-IBIS-1.7.6-
tx
digestive system
ulcerative colitis
Nutrition
dietary guidelines
eating principles:
Decrease consumption of refined foods. Move to a high complex carbohydrate, high fiber diet. Initially must be very careful not to aggravate the condition so refined and easy to digest foods are important. As the person stabilizes, fiber and unrefined foods are important to continue the health of the colon.
(Grimes. Lancet 1:395, 1976)
Elimination/rotation diet, rotation diet, rotation diet expanded
Correct nutrient deficiencies
Provide adequate calories
Be careful, and observant, with food combinations: especially avoid starch, sugar, protein combinations (i.e. cheesecake). Avoid eating too many types of foods at one time. Stick to one type of starch per meal. Eat more steamed vegetables than raw ones. See General Guidelines for Eating
Short (3-5 day) fasts are recommended as are an alkaline juice fast (see Fasting in materia medica)
All foods must be eaten slowly, chewed and salivated well; eat in a calm atmosphere, do not read or watch television while eating
Factors that promote translocation across damaged mucosal barrier:
- Changes in bacterial flora
- Impaired host deficiency mechanisms
- Trauma
- Endotoxemia
- Protein calorie malnutrition
- Long term treatment with cortisone
sample diet:
» acute phase (1-3 weeks)
breakfast: whole brown rice cereal (cook 3-4 tbsp. rice flour with 2 cups water, stirring constantly over heat), 2 tsp. olive or corn oil
morning snack: raw grated apple or applesauce or baked apples (sour or semi-sour only)
lunch: vegetable soup from celery, parsley, zucchini, squash, pumpkin, carrot, potatoes (blended and strained), steamed carrots and squash, rice or millet or barley or potato, 2 tsp. olive or corn oil
afternoon snack: same as morning
dinner: same as lunch
» as improvement occurs:
breakfast: oatmeal 3x/week; add soft boiled egg during one meal 3x/week
snacks: add almonds (raw and blanched) with apples
lunch and dinner: if no intolerance to dairy, add yogurt (preferably goat), green beans, waxed beans, lettuce, cucumber, green onion, parsley, celery, garlic, lentils, peaches, apricots, watermelon, grapefruit, grapes, ripe bananas, goat whey
food supplements: liquid chlorophyll, alfalfa tabs, chlorella, calming herb teas
» after stabilization:
Vegetarian Sample Diet
cruciferous vegetables to be eaten only with carminatives (fennel, caraway, cumin, anise, dill)
therapeutic foods:
Foods that calm the Shen (Spirit), harmonize the Stomach and Spleen, potato broth, carrots cooked, okra, parsnips-steamed and mashed, squash, pumpkin, figs and flax seed tea, steamed zucchini and squash, papaya, grated raw apple, applesauce, ripe peaches without skin, banana (not in Cold conditions), rice porridge (Shefi)
Miso soup, slippery elm gruel, psyllium seed powder, flaxseed powder (Marz)
Foods high in the omega-3 and omega-6 fatty acids: vegetable, nut, seed oils, cold water fish, evening primrose oil, black currant oil, flaxseed oil (Marz)
fresh juices:
Carrot (Walker, p. 132)
Carrot and spinach (Walker, p. 132)
Carrot, celery, parsley, and spinach (Walker, p. 132)
Celery (Shefi)
Apple (Shefi)
Carrot and sour apple(Shefi)
Papaya (Shefi)
Coconut milk and carrot (Jensen, p. 50)
foods contraindicated:
artichoke, grapeskins and seeds, roughage, raw foods, cold foods
avoid:
Avoid allergens and food intolerances: Avoiding allergens or food sensitivities is essential part of the treatment. In addition there may be some lectin incompatibilities so doing specialized blood typing may be helpful. (Nanda, et al. Gut 30:1099-104, 1989; DAdamo)
Wheat, corn and dairy, carrageenan-containing foods
Peanuts, meat, sugar and sweet food, refined and processed foods, corn, soybeans, most legumes, coffee, caffeine, oranges, alcohol, hot sauces, spicy foods, fried foods, fatty foods, rich foods, salty foods
Be cautious with vitamin A as it can cause problems if there is liver involvement.
supplements
Lactobacillus acidophilus re-establishes flora. (Bennet and Brinkman. Lancet Jan, 21, 1989)
Vitamin A and Beta carotene: 50,000-75,000 IU per day Be careful with vitamin A as it can cause problems if there is liver involvement.
Vitamin B12 IM
Vitamin C and selenium. 1 g per day or more. Vitamin C must be given as tolerated. This will vary from person to person. In the acute phase of the disease it is important not to irritate the intestinal mucosa. Thus, vitamin C may be contraindicated; use milk-free product. Selenium can be given in doses up to 300 mcg. (Marz, p. 380, 1997)
Vitamin E: 800 IU per dayA free radical scavenger with anti-inflammatory properties, vitamin E is also involved with increasing sIgA, which helps to protect mucosal lining from invading bacteria and other toxins.
Folate: 20-30 mg per day Drugs commonly used in the treated of colitis inhibit folate absorption and also act directly as antagonists (sulfasalazine specifically). Also, folate has been shown to possibly decrease diarrhea in some studies; folate supplementation associated with a reduced risk of colon cancer (Lashner, et al., Gastroenterol, 1988; 19 (5 part 2); 1989; 49: 127-131; Lashner. Gastroenterology 97:255-59, 1989; Elsborg, Larsen. Scand J. Gastroenterol. 14:1019-24, 1979)
EFAs, particularly Omega 3 oils. 2-3 g three times daily
Synthesis of lipoxygenase products and inflammatory leukotrienes are inhibited by these oils. For this reason it is a good idea to avoid saturated fats. There is some debate about omega 6 oils because, in animals, they can get converted into arachidonic acid (AA) via D5 desaturase. In humans this enzyme has very little activity so that very little DHGLA gets converted to arachidonic acid. It is possible that in times stress this enzyme becomes more active and thus converts more of omega 6 FA into AA.
In the acute phase it is necessary to keep the amount of fats down to a minimum to avoid the synthesis of PGE2. It has been found that elemental formulas with greater than 15% fat tend to decrease protein balance.
(Gainsborough, H. Lancet June 10, 1939; Mochizuki, Trocki, Dominioni, et al. JEPN 8:638-646, 1984)
Note: many enteric formulas contain 35-50% fat.
Arginine: 3 g per day (Siefter, Returra, Barbul et al. Surgery 84:224-30, 1978)
Glutamine: 3-12 g per day, a conditionally essential amino acid. Muscle contains about 14% glutamine and alanine. During severe stress or surgery these 2 amino acids make up 60% of released amino acids. The majority goes to the gut and the kidneys where it is used for fuel.
(Soubo, Smith, Wilmore. JPEN 9:608-17, 1985. Marz, p. 380, 1997)
Butyrate enema: can do a series. Can also take orally. (Breuer, R (Associate Professor of Medicine, NW U Chicago). Presentation at a Boston meeting of the American College of Gastroenterology. Med World News December, 1991; Inflammatory Bowel Disease:Arginine:Siefter (study)Harig JM et al. NEJM 320:23-28, 1989)
Cod liver oil enema: can also do a series of these combining with butyrate
Chlorella
Digestive enzymes (pancreatic and HCL), may be used to acidify colon.
Glycyrrhiza has anti-fungal and anti-inflammatory activity
Liquid chlorophyll
N-Acetylated glucosamino sugars: 800 mg three times daily, bypasses the rate limiting step in mucopolysaccharide synthesis by providing preformed N-acetylated glucosamines. (Am. J. Gastroent 78:19, 1983)
Quercetin 500-1000 mg per day 15 minutes before meals, inhibits mast cell degranulation, decreases leukotriene synthesis (by blocking phospholipase A2 and lipoxygenase), and protects cell membranes via its antioxidant activity. (Stefanini, Bazzocchi, Prati, Lanfranchi, Gasbarrini. Lancet 1:207-8, 1986; JAMA 242:1169, 1979; Lancet June 16: 1270, 1969.
Magnesium (Galland, L. Mag and IBD. Magnesium 7:78-83, 1988)
Zinc picolinate: 30 mg per day
» drug interaction:
Notes on Cortisonecortisone and NSAIDs.
Increased permeability and an increase the number of food reactions were related to cortisone and NSAIDS.
Prednisone/prednisolone:
- causes Sodium retention
- causes reduced activation of Vitamin D (Travato, 1991;44:1651-1658; Tuttle, 1982;126:1161-1162); 1,25(OH)2D3 can be measured to determine if supplementation necessary, with low levels can use calcitriol
- causes increased urinary excretion of Zinc, Vitamin K and Vitamin C (Buist, 1984;4(3):114)
Folic acid and sulfasalazine (Azulfidine): causes decreased absorption of folic acid (Longstretch, Green, 1983; 143: 902-904)
footnotes
[No author listed] Immune complexes containing food proteins in normal and atopic subjects after oral challenge and effect of sodium cromoglycate on antigen absorption. Lancet June 16, 1969:1270.
Bennet JD, Brinkman M. Treatment of ulcerative colitis by implantation of normal colonic flora. Lancet. 1989 Jan 21;1(8630):164.
Abstract: JDB had continuously active, severe UC for 7 years confirmed endoscopically and histologically. The condition was refractory to standard management including steroids and sulphasalazine and every time daily prednisone dosage was reduced below 30mg severe symptoms (bloody diarrhea, cramping tenesmus, skin lesions and arthritis recurred. For the past 4 years symptoms had been controlled with 4.2gms of alpha tocopherylquinone and a low fat diet. When the tocopheryl was discontinued or reduced, symptoms returned within 1-2 days. With a protocol developed to sterilize the bowel before surgery, his flora was greatly reduced. The donor flora was introduced by large volume retention enemas. 1 wk later tocopheryls were discontinued without any recurrence of symptoms. It has now been 6 months since this implantation of normal flora and patient has been symptom free for the first time in 11 years without any medications. 3 months after the implantation, colonic biopsy revealed chronic inflammatory cells but no active inflammation.
Breuer R. Presentation at a Boston meeting of the American College of Gastroenterology. Med World News December, 1991.
Abstract: 21 patients with left sided ulcerative colitis treated themselves with an enema of acetate, proprionate, and butyrate in a 100ml solution 2x per day while the control group of 20 patients used enemas with saline alone. After 6 weeks 10 of 17 patients in the treatment group had improved significantly compared to 6 of 20 in the controls. 2 of the treated patients had complete remission of all symptoms and a follow up after one year showed that some of the patients had no relapse.
Cummings J. Short-Chain fatty acids in the human colon. Gut 1981;22:763-779.
Abstract: It was found that 3 short chain fatty acids, butyrate, acetate, and propionate, compose a major solute fraction of fecal water. Basically they come from unabsorbed dietary carbohydrates which have been fermented. Of these three fatty acids, butyrate is the single biggest metabolite of fiber. It has been shown that several cell types in the colon used butyrate to help induce differentiation.
D'Adamo P. Eat Right For Your Type. Putnam, NY, 1996.
Decreased incorporation of 14c glucosamine relative to 3H-N-Acetyl glucosamine in the intestinal mucosa of patients with IBD. Am J Gastroent 1983;78:19.
Elsborg, Larsen. Folate deficiency in chronic IBD. Scand J Gastroenterol. 1979;14:1019-1024.
Abstract: Of 216 patients with chronic IBD, low serum folate levels were found in 59% and low red blood cell levels in 26%. It is suggested that folate deficiency is of multiple origin; inadequate diet, malabsorption and chronic drug induced low grade hemolysis.
Fukushima Y, Kawata Y, Hara H, Terada A, Mitsuoka T. Effect of a probiotic formula on intestinal immunoglobulin A production in healthy children. Int J Food Microbiol 1998 Jun 30;42(1-2):39-44.
Abstract: The anti-infectious effect of probiotics has recently been reported and one mechanism may be the non-specific stimulation of immunity. This study was performed to elucidate the influence of a probiotic formula on intestinal microflora and local immunity in healthy children. A follow-up formula containing viable bifidobacteria was given to seven healthy Japanese children (15 to 31 months old) for 21 days. During intake of the formula, the administered strain was detected in feces from five subjects (71%) and total fecal bifidobacteria slightly increased. Fecal levels of total IgA and anti-poliovirus IgA during intake of the formula were significantly higher than those before intake (P < 0.05). The increase in local IgA levels resulting from ingestion of the probiotic formula may contribute to enhancement of the mucosal resistance against gastrointestinal infections.
Fuller R, Gibson GR. Modification of the intestinal microflora using probiotics and prebiotics. Scand J Gastroenterol Suppl 1997;222:28-31.
Abstract: Probiotics and prebiotics modulate the composition of the human gut microbiota. The beneficial effects may result from suppression of harmful microorganisms or stimulation of organisms which contribute in a positive way to the nutrition and health of the host. Both types of supplement represent an attempt to reconstitute the gut flora to its normal composition which has been adversely affected by dietary and environmental stresses.
Gainsborough H. Treatment of ulcerative colitis with cod-liver oil retention enema. Lancet June 10, 1939.
Abstract: 6 cases of UC were treated with high calorie/low residue diet. The retention enemas were administered with cod liver oil and starch. Opium and/or morphine was also given if necessary to allow for retention of the enema. Early infections were given during the day. For longer term infections, enemas were given at night and, ideally, retained over night. The initial dose was 2oz and was increased by 2oz at a time to a maximum of 8oz in accordance with the patients capability to retain the enema. When the ulcer appeared on radiography up to and past the splenic flexure, the foot of the bed was raised by one foot to facilitate the spread of the oil. 3 of the patients who had symptoms for up to 1.5 years showed marked improvement and were symptom free for 2 years after. One patient who had the condition for 12 years was well for 15 months, then relapsed, but got better again The 5th case remained mostly well, but the 6th patient eventually went on to require an ileostomy.
Galland L. Magnesium and IBD. Magnesium 1988;7:78-83.
Abstract: This review article discusses possible reasons for deficiency: 1) decreased intake from restrictive diet or anorexia; 2) formation of magnesium soaps from steatorrhea, and from general diarrhea; 3) magnesuria induced via steroids or surgery; 4) increased requirements for healing and for rapid cell turnover. Symptoms include muscle cramps, bone pain, delirium, acute tetany, fatigue, depression, cardiac abnormalities, impaired healing and colonic motility problems.
Grimes. Refined carbohydrate, smooth muscle spasm and disease of the colon. Lancet 1976;1:395.
Abstract: Lack of fiber does not stimulate normal bowel function and, as a result, an intensification of the muscle spasm that normally occurs with bowel disease becomes worse.
Harig JM, et al. Treatment of diversion colitis with short-chain fatty acid irrigation. NEJM 1989;320:23-28.
Holzapfel WH, Haberer P, Snel J, Schillinger U, Huis in't Veld JH. Overview of gut flora and probiotics. Int J Food Microbiol 1998 May 26;41(2):85-101. (Review)
Abstract: Scientific developments in recent years have opened new frontiers and enable a better understanding of the gastrointestinal tract (GIT) as a complex and delicately balanced ecosystem. This paper focuses on more recent information related to the microbial population of the GIT and its functional role in human physiology and health. Special attention is also given to modern approaches for improving or stabilising the intestinal system and its functioning by the deliberate application of viable microbial cultures, so-called 'probiotics', selected for special functional properties.
Jewel, Truelove. Circulating antibodies to cow's milk in Ulcerative colitis. Gut 1972; 13:796.
Abstract: IgG and IgM antibodies to cow's milk proteins were found to be increased in patients .
Kasper H. Protection against gastrointestinal diseases--present facts and future developments. Int J Food Microbiol 1998 May 26;41(2):127-131.
Abstract: The importance of the intestinal microflora and, more specifically its composition, in physiological and pathophysiological processes in the human GIT is becoming more evident. Examples of such processes are translocation, the production and resorption of endotoxins, immune-modulation, and colonic motility. This leads to new possibilities for prevention and therapy of diseases, mainly of the gastrointestinal organs. New discoveries are specifically related to the beneficial effects of lactobacilli which have been discussed for decades. It is possible to increase the proportion of lactobacilli in the gastrointestinal microflora by consumption of fermented dairy products or by oral administration of specific non-digestible substrates such as oligofructose. Results from clinical trials and scientific studies have confirmed the preventive and therapeutic effects of selected strains of lactobacilli in viral- and bacterial-induced intestinal infections, in positively influencing immunological parameters, in normalizing the intestinal motility, and in inhibiting metabolic events in the gut lumen which promote colonic carcinogenesis. Nevertheless, there are still unresolved issues which can only be answered by well designed and well controlled clinical trials.
Kennedy M, Volz P. Ecology of Candida albicans gut colonization: Inhibition of Candida adhesion, colonization, and dissemination from the gastrointestinal tract by bacterial antagonism. Infection and Immunology 1985;49:654-663.
Abstract: Increased indigenous microflora reduced the mucosal association of C. albicans by forming a dense layer of bacteria in the mucus gut, out-competing yeast cells for adhesion sites, and producing inhibitor substances (possibly volatile fatty acids, secondary bile acids or both) that reduced C. albicans adhesion.
Lankaputhra WE, Shah NP. Antimutagenic properties of probiotic bacteria and of organic acids. Mutat Res 1998 Feb 2;397(2):169-182.
Abstract: Antimutagenic activities of live and killed cells of 6 strains of Lactobacillus acidophilus and 9 strains of bifidobacteria and of organic acids usually produced by these probiotic bacteria were determined using 8 potent chemical mutagens and promutagens. The mutagens and promutagens used were N-methyl, N'-nitro, N-nitrosoguanidine; 2-nitroflourene; 4-nitro-O-phenylenediamine; 4-nitroquinoline-N-oxide; Aflatoxin-B; 2-amino-3-methyl-3H-imidazoquinoline; 2-amino-1-methyl-6-phenyl-imidazo (4,5-b) pyridine, and 2-amino-3-methyl-9H-pyrido (3,3-6) indole. The mutagenicity of these mutagens and antimutagenic activity of probiotic bacteria against the mutagens were determined according to the Ames TA-100 assay using a mutant of Salmonella typhimurium. Efficiency of bacterial cells in binding or inhibiting these mutagens was also investigated. Live cells of probiotic bacteria showed higher antimutagenic activity and their efficiency in inhibiting the mutagens was better than killed bacterial cells. Live bacterial cells bound or inhibited the mutagens permanently, whereas killed bacteria released mutagens upon extraction with dimethyl sulfoxide. Among the organic acids, butyric acid showed highest inhibition of mutagens followed by acetic acid. Lactic and pyruvic acids did not show appreciable levels of inhibition.
Lashner. Effect of Folate supplementation on the incidence of dysplasia and cancer in chronic UC Gastroenterology 1989;97:255-259.
Abstract: 99 patients with chronic colitis for more than 7 years were examined. 35 patients with neoplasia were compared with 64 patients in whom dysplasia was never found. The purpose was to determine the effect of folate supplements on the rate of development of neoplasia. Folate supplementation at 1mg was associated with a 62% lower incidence of neoplasia compared with individuals not receiving supplements.
Majamaa H, et al. Probiotics: a novel approach in the management of food allergy. J Allergy Clin Immunol. 1997 Feb; 99(2): 179-185.
Malin M, Suomalainen H, Saxelin M, Isolauri E. Promotion of IgA immune response in patients with Crohn's disease by oral bacteriotherapy with Lactobacillus GG. Ann Nutr Metab 1996;40:137-145.
Mochizuki, Trocki, Dominioni, et al. Optimal lipid content for enteral diets following thermal injury. JEPN 1984;8:638-646.
Abstract: Rats were anesthetized and then burned and fed set diets with varying amounts of fats from 0% to 50%, mainly consisting of safflower oil. It was determined that total nitrogen balance was greatest at 15%. It was noted that in growing rats, EFA deficiency can occur in a very short period of time during acute stress. This deficiency can lead to death quickly.
Nanda, et al. Food intolerance and the IBS. Gut 1989;30:1099-1104.
Abstract: 200 patients with IBS were treated with dietary exclusion for 3 weeks. Of the 189 who completed this study, 48.2% showed symptom improvement. Subsequent challenge with individual foods showed that 73 of 91 responders remained well on a modified diet during the follow-up period of about 15 months. Of the 98 patients who showed no improvement during the trial, only 3 were symptomatically well at the time of follow up. There was a wide range of food intolerance. The majority (50%) identified 2-5 foods that upset them. The foods most commonly incriminated were dairy (40.7%) and grains (39.4%).
Plein K, Hotz J. Therapeutic effects of Saccharomyces boulardii on mild residual symptoms in a stable phase of Crohn's disease with special respect to chronic diarrhea - a pilot study. Z Gastroenterol 1993;31:129-134.
Salminen S, et al. Clinical uses of probiotics for stabilizing the gut mucosal barrier: successful strains and future challenges. Antonie Van Leeuwenhoek. 1996 Oct; 70(2-4): 347-358. (Review)
Siefter, Returra, Barbul, et al. Arginine: an essential amino acid for injured rats. Surgery 1978;84:224-230.
Abstract: Supplementation of arginine to rat chow enhanced healing significantly in rats compared to control diets.
Siegel. Inflammatory bowel disease: Another possible facet of the allergic diathesis. Ann. Allergy 1981;47:92-94.
Abstract: 42 of 59 patients were judged to be possibly allergic with both respiratory and abdominal problems were treated( along with the other 59) with inhalant hyposensitization and a rotary diversified diet. Over 50 of these patients were considerably improved after treated.
Soubo, Smith, Wilmore Glutamine metabolism by the intestinal tract. JPEN 1985;9:608-617.
Stefanini, Bazzocchi, Prati, Lanfranchi, Gasbarrini. Efficacy of oral disodium cromoglycate in patients with IBS and positive skin tests to foods. Lancet 1986;1:207-208.
Abstract: 28 patients were given disodium cromoglycate, which is useful for specific food allergies that are mediated through mast cells and basophils. These patients were skin pricked and then placed on an elimination diet along with 1.5gms/day of disodium cromoglycate for 8 weeks. 19 of these with + skin tests had successful remission while only 1 of 9 who had negative skin tests improved with the treatment.
Use of cromolyn in combined GI allergy JAMA 1979;242:1169.
Wright, Truelove. A controlled therapeutic trial of various diets in ulcerative colitis. Brit Med J. 1965;2:138.
Abstract: After 1 year, 10 of 13 patients on a dairy free diet had remained symptom free compared to 5 of 13 patients on a dummy controlled diet.