copyright © 2012 all rights · • all vegetables: well-cooked • legumes: dahl lipski,...

Copyright © 2012 All rights reserved.

Neither this document nor any part of it may be reproduced or transmitted in any form or

by any means including photocopying, email, fax, etc. without prior written

permission of the author.

Inflammatory Bowel Disease An Evidence-Based Integrative Approach

Josh Gitalis Ba(H) CNP RNCP/ROHP

evidence based clinical nutrition and integrative healthcareJoshGitalis.com

Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335

Inflammatory Bowel Disease:An Evidence-Based Integrative Approach

What you will learn...

• What is health?

• What is digestion?

• IBD: Theories of etiology

• Autoimmune disease

• Food/Diets

• Nutrients

• Botanicals

• Probiotics

• Body-mind



Current Standard of Care



Future Standard of Care



What Is Health?

“Health is a state of complete physical, mental [spiritual] and social well-being and not merely the absence of disease or infirmity.” - WHO

Copyright © 2012 All rights reserved. Neither this document nor any part of it may be reproduced or transmitted in any form or by any means including photocopying, email, fax, etc. without prior written permission of the author.



What Is Digestion?

• The mechanical and chemical breakdown of food into smaller components that are more easily absorbed into a blood stream.

http://en.wikipedia.org/wiki/Digestion



What Affects Digestion?

• Chewing

• Food

• Allergies

• Sensitivities

• Stress

• Medications



Theories of Etiology

Genetic

Infection Immunologic

Psychosomatic Diet



What Is Autoimmune Disease?

• An inappropriate immune response of the body against substances and tissues normally present in the body.

http://en.wikipedia.org/wiki/Autoimmune_disease



Why Does The Body Attack Itself?



Autoimmune Disease

Genetics Environmental Trigger Gut Permeability

- Nat Clin Prac Gastro & Hep, Sept 2005, Vol2;No.9




Genes or Environment?

Arq. Gastroenterol. vol.46 no.1 São Paulo Jan./Mar. 2009

1986-2005:↑ of 15-24x



Epigenetics

January, 2011



Leaky Gut Syndrome

“The autoimmune process can be arrested if the interplay between genes and environmental triggers is prevented by re-establishing intestinal barrier function.” Nut Clin Prac Gastro & Hep. Sept 2005 Vol. 2 No.9

Genes Environment

You

“Phenotype”Josh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335


Leaky Gut Syndrome

• Holes in the intestinal lining



Leaky Gut Syndrome - Causes• Dysbiosis

• Allergies

• Infections, parasites

• Drugs - NSAIDs, BCP, steroids radiation

• Alcohol

• Putrefying food

• Stress

• Environmental contaminantsJosh Gitalis • Ba(H) CNP RNCP/ROHP • joshgitalis.com • 416-895-7335


The Viscous CycleGI Irritant

Leaky Gut

Allergy,Sensitivity, Microbe

Damage to GI

Malabsorption

Inflammation




Fibre: Friend or Foe?



FibreEast Africans• 100 g of Fibre• 18-24 hours

transit time

North Americans• 25 g of Fibre• 72 hours transit time

Jensen, Bernard. Dr. Jensen’s Guide to Better Bowel Care. Avery: 1999.



“Relax, sir. The hair in your soup provides fibre.”



FibreSoluble Fibre:

• Soothing• Partially and Completely

Fermented:• Short Chain Fatty Acids• Gases

Insoluble Fibre:• Not fermented• Speeds transit time• Adds bulk



Mucilaginous Foods/Herbs

• Slippery elm powder

• Marshmallow root

• Flax seed

• Chia seed

• Aloe vera

• Okra



IBD and Diet: What we know...

• “SAD” diet

• Refined sugar (Study: 122g/day vs 65g/day)

• Food allergies: wheat and dairy

• Reduced intake of omega-3

Thornton JR, Emmett PM, Heaton KW. Br Med J 1979;279:762-764.Jones VA et al. Lancet. 1985 Jul 27;2(8448):177-80.Shoda R, Matsueda K, Yamato S, Umeda N. Am J Clin Nutr 1996;63:741-745






Diets For GI Healing

• Comprehensive Elimination Diet

• Gluten Free/Casein Free

• SCD Diet

• GAPS Diet

• FODMAP

• Palaeolithic Diet

• Restoration Diet



Restoration Diet

• Animal protein: all unprocessed

• Dairy: cultured goat and sheep

• Fats/oils: ghee, coconut, olive, hemp, flax

• Nuts/seeds: butters

• All vegetables: well-cooked

• Legumes: dahl

Lipski, Elizabeth. Digestive Wellness: 4th Ed.. 2011



Restoration Diet

• Fruits: cooked, smoothies, very ripe

• Grains: rice congee

• Herbs/spices: turmeric, ginger, cumin, coriander, etc.

• Beverages: water, broth, herbal tea, diluted fresh juice

Lipski, Elizabeth. Digestive Wellness: 4th Ed.. 2011



Vitamin D• Vitamin D deficiency is a

world-wide epidemic,1 2 3

with recent estimates indicating greater than 50% of the global population is at risk.4

• A high prevalence of vitamin D deficiency has been found across all age groups in all populations studied in countries around the globe. 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

1. Prentice, A. Vitamin D deficiency: a global perspective. Nutr Rev. 2008 Oct; 66 (10 Suppl 2): S153-64.2. Pettifor, J. M. Vitamin D &/or calcium deficiency rickets in infants & children: a global perspective. Indian J Med Res. 2008 Mar; 127 (3): 245-9.3. Holick, M. F. Chen, T. C. Vitamin D deficiency: a worldwide problem with health consequences. Am J Clin Nutr. 2008 Apr; 87 (4): 1080S-6S.4. University of California Riverside More Than Half the World’s Population Gets Insufficient Amounts of Vitamin D, Says UC Riverside Biochemist. 15 July 2010;5. Science Daily Millions Of U.S. Children Low In Vitamin D. 3 Aug 2009;6. Schwalfenberg, G. K. Genuis, S. J. Hiltz, M. N. Addressing vitamin D deficiency in Canada: a public health innovation whose time has come. Public Health. 2010 Jun; 124 (6): 350-9.7. Kuriacose, R. Olive, K. E. Prevalence of vitamin D deficiency and insufficiency in northeast Tennessee. South Med J. 2008 Sep; 101 (9): 906-9.8. Bandeira, F. Griz, L. Dreyer, P. Eufrazino, C. Bandeira, C. Freese, E. Vitamin D deficiency: A global perspective. Arq Bras Endocrinol Metabol. 2006 Aug; 50 (4): 640-6.9. Ardestani, P. M. Salek, M. Keshteli, A. H. Nejadnik, H. Amini, M. Hosseini, S. M. Rafati, H. Kelishadi, R. Hashemipour, M. Vitamin D status of 6- to 7-year-old children living in Isfahan, Iran.

Endokrynol Pol. 2010 Jul-Aug; 61 (4): 377-82.10. Bener, A. Al-Ali, M. Hoffmann, G. F. Vitamin D deficiency in healthy children in a sunny country: associated factors. Int J Food Sci Nutr. 2009; 60 Suppl 560-70.11. Teale, G. R. Cunningham, C. E. Vitamin D deficiency is common among pregnant women in rural Victoria. Aust N Z J Obstet Gynaecol. 2010 Jun; 50 (3): 259-61.12. Harinarayan, C. V. Joshi, S. R. Vitamin D status in India--its implications and remedial measures. J Assoc Physicians India. 2009 Jan; 5740-8.13. Andersen, R. Molgaard, C. Skovgaard, L. T. Brot, C. Cashman, K. D. Chabros, E. Charzewska, J. Flynn, A. Jakobsen, J. Karkkainen, M. Kiely, M. Lamberg-Allardt, C. Moreiras, O. Natri, A. M.

O'Brien, M. Rogalska-Niedzwiedz, M. Ovesen, L. Teenage girls and elderly women living in northern Europe have low winter vitamin D status. Eur J Clin Nutr. 2005 Apr; 59 (4): 533-41.14. Rodriguez Sangrador, M. Beltran de Miguel, B. Quintanilla Murillas, L. Cuadrado Vives, C. Moreiras Tuny, O. [The contribution of diet and sun exposure to the nutritional status of vitamin D in

elderly Spanish women: the five countries study (OPTIFORD Project)]. Nutr Hosp. 2008 Nov-Dec; 23 (6): 567-76.15. Bhattoa, H. P. Bettembuk, P. Ganacharya, S. Balogh, A. Prevalence and seasonal variation of hypovitaminosis D and its relationship to bone metabolism in community dwelling postmenopausal

Hungarian women. Osteoporos Int. 2004 Jun; 15 (6): 447-51.16. Allali, F. El Aichaoui, S. Khazani, H. Benyahia, B. Saoud, B. El Kabbaj, S. Bahiri, R. Abouqal, R. Hajjaj-Hassouni, N. High prevalence of hypovitaminosis D in Morocco: relationship to lifestyle,

physical performance, bone markers, and bone mineral density. Semin Arthritis Rheum. 2009 Jun; 38 (6): 444-51.17. Du, X. Greenfield, H. Fraser, D. R. Ge, K. Trube, A. Wang, Y. Vitamin D deficiency and associated factors in adolescent girls in Beijing. Am J Clin Nutr. 2001 Oct; 74 (4): 494-500.18. Peters, B. S. dos Santos, L. C. Fisberg, M. Wood, R. J. Martini, L. A. Prevalence of vitamin D insufficiency in Brazilian adolescents. Ann Nutr Metab. 2009; 54 (1): 15-21.19. Judkins, A. Eagleton, C. Vitamin D deficiency in pregnant New Zealand women. N Z Med J. 2006; 119 (1241): U2144.



Vitamin D“Vitamin D deficiency may compromise the mucosal barrier, leading to increased susceptibility to mucosal damage and increased risk of IBD.”Am J Physiol Gastrointest Liver Physiol, 2008 Jan;294(1):G208-16




Tight Junctions



Tight Junctions



Vitamin D“[Vitamin D] markedly enhanced tight junctions by increasing junction protein expression and preserved the structural integrity of tight junctions.”Am J Physiol Gastrointest Liver Physiol, 2008 Jan;294(1):G208-160



Vitamin D“Vitamin D...favours less Inflammation.”

Kidney International, Vol. 68 (2005), pp 1973-1981.



Alimentary Pharmacology & Therapeutics Volume 32, Issue 3 pages 377- 383, 11 MAY 2010

• Patients received 1200iu/day

• Blood levels started at 69 nmol/L and went to 96 nmol/L at 3 months

• Vitamin D group: 13% relapse

• Placebo: 29% relapse

Clinical Trial: Vitamin D3 treatment in Crohn’s disease



Zinc

• Approximately 45% of those with Crohn’s = deficient

• Disease activity correlated with zinc deficiency

J Physiol Gastrointest Liver Physiol, 2008 Jan;294(1):G208-160




Zinc Carnosine“Regarding intestinal permeability, Zinc Carnosine caused an approximate threefold increase in gut integrity and repair.”

Gut. 2007 Feb;56(2):168-75



Zinc Carnosine• Relieves gastric discomforts such as occasional heartburn and

indigestion, upset stomach, mild nausea, bloating, belching, and burping

• Promotes healthy gastric bacterial balance

• Provides antioxidant protection for gastric mucosal cells

• Helps maintain the integrity of the protective gastric mucosal lining by supporting healthy mucus secretion

• Gastro-supportive benefits demonstrated in over 20 published studies



• Preferential fuel for small intestines

• Vital for maintenance of mucosal growth, structure, and function

• Deficiency = small bowel atrophy

• Maintains sIgA levels• #1 prescription for ulcers

in Asia

L-Glutamine



L-Glutamine“The gastrointestinal tract is by far the greatest user of glutamine in the body, as [the intestinal cells] use glutamine as their principal metabolic fuel.” Alternative Medicine Review Volume 6, Number 4 2001



L-Glutamine“[L-Glutamine] decreases villous atrophy, increases jejunal weight, and decreases intestinal permeability.” Alternative Medicine Review Volume 6, Number 4 2001



Essential Fatty Acids

Omega-3

• Fish, walnuts, flax, chia, eggs

• Anti-inflammatory

Omega-6

• Corn, safflower, red meat, cottonseed

• Anti-inflammatory or pro-inflammatory




Essential Fatty Acids• Omega 3 converts into

EPA and DHA

• EPA = anti-inflammatory

• DHA = structure

Omega 3 (Flax)

EPA (Fish)

DHA (Fish)PG3 (Anti-inflammatory)



Essential Fatty Acids

“EPA appears to exert much of its anti-inflammatory benefit by suppressing [pro-inflammatory] activation...thus reducing elaboration of pro-inflammatory mediators.” Nutritional Perspectives, Vol. 28, no. 1, 1-16



Essential Fatty Acids“When ...evaluating the role of fish oil in the treatment of ulcerative colitis, 3 of 3 studies showed statistically significant improvement in the study group that received fish oil supplementation.” Nutrition in Clinical Practice 23:9, Feb 2008



Fish Oils and IBD:Animal Studies

• 6/6 mice models of ulcerative colitis showed protection from injury and healing with omega-3 fatty acids.

Proc Natl Acad Sci U S A. 2006;103(30):11276-11281.Clin Nutr. 2006;25(3):466-476.Nutrition. 2006;22(3):275-282.World J Gastroenterol. 2005;11(47):7466-7472.Proc Natl Acad Sci U S A. 2005;102(21):7671-7676.Inflamm Bowel Dis. 2005;11(4):340-349.

Fish Oil Placebo

Protection UC



Ulcerative Colitis - Summary• 9 randomized controlled trials

• 4.7 g EPA/DHA/day (Average)

• Duration 35 weeks (Average)

0%

18%

35%

53%

70%

No treatment Treated

Two or more:

• Reduce ulceration

• Reduce Overall disease

• Reduce drug use

• Reduce relapse

• Increase remission



Cell membrane

Phospholipase A2

Arachadonic Acid

Cyclooxygenase Lipooxygenase

LeukotrienesSRS-A

Prostaglandin 2 series

Thromboxane A2

Pharmaceutical modulation of Inflammation

IndomethacinAspirinIbuprofenSulfasalazine

X

Cortisone X

X Colchicine

SulfasalazineX

Mullin GE, et al, Expert Review of Gastroenterology and Hepatology, April 2008




Botanical Modulation of Inflammation

Mullin GE, et al, Expert Review of Gastroenterology and Hepatology, April 2008

Cell membrane

Phospholipase A2

Arachadonic Acid

Cyclooxygenase Lipooxygenase

LeukotrienesSRS-A

Prostaglandin 2 series

Thromboxane A2

IndomethacinAspirinIbuprofenSulfasalazine

X

Cortisone X

X Colchicine

SulfasalazineXQuercetinLiquorice root

Quercetin GingerTurmericBromelainWhite Willow Bark

Quercetin TurmericOnionGarlicBoswellia

Potentiates cortisol:Liquorice rootTurmeric

X X

XX

Ginger



Turmeric

• Active component: Curcumin

• Anti-inflammatory

• Inhibits leukotriene formation

• Inhibits platelet aggregation

• Promotion of fibrinolysis

• Inhibition of neutrophil inflammatory process

• Stabilization of lysosomal membranes



Turmeric MechanismHumira,

Remicade

Erbitux, Erlotinib, Geftinib

AsacolBharat B. et al. 2006



Turmeric“Turmeric,...or its component curcumin, has shown surprisingly beneficial effects in experimental studies of acute and chronic diseases characterized by an exaggerated inflammatory reaction. There is ample evidence to support its clinical use, both as a prevention and a treatment.” J of Par and Ent Nut Vol. 30,no.1,2006,45-51



Turmeric

“Studies involving curcumin to date in the field of IBD have been consistently positive.” Nutrition in Clinical Practice 23:49-62, Feb 2008



Quercetin

• Inhibits mast cell and basophil degranulation

• Inhibits phospholipase A2 and lipoxygenase




Quercetin

• “We suggest that the addition of polyphenols (quercetin)...would improve outcomes of patients with IBD...”

Gut 56:426-436, Mar 2007



Probiotics



Probiotics



Probiotics• Reduce:

• Diarrhea

• Intestinal inflammation

• Risk of relapse

• Increase:

• Absorption of minerals

• Immune function

• Breakdown of toxinsWelcome to

GUTPOP: 100 Trillion



Probiotics

• Compete with pathogens

• Antimicrobial activity

• Enhance barrier function

• Decrease inflammation



Probiotics

• “The unraveling of these mechanisms of action has led to new support for the use of probiotics in the management of clinical IBD.”

Inflamm Bowel Dis. 10(3):286-99, May 2004




Probiotics

• “Disturbance in the intestinal microflora is a key factor causing inflammatory bowel disease.”

- Allison Tannis. Probiotic Rescue, pg. 86



Probiotics: Anti-inflammatory

• Evidence demonstrates the anti-inflammatory and antiallergic effects of probiotics on healthy gut

• Reversal of increased intestinal permeability (aka “leaky gut”)

Isolauri E, et al. Gut. 2002;50(S3):III54-59.



Induction of Remission in Ulcerative Colitis with High-Dose Probiotics

• 34 patients with active UC (non-responsive to conventional treatment), were given 3.6 trillion cfu of bacteria daily for six weeks.

• Treatment of patients with mild to moderate UC resulted in a combined induction of remission/response rate of 77% -- with no adverse events.

• Bacterial species in the probiotic product were detected at the target site.

Am J Gastroenterol. 2005;100:1539-1546.

53%

24%



The Second Brain• The gut has more nerve

endings than the spine !

• 90% of all serotonin is made in the gut



Body-Mind and DigestionRest and DigestStop and Think

(Parasympathetic Nervous System)

or

Fright, Flight or Fight

(Sympathetic Nervous System)



• Chronic stress, adverse life events, and depression can cause a relapse in patients with IBD

• HPA function, gut flora, mast cell activation, and CRF mediate the effect of stress on inflammation in IBD

• The symptoms of IBD may be exacerbated by the effects of stress on gut motility and fluid secretion

• There is a need for further studies of the potential benefits of stress reduction therapy in IBD

Psychological Stress and IBD

Mawdsley J E, Rampton D S Gut 2005;54:1481-1491





Mawdsley J E, Rampton D S Gut 2005;54:1481-1491




• Meditation

• Light Exercise

• Yoga

• Acupuncture, massage, bodywork

• Nature walks

• Music



Applied Knowledge Is Power.



Future Standard of CareIs Happening NOW

evidence-based clinical nutrition and integrative healthcare

JoshGitalis.com


copyright © 2012 all rights · • all vegetables: well-cooked • legumes: dahl lipski,...

Documents