Crohns Disease - Nutritional Therapy For Crohn's Disease
Nutritional Therapy For Crohn's Disease
A paper presented at the Fourth Annual Sympoium on Alternative Therapies
at the New York Marriott World Trade Center
March 28, 1999
By Leo Galland, M.D.
To determine whether dietary modification and nutritional supplementation for adult patients with Crohn's disease can relieve symptoms, induce clinical remission, and decrease the use of anti-inflammatory and immune suppressive drugs.
Individualized dietary therapy combined with nutritional supplementation will be disease modifying for patients with Crohn's disease. Individual patients will respond differently to different dietary interventions.
Initial evaluation included recording of all Crohn's disease relevant symptoms (diarrhea, abdominal pain, fever, fatigue, blood or mucus in stool, weight loss) and the following laboratory tests: complete blood count, sedimentation rate, serum albumen, excretion of lactulose and mannitol after an oral challenge. Changes in symptoms were evaluated at each office visit using a digital analog scale. Laboratory parameters were re-tested at three-month intervals. The dietary treatment was administered in a tiered fashion. The initial diet was a grain free, low disaccharide diet (the specific carbohydrate diet, SCD); this was followed for 30 days. If a symptom reduction of 50 percent or more occurred the diet was maintained and nutritional supplementation was begun with fish oil capsules supplying 875 mg of EpA per day and a multi-vitamin/multi-mineral preparation supplying 400 mg of vitamin E, 20 mg of zinc, 200 mcg of selenium, 800 mcg of folic acid. If there was less than a 50 percent reduction in symptoms, additional dietary changes were made on an individual basis. These were (a) complete elimination of all milk derived products, (b) reduction in dietary yeast and monosaccharides, (c) avoidance of all nuts and nut flours, (d) addition to the diet of non-glutenous starches (e.g., rice and potatoes). After 30 days of the amended diet fish oil capsules supplying 875 mg of EpA per day were added. If, at the end of 90 days, symptoms persisted at any level, aloe derived mucopolysaccharides (MpS) at a dose of 4 grams per day and glutamine(3 grams per day) were added. Anti-microbial drugs were used as needed when clinical evidence suggested inter-current intestinal infection. patients have been followed for periods of six months to eight years. No patients have been lost to follow up.
All 20 patients demonstrated a decrease in symptoms and reduction in medication use. Six patients have entered complete clinical remission, discontinued all medication, and maintained remission for five to 80 months. The most rapid response in this category belongs to a 28 year old male who presented with daily fevers of 40 degrees C, bloody diarrhea six times per day, a serum albumen of 2.6 g/dl, ESR of 90 and oxalic acid excretion of 164mg per day, despite the use of azathioprine 100 mg per day and prednisone 40mg per day. This patient achieved complete clinical and laboratory remission during the first 60 days and has maintained remission for three years. For the remaining 14 patients, reduction in symptoms scores were from 90 percent to 40percent (mean reduction of 65 percent). Mean prednisone dose (6 patients) decreased from 17 mg to 5 mg, mean dose of azathioprine or 6-mercaptopurine (3patients) decreased from 100 mg per day to 33 mg per day, mean dose of5-aminosalicylate preparations was reduced by 33 percent, mean ESR decreased from 66 to 32, mean serum albumen increased from 3.2 g/dl to 4.1 g/dl and mean intestinal permeability index (differential lactulose/mannitol absorption) decreased from 0.275 to 0.074. Eleven patients responded to the initial SCDand nine proceeded to other dietary interventions. All nine returned non-glutenous starches to their diets. Yeast illumination was the diet of choice for five, complete milk limitation for five, and elimination of nuts for four. Sixteen patients received fish oil supplements, 9 received glutamine and MpS supplements.
Discussion & Conclusions
The pathophysiology of Crohn's disease is thought to involve a hypersensitive cellular immune response to components of the indigenous intestinal flora. Diet has been shown to influence the nature ofthe intestinal flora and several studies have shown that specific foods can trigger symptoms in patients with Crohn's disease; moreover avoidance of those foods has previously been shown to help reduce symptoms or maintain clinical remission. (The East Anglia Diet and Crohn's Disease Study). Nutritional deficiencies are common in patients with active Crohn's disease; deficiencies of protein, zinc, selenium and folic acid have been described and may alter immune responses. Fish oil has been shown to help maintain remission of Crohn's disease and glutamine and aloe derived MpS have been shown to improve healing. The present study demonstrates the feasibility of applying established knowledge concerning nutritional and dietary influences on Crohn's disease in treating patients in an Integrated Medicine practice. Individualized dietary modification and nutritional supplementation was associated with a reduction in symptoms, induction of clinical remission, and decreased use of medication. All patients in this study were already receiving conventional therapy. Further studies are warranted to determine whether individualized nutritional therapy should be considered first line treatment of adult Crohn's disease.