Functional Nutrition Interventions for Inflammatory Bowel Disease
Inflammatory Bowel Disease is a chronic, debilitating disease that affects over 3 million people according to the U.S. Centers for Disease Control and Prevention.
While very effective, many of the medications used for IBD are expensive and come with the risk of serious side effects.
Difficulty controlling the disease with medications, flare ups while on medication, and the continued need for stronger medications over time present significant challenges for doctors and patients with IBD. Patients have begun to search for solutions to IBD, particularly nutritional interventions in addition to what their doctors are offering, to help mitigate the challenges associated with IBD.
Fortunately, more and more research is beginning to focus on the role of nutritional interventions, dietary supplements, the gut microbiome, and lifestyle factors that can help support the management of IBD.
In this article, we will look at the etiology and epidemiology, risk factors, assessment, Conventional medicine and Functional Nutrition interventions for IBD with the hope of shedding light on areas that can be effective for improving symptom control, improving remission rates, improving quality of life, reducing relapse rate and frequency, and potentially reducing the need for stronger, more expensive and higher risk medications over time.
Epidemiology & Etiology
The two primary types of Inflammatory Bowel Disease (IBD) are Crohn’s disease (CD) and Ulcerative Colitis (UC). These conditions are forms of chronic enteritis, which means they involve chronic inflammation of the gastrointestinal tract.(1) Even though both types of IBD are associated with inflammation of the GI tract, UC primarily affects the rectal area and the large intestine, and is accompanied by ulcerations of the intestinal mucosa which can lead to bleeding and other complications such as perforation of the colon and carcinoma.(1)
CD can affect the entire GI tract from the mouth to the anus, however it primarily affects the ileum and ascending colon.(1) Thickening of the bowel wall called “cobble-stoning” is a classic endoscopic presentation of CD.(1) While ulcerations can occur with CD, they are more common in UC.(1) Complications due to the thickening of the bowel wall in CD include scarring and bowel obstruction.(1) Symptoms can be similar in CD and UC and may include: diarrhea, abdominal pain, bloody stools, weight loss, fatigue, and anemia.(2-3) Fevers are more common with CD, while blood in the stool is more often associated with UC.(3-4)
Many publications suggest that the etiology of IBD is unknown, however more and more research is beginning to point toward the involvement and the interplay between “genetic, environmental, immunological, and gut microbial factors.”(2)
Consensus has not been reached in the medical community regarding the exact role of the gut microbiota in the etiology of IBD, however there is a growing body of research that is looking at how commensal bacteria may influence the innate immune response and how it is affected by antibiotics and probiotics.(4) Research is also beginning to recognize the role of the intestinal barrier and how a disruption in barrier function, and the development of increased intestinal permeability, may contribute to IBD.(3)
Looking at the epidemiology of IBD we find that approximately 25% of patients with IBD are diagnosed before the age of 20 years old. According to Ye, et al., in 2015 the incidence of IBD worldwide was increasing, and the highest prevalence of both CD and UC was found in Europe followed by North America, with the highest rates of IBD in western countries.(5) Ye et al., also acknowledges that the the incidence of IBD is increasing in developing countries and “may be ascribed to the lack of medical resource”.
However, I would like to suggest that the rise of IBD in developing countries, and the prevalence of IBD in western nations, is instead connected to the consumption of a western diet and stressful modern lifestyle.
Even though the exact etiology of IBD is still under debate, certain dietary and environmental risk factors have been identified including (3, 5-6, 8-9):
bottle feeding instead of breastfeeding
antibiotics during childhood
major life stressors and a heightened perception of stress
a high sugar / high trans-fat / low fiber diet
a high dietary omega-6 to omega-3 ratio
vitamin D insufficiency
food and microbial allergies or sensitivities
increased intestinal permeability
medications including antibiotics, NSAIDs and oral contraceptives
Stress is an interesting risk factor for IBD, and seems to be a major factor in the etiopathogenesis of many autoimmune disorders.(7) In IBD specifically, stress has been shown to “aggravate the symptoms of IBD and has an association with the exacerbations of CD and UC.” Poor coping strategies along with a heightened perception of stress has been shown to cause early relapse of IBD symptoms according to Ye et al.(5)
Another interesting set of risk factors to take a closer look at are food and microbial antigens. It has been found that antibodies to food and microbial proteins can develop when there is an increased intestinal permeability.(3) Frehn et al. found significantly higher IgG and IgA antibodies for B. fragilis in CD patients, but no significant differences in antibodies for ovalbumin, wheat, milk, or E. coli compared with control groups.(8) However, in another study, Limketka et al. found that Gluten Sensitivity “was common in IBD and associated with having had a recent flare.”(9)
Gut barrier integrity, and the role of increased intestinal permeability, is also important to consider for IBD. The development of antibodies to food and microbial antigens may be a direct result of a compromised mucosal barrier.(10) In their 2015 article Michielan and D’Incà discuss how IBD may be an impaired barrier disease.(10) They go on to explain how “IBD patients display increased paracellular permeability with tight junction abnormalities that have been documented in several studies.”(10)
What this means is that when the tight junctions that hold the enterocytes together become compromised, contents within the lumen that are not intended to enter systemic circulation (e.g. partially undigested food proteins, endotoxins, lipopolysaccharides, etc.) may be allowed to pass through the gut wall and enter the body.
When this happens the immune system can become activated and launch an attack to defend the body against what it perceives to be a “foreign invader”. This can lead to a chronic inflammatory response, which may be linked to the pathogenesis of IBD.(10) Michielan and D’Incà also mention that the inflammatory process of IBD can lead to a worsening of mucosal barrier dysfunction.(10)
To obtain an official diagnosis of IBD, and to differentiate between CD and UC, an endoscopy with biopsy is required. There are also non-invasive biomarkers that can be used for the initial diagnosis and monitoring of the disease. Antibody markers such as anti-Saccharomyces cerevisiae (ASCA) and perinuclear antineutrophil cytoplasmic antibody (pANCA) are two of the most common antibodies checked in IBD.(3)
Other non-invasive lab tests that are used to help detect and monitor IBD include fecal calprotectin and the protein S100A12.3 C-reactive protein (CRP) is a serum marker that is also commonly checked.(3)
Clinical presentation of symptoms may include: diarrhea, abdominal pain and cramping, blood in the stool, weight loss, anemia, fatigue, and fevers.(3) However, these symptoms may be associated with other conditions and should not be used exclusively for a diagnosis.
Since there is no known cure for IBD, the main goal of treatment and intervention is remission of inflammation and symptoms, and improved quality of life for the patient.
Conventional Medicine uses pharmaceuticals, and sometimes surgery to treat IBD. The goal of pharmaceutical intervention is to control inflammation and suppress the immune system to provide symptom relief and reduce flare ups.
There are many different classes of medications that are used for IBD including aminosalicylates, antibiotics, biologics, corticosteroids and immunomodulators.(11) Typically, medications are selected in a step-therapy manner, meaning lower cost medications with fewer risks of side effects are chosen first, followed by more expensive medications with potentially greater risk of side effects if the other therapies do not work.(12)
Unfortunately, many of the medications used for IBD come with a risk of side effects, sometimes very serious side effects.
Fortunately, there is a growing body of research that supports the benefits of dietary and lifestyle interventions, and the use of a functional and integrative approach to IBD in addition to Conventional Medical treatment. According to Pizzorno and Katzinger, some of the interventions that have been shown to be safe and efficacious for IBD include: identifying and removing food antigens, utilizing an elimination diet to reduce intestinal inflammation, and supplementation of nutrients, herbs and probiotics to give the body the tools it needs to restore balance naturally.(3)
Nutrients that have been found to be particularly helpful for IBD include: vitamins A, B-complex, C, D, E, K, zinc and calcium.(3) Herbs such as curcumin and boswellia have been shown to be helpful for reducing inflammation associated with IBD.3 Research has shown that 3,000 mg/day of combined EPA and DHA can help “reduce disease activity and improve endoscopic scores.”(3)
Specific strains of probiotics have been shown to be beneficial for IBD including: Lactobacillus rhamnosus, Saccharomyces boulardii, Lactobacillus acidophilus, Lactobacillus bulgaricus, Lactobacillus casei, and Lactobacillus plantarum; along with bifidobacteria (B. breve, infantis, and longum) and Streptococcus thermophilus.(3)
Anti-inflammatory short chain fatty acids, such as butyrate, are supposed to be produced by the beneficial bacteria in the gut, however, in a dysbiotic state, which is common in IBD, these bacteria may be compromised. Studies have shown that supplementing with 4 g/day of oral sodium butyrate has resulted in clinical improvement or remission, as well as improving the efficacy of oral mesalazine, and is considered a safe and well tolerated intervention for IBD.(13-14)
Another supplement that has been gaining the attention of researchers for IBD patients is oral serum bovine immunoglobulin supplements (SBI).
In 2015, Shafran et al. found that patients with IBD who were still symptomatic even though they were on conventional therapy showed symptom improvement when SBI supplementation was added to their therapy.(15) One of the mechanisms by which SBI supplementation helps to improve symptoms of IBD is by improving intestinal permeability and “restoring homeostasis to gut barrier function” as Kuchibhatla et al. discuss in their 2015 meta-analysis.(16)
Even more encouraging, Shaw et al. and Liaquat et al. have found that when SBI supplementation is added to conventional medications, IBD patients report less frequent bowel movements, less abdominal pain and bloating, and also an overall improvement in quality of life.(17-18)
The FDA has considered SBI to be a safe and well tolerated nutritional supplement.(19) In my opinion, SBI supplementation may offer a safe and effective supportive nutrient for helping to improve gut barrier function, and appears to be resulting in very positive improvements for IBD patients.
In addition, elimination diet interventions such as a no-carrageenan diet, Low FODMAP diet, the Specific Carbohydrate Diet, and the Autoimmune Paleo diet have shown good promise for helping to improve the symptoms and inflammation associated with IBD.(20-23)
Research has shown that the alpha-gliadin peptide in gluten-containing grains directly contributes to increased intestinal permeability in all individuals whether or not they have Celiac disease or Non-Celiac Gluten Sensitivity due to its effect on tight junction regulation via zonulin signalling. Therefore, it may also be prudent to consider avoidance of gluten to support the normalization of intestinal permeability, and restoration of gut barrier function.(24)
Conclusion If we consider the risk factors associated with IBD, along with the etiological factors thought to play a role in the development of IBD, we can begin to see how a “perfect storm” can develop, especially in genetically susceptible individuals.
Based on the research we have reviewed in this article, it is my opinion that, for example, if a genetically susceptible child has a compromised gut microbiota due to bottle feeding and/or antibiotic use during childhood, and has a low intake of fruits and vegetables or other sources of dietary fiber that feeds the beneficial bacteria in the gut, is deficient in vitamin D, develops increased intestinal permeability, and has stress in their life, this may set the stage for the onset or worsening of IBD.
The good news is that by understanding how these factors interact with each other, we can begin to see areas of opportunity where nutrition and lifestyle interventions can make a big difference in the symptoms, quality of life, and disease process for IBD patients.
That being said, based on the research reviewed in this article, I recommend the following Functional Nutrition considerations for an IBD client in addition to their medical treatment: a nutrient dense, whole food, no-carageenan, no gluten diet combined with either a Low FODMAP, AIP or SCD diet; investigation and elimination of personal food sensitivities; an evaluation of nutritional status and repletion of sub-optimal nutrients; herbal therapy with curcumin and/or boswellia; additional supplementation including high quality EPA and DHA, butyrate, and oral serum bovine immunoglobulins (SBI).
I would also recommend a comprehensive stool analysis to identify and address dysbiosis and to help select the appropriate probiotic therapy. Lifestyle interventions to manage stress should also be incorporated given the role stress has shown to play in the onset and worsening of IBD symptoms.
I do not believe at this point in time it would be wise to abandon the use of conventional therapies for IBD, in fact, research supports that the integration of conventional therapies and nutrition and lifestyle interventions can offer a lot of help for this population. As we have discussed, there are many Functional Nutrition “tools” that can be utilized as adjunct to conventional treatments that may offer benefits in terms of better symptom control, better remission rates, improved quality of life, a reduction in relapse rate and frequency, and potentially less of a need for increasingly stronger, more expensive, and higher risk medications.
It is my hope that nutrition and lifestyle interventions will continue to be researched so that we can better understand the therapies that will help the IBD population.
The information presented in this article is not intended to take the place of your personal physician's advice and is not intended to diagnose, treat, cure, or prevent any disease. Discuss all health-related information with your doctor to determine what is right for you. All information is intended for your general educational purposes only and is not a substitute for medical advice or treatment for specific medical conditions.
Jaime Ward, MS, INHC, CGP Clinical Nutritionist Board Certified Health Coach Certified Gluten-free Practitioner Autoimmune Survivor
Jaime is a Clinical Nutritionist who graduated summa cum laude from The University of Bridgeport with a Master's degree in Human Nutrition from a Functional Medicine approach. Jaime is also a Board Certified Health Coach, Certified in BioIndividual Nutrition, and is a Certified Gluten-free Practitioner.
Jaime has over 10 years of experience coaching women and families with autoimmunity to successfully implement the personalized nutrition and lifestyle changes that restores health and provides freedom from the persistent challenges of autoimmunity like fatigue, inflammation, unhealthy weight, hormone imbalances, gas, bloating, and digestive distress.
Over the past 10 years, Jaime has helped over 700+ women and families with many different types of autoimmune conditions achieve freedom from chronic symptoms through the power of personalized nutrition and healthy lifestyle solutions. In her work with clients, Jaime uniquely combines her clinical expertise with a heart-centered coaching approach filled with love, support, and compassion.
In addition to her professional work, Jaime is a Christian, a speaker, a writer, a busy mom, a competitive Dressage equestrian, and an autoimmune disease survivor.
Learn more about working with Jaime here: Hope4Autoimmunity.com
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