 Some cases respond well to dessicated adrenal extract and various adrenal supplements, but we have had more success with low-dose hydrocortisone, given according to bioidentical hormone replacement principles, than any other oral therapy.
Obstacle Eight: Constitutional Imbalance
We do not have data supporting treatment of the “constitutions” of our patients, and this is the least evidence-based area in naturopathic medicine. When we refer to treatment of the “constitution,” we are referring to a dominant pattern of symptoms that lead us to prescriptions of homeopathic remedies, Chinese medicine treatments, and other interventions that Naturopathic Physicians spend a good deal of time studying during their medical training. We find it important to examine constitutional imbalances and address them as they present themselves, whether employing the “simillimum” described in classical homeopathic literature, addressing the indicated “miasm” or “reactional mode,” or treating the constitutional patterns perceived by practitioners of Chinese Medicine. In our clinic, most patients receive acupuncture once a Chinese differential diagnosis has been established. A significant number of our IBD patients are intolerant of Chinese herbal formulas, except when they are well along the path to remission.
Handing Acute Exacerbations in Naturopathic Medicine
If you have IBD, then you know that managing acute exacerbations competently is essential. Before going for the “root” of the condition, it is necessary to get acute symptoms under control. A shopping bag of hard-to-digest supplements will rarely do the job, so we rely on acupuncture, a well-chosen homeopathic remedy, the introductory phase of SCD, and, when necessary, oral corticosteroids or other typical IBD medications to “manage” acute symptoms. Of course, there are other methods to consider, such as an “elemental diet,”41 which has shown to be as effective as corticosteroids. Depending on the goals of the patient, the severity of symptoms, and the staging of the disease, acute flares in ulcerative colitis or Crohn’s diseae may be able to managed without the use of steroids or other conventional medications. In Oregon, Washington, Arizona, New Hampshire, Vermont, and Maine, where N.D.’s have a wide scope of practice that includes the ability to prescribe conventional medications, your Naturopathic physican may employ a medication to help troubling symptoms. In states where N.D.’s do not have prescribing rights, patients should understand that the N.D.’s nonetheless have the training to appropriately recognize the need for pharmacologic agents in acute care and make appropriate referrals. In our practice, we coordinate with our patients gastroenterologists to assure that acute exacerbations of IBD are addressed appropriately.
Obtain Necessary Support
IBD patients typically arrive in our clinic after exhausting other avenues of care. They often present, expressing confusion about the choices they face, experiencing a conflict of paradigms, ie, between conventional treatments offering less-than-promising results and with dangerous side effects, and alternative and complementary care that is driven by a different set of principles and using treatments that appear to lack “proven results.” Patients may have been discouraged by medical professionals to engage in naturopathic therapies, or been told that “diet doesn’t matter.” What we ask of the patient – ie, to embrace a new paradigm—is immense. And when patients are flaring, they do not have a lot of energy to invest in their wellness and embrace complicated treatment. In our clinic, we compensate for this with a staff member, an occupational therapist who specializes in helping IBD patients to implement the necessary lifestyle changes to assure a successful treatment plan. We have set up systems, personnel, and a reimbursement strategy to provide programmatic assistance to help patients get well. The waxing and waning of IBD requires frequent follow-up, careful monitoring, and availability to address flares.
Monitor Responses Carefully
As physicians, we believe it is important to share the concerns of gastroenterologists, not only to monitor signs and symptoms, but to assure mucosal healing and prevention of colorectal cancer, which occurs in a significant number of IBD patients.42 Regular surveillance appears necessary,43 with colonoscopy considered the gold standard for diagnosing early dysplastic alterations. It is also important to use biomarkers to assess clinical progress.44 Fecal biomarkers such as calprotectin and lactoferrin, as well as serological markers such as ESR and CRP, are valuable to gather at baseline and to monitor over time as a dietary strategy is implemented and obstacles to remission are removed.45,46 These markers are invaluable in helping to assess degrees of mucosal healing prior to further endoscopy, although mucosal healing has been defined as “complete absence of all inflammatory and ulcerative lesions in all segments of gut” at endoscopy.47
Integrate, Don’t Separate
Many patients with IBD feel they have to make a “either/or” decision about whether to work with a naturopathic physician or a gastroenterologist. I believe that patients are best served by integrating their care. This works best, of course, with naturopathic physicians that seek integration, and gastroenterologists with a collaborative spirit who recognize the need to address many of the areas discussed above. IBD is one of those conditions where the troubling symptoms, profound discomfort of our patients, and the serious health risks of disease progression test our philosophical resolve (and indeed, the resolve of gastroenterologists as well). We employ sound naturopathic measures, and yet sometimes we cannot get the symptoms under control and stimulate mucosal healing. This is no time for philosophical grandstanding about what is natural; the Naturopathic Physician needs to be integrative and remember that we are physicians “specializing” in natural therapeutics but trained (and in many locales, licensed) to use pharmacologic agents appropriately. This is a disease in which management requires integration of our naturopathic skills with some of the modalities of our allopathic brothers and sisters. It is often in your best interest to also maintain an integrative approach to the treatment of your IBD. It is in your interest to promote the healing of your condition and reduce reliance on medications that are either ineffective or causing serious side effects or other adverse effecs. However at the same time, it is important to be objective in evaluating whether you are making progress using more natural approaches, and whether it is leading to both sustained symptomatic and mucosal remission.
IBD is where the rubber meets the road. The contact point of the tire (our medicine) with the road (the patient’s experience of the disease) should yield positive results. However, when we do not see adequate progress, the symptomatic and pathological pushback is so great that there had better be tread on those naturopathic tires.
The needed tread is integration, not separation. As we proceed with our pursuit of the condition’s root, we apply multiple therapies, observe the outcomes, adjust therapies as we go, and maintain awareness of our patient’s responses. We assume the responsibility to manage the case, or work with gastroenterologists or other providers to add medications when the condition flares, or remove medications when we begin to see signs that the vis medacatrix naturae will take the patient, as it often does, to the promised land.
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- Gottschall E. Breaking The Vicious Cycle: Intestinal Health Through Diet. Baltimore, Ontario, Canada: Kirkton Press; 2007.
- Olendzki BC, Persuitte G, Silverstein T, et al. Pilot Testing a Novel Treatment for Inflammatory Bowel Disease. Clinical and Translational Science Research Retreat, May, 2011. http://works.bepress.com/barbara_olendzki/46. Accessed: October 12, 2013.
- Suskind DL, Wahbeh, G, Gregory, N, et al. Nutritional Therapy in Pediatric Crohn’s Disease: The Specific Diet. J Pediatr Gastroenterol Nutr. 2013 Sept 16. [Epub ahead of print]
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- Elliott TR, Hudspith BN, Wu G et al. Quantification and Characterization of Mucosa-Associated and Intracellular Escherichia coli in Inflammatory Bowel Disease. Inflamm Bowel Dis. 2013;19(11):2326-2338.
- Scaldaferri F, Gerardi V, Lopetuso LR, et al. Gut microbial flora, prebiotics and probiotics in IBD: their current usage and utility. BioMed Res Int. 2013;2013:435268.
- Fung QM, Szilagyi A. Carbohydrate Elimination or Adaptation Diet for Symptoms of Intestinal Discomfort in IBD: Rationales for “Gibsons’ Conundrum.” Int J Inflamm. 2012;2012:493717.
- Machiels K, Joossens M, Sabino J, et al. A decrease of the butyrate-producing species Roseburia hominis and Faecalibacterium prausnitzii defines dysbiosis in patients with ulcerative colitis. Gut. 2013 Sep 10. doi: 10.1136/gutjnl-2013-304833.
- Pacheco RG, Esposito CC, Müller LC, et al. Use of butyrate or glutamine in enema solution reduces inflammation and fibrosis in experimental diversion colitis. World JGastroenterol. 2012;18(32):4278-4287.
- Uronis JM, Arthur JC, Keku T, et al. Gut microbial diversity is reduced by the probiotic VSL#3 and correlates with decreased TNBS-induced colitis. Inflamm Bowel Dis. 2011;17(1):289–297.
- Damman CJ, Miller SI, Surawicz CM, Zisman TL. The microbiome and inflammatory bowel disease: is there a therapeutic role for fecal microbiota transplantation? Am J Gastroenterol. 2012;107(10):1452-1459.
- Smits LP, Bouter KE, de Vos WM, et al. Therapeutic potential of fecal microbiota transplantation. Gastroenterology. 2013;145(5):946-953.
- Elliott DE, Weinstock JV. Helminth–host immunological interactions: prevention and control of immune-mediated diseases. Ann N Y Acad Sci. 2012;1247:83–96.
- Shih DQ, Targan SR. Insights into IBD Pathogenesis. Curr Gastroenterol Rep. 2009;11(6):473–480.
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- Smith JP, Bingaman SI, Ruggiero F, et al. Therapy with the opioid antagonist naltrexone promotes mucosal healing in active Crohn’s disease: a randomized placebo-controlled trial. Dig Dis Sci. 2011;56(7):2088–2097.
- Fries W, Belvedere A, Vetrano S. Sealing The Broken Barrier in IBD: Intestinal Permeability, Epithelial Cells and Junctions. Curr Drug Targets. 2013 Sep 23. [Epub ahead of print]
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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.