Holistic Management as an Adjunct in IBD: Encourage your patient to own their disease

Holistic Management as an Adjunct in IBD:
Encourage your patient to own their
disease
Patricia L. Raymond MD FACG
Rx For Sanity/Eat Well MD
Monday, May 23, 2022
4:15 PM - 5:15 PM

The Society of Gastroenterology Nurses and Associates,
Inc. is accredited as a provider of nursing continuing
professional development by the American Nurses
Credentialing Center’s (ANCC) Commission on
Accreditation.
The presenter has identified no relevant relationships with
commercial interest organizations whose products are related
to the program content.

I remember when…
1978 Graduation High School
1982 Graduation College
1986 Graduation Medical School
1989 Completion Internship/residency
1992 Completion GI Fellowship
2021 Completion GI Career (29.5 years)

Credit
http://www.davidshifrinmd.com

Treatments for IBD 2022
Mesalamines
• Oral &/or Rectal
• Azulfidine, Asacol, Delzicol, Lialda,
Apriso, Pentasa, Dipentum, Colazol
• And others…
Anti TNF Antibodies
• Infliximab (Remicade)
• Adalimumab (Humira)
• Certolizumab pegol (Cimzia)
• Ustekinumab (Stelara)
• Vedolizumab (Entyvio)
• Biosimilars
• And others…
Immunosuppression
• Prednisone
• Budesonide
• Azathioprine/ 6MP
• Methotrexate Surgery

But what about Infliximab?
Akobeng A.K., Zachos M. Tumor necrosis factor-alpha antibody for induction of remission in Crohn’s
disease. Cochrane Database Syst. Rev. 2003;10–13:10–13.
doi: 10.1002/14651858.CD003574.pub2.
That was soooo 2003….

The medication advancements DO work…
As a result, anti-TNF-α agents have become the primary cost driver
in the treatment of CD,
as the frequency of hospitalizations
and surgical interventions
have been drastically reduced.
Marc Berns & Daniel W. Hommes (2016) Anti-TNF-α therapies for the treatment of Crohn’s disease: the past, present and future,
Expert Opinion on Investigational Drugs, 25:2, 129-143, DOI: 10.1517/13543784.2016.1126247

Precisely, how much reduction?
In CD and UC, anti-TNF biologics are efficacious in
reducing the odds of
hospitalization by half
and surgery by 33-77%
Mao EJ, Hazlewood GS, Kaplan GG, Peyrin-Biroulet L, Ananthakrishnan AN. Systematic review with meta-analysis: comparative efficacy of immu

However,
this is not
THAT presentation!

This presentation:
What your patient can do
(besides/in addition to medications)
to improve their IBD symptoms
Adjunct:
• something added to another thing but not essential to it.
• joined or associated, especially in an auxiliary or subordinate relationship.
• attached or belonging without full or permanent status.

Talking about…
• Self Monitoring
• Dietary changes- macro and micro
changes
• Lifestyle changes
• Tobacco
• Cannabis
• Exercise
• Meditation

How to self-monitor for
incipient activity/flares

CDAI
๏Modified version of the Crohns Disease Activity Index, a tool used to
study pharmaceuticals. https://www.mdcalc.com/crohns-disease-activity-
index-cdai-- choose a standard number for the hemoglobin value and
continue to use same number to roughly standardize the calculations.
๏Check weekly and record
๏Perhaps you can see efficacy of holistic management, or predict the
onset of a flare early enough to adjust treatment
๏Input: weight, sex, # soft/liquid stools in past 7 days, abdominal pain,
sense of well being, use of antidiarrheals, abdominal mass, “Hct”, EIM
(arthritis, iritis/uveitis, skin findings (E nodosum, pyoderma
gangrenosum, stomatitis), anal disease/fistula, temperature >100
degrees F)

UCDAI, modified
Would follow your symptoms
weekly using a modified UCDAI
(Ulcerative Colitis-Disease
Activity Index 0-9) - edited to
remove ‘endoscopic
appearance of colon lining’.
Stool frequency
0 = Normal
1 = 1–2 Stools/day more than normal
2 = 3–4 Stools/day more than normal
3 = more than 4 Stools/day over
normal
Patient's rating of disease
activity
0 = Normal
1 = Mild
2 = Moderate
3 = Severe
Continue to monitor with
periodic surveillance
colonoscopy (looking for
dysplasia of the colon, an
early precancerous change)
as well as blood work for
kidney and liver function
(which may be affected by
the drug mesalamine).
Rectal bleeding
0 = None
1 = Streaks of blood
2 = Obvious blood
3 = Mostly blood

P-SCCAI for UC
๏Patient-based Simple Clinical Colitis Activity Index
๏Six domains:
๏bowel frequency (during the day) ranging from 1 to > 9
๏bowel frequency (during the night) ranging from 0 to 6
๏urgency of defecation ranging from none to incontinence
๏blood in stool ranging from none to usually frank (> 50% of defecation)
๏general well-being ranging from very well to terrible (1–10)
๏extracolonic features of UC (i.e. arthritis, erythema nodosum,
pyoderma gangrenosum, uveitis).
๏inactive disease (SCCAI score < 5); disease (SCCAI score ≥ 5).
Bennebroek Evertsz' F, Nieuwkerk PT, Stokkers PC, Ponsioen CY, Bockting CL, Sanderman R, Sprangers MA. The patient simple clinical colitis ac

P-SCCAI for UC
Bennebroek
Evertsz'
F,
Nieuwkerk
PT,
Stokkers
PC,
Ponsioen
CY,
Bockting
CL,
Sanderman
R,
Sprangers
MA.
The
patient
simple
clinical
colitis
activity
index
(P-SCCAI)
can
detect
ulcerative
colitis
(UC)
disease
activity
in
remission:
a
comparison
of
the
P-SCCAI
with
clinician-based
SCCAI
and
biological
markers.
J
Crohns
Colitis.
2013
Dec;7(11):890-
900.
doi:
10.1016/j.crohns.2012.11.007.
Epub
2012
Dec
24.
PMID:
23269224.

Vitamin D & Crohns
๏Less IBD in southern than the northern US
๏Increased surgery and hospitalization, relapse with low vitamin D
levels
๏Is Vitamin D protective, or does improved bowel health correlate
with vitamin D?
Raftery T, Martineau AR, Greiller CL, Ghosh S, McNamara D, Bennett K, Meddings J, O'Sullivan M. Effects of vitamin D supplementation on intesti
Yang L, Weaver V, Smith JP, Bingaman S, Hartman TJ, Cantorna MT. Therapeutic effect of vitamin d supplementation in a pilot study of Crohn's pa

Vitamin D & Crohns
๏N=18 mild-to-moderate (150-400 CDAI scores) Crohn's disease
๏Vitamin D3 oral therapy was initiated at 1,000 IU/d and after 2 weeks, the dose was
escalated incrementally until patients' serum concentrations reached 40 ng/ml
25(OH)D3 or they were taking 5,000 IU/d
๏Patients continued on the vitamin D supplements for 24 weeks
๏14 of 18 patients required the maximal vitamin D supplement of 5,000 IU/d (way
over normal RDA , but verified with blood levels )
๏Serum 25(OH)D3 levels from 16±10 ng/ml to 45±19 ng/ml (P<0.0001)
๏Reduction the mean CDAI scores by 112±81 points
๏ From average baseline 230±74 to 118±66 (P<0.0001) (Remission score is <150)
๏Quality-of-life scores also improved following vitamin D supplementation
(P=0.0004).

Vitamin D & Crohns

Vitamin D & Crohns
“Twenty-four weeks
supplementation with up to 5,000
IU/d vitamin D3 effectively raised
serum 25(OH)D3 and reduced
CDAI scores in a small cohort of
Crohn's patients suggesting that
restoration of normal vitamin D
serum levels may be useful in the
management of patients with mild-
moderate Crohn's disease.”

Cannabis & Crohns Disease:
13 patients, 3 months' use of 1/3 lb cannabis ad lib
Improvements in
• General health perception (p = 0.001)
• Improved numeric score from 4.1 ± 1.43 to 7 ± 1.42 (p = 0.0002)
• Social functioning (p = 0.0002)
• Ability to work (p = 0.0005)
• Physical pain (p = 0.004)
• Depression (p = 0.007).
• Weight gain of 4.3 ± 2 kg during treatment (range 2-8; p = 0.0002)
• Increased BMI of 1.4 ± 0.61 (range 0.8-2.7; p = 0.002)
• Harvey-Bradshaw index was reduced from 11.36 ± 3.17 to 5.72 ± 2.68 (p = 0.001).
Digestion. 2012;85(1):1-8. doi: 10.1159/000332079. Epub 2011 Nov 17. Impact of cannabis treatment on the quality of life, weight and clinical dise
https://pubmed.ncbi.nlm.nih.gov/22095142/

Cannabis & Crohns Disease:
Issues:
• No control group
• Not blinded
• Discounts potential placebo effect and natural history of disease
Digestion. 2012;85(1):1-8. doi: 10.1159/000332079. Epub 2011 Nov 17. Impact of cannabis treatment on the quality of life, weight and clinical dise
https://pubmed.ncbi.nlm.nih.gov/22095142/

Cannabis & Crohns 2:
N = 21 refractory Crohn’s disease (CDAI>200)
Randomized to smoke 2 joints a day of real pot or placebo pot (cannabis flowers from
which the THC had been extracted) for two months
Complete remission (CDAI score, <150)
• 5 of 11 cannabis group (45%)
• 1 of 10 in the placebo group (10%; P = .43)
Clinical response (decrease in CDAI score of >100)
• 10 of 11 subjects in the cannabis group (90%; from 330 ± 105 to 152 ± 109)
• 4 of 10 in the placebo group (40%; from 373 ± 94 to 306 ± 143; P = .028).
Three patients in the cannabis group were weaned from steroid dependency.
Subjects receiving cannabis reported improved appetite and sleep, with no significant
side effects.
Naftali T, Bar-Lev Schleider L, Dotan I, Lansky EP, Sklerovsky Benjaminov F, Konikoff FM. Cannabis induces a clinical response in patients with

But….
• Researchers employed by medical cannabis advocacy company (Tikun
Olam Organization, largest supplier medical marijuana in Israel)
• Not possible to blind psychoactive drug (placebo was not indistinguishable
from test agent)
• No change in CRP
• Quick rebound in symptoms 2 weeks after study completed— suggests no
change in disease but masking symptoms
So why isn’t improvement in symptoms and QOL good enough?

Consecutive patients with IBD (n = 313) seen in the University of Calgary from July 2008 to March
2009
• Structured anonymous questionnaire covering motives, pattern of use, and subjective beneficial
and adverse effects associated with self-administration of Cannabis.
• Subjects who had used Cannabis specifically for the treatment of IBD or its symptoms were
compared with those who had not.
• Of users, 42 (75.0%) had CD, 10 (17.9%) had UC, and 4 (7.1%) had indeterminate colitis
• Similar for non users
• Cannabis had been used by 17.6% of respondents to relieve symptoms associated with their IBD
• Inhalational route (96.4%)
• Cannabis improved abdominal pain (83.9%), abdominal cramping (76.8%), joint pain (48.2%), and
diarrhea (28.6%)
Great, but….
Storr M, Devlin S, Kaplan GG, Panaccione R, Andrews CN. Cannabis use provides symptom relief in patients with inflammatory bowel disease but

Cannabis & Crohns 3: Potentially Harmful
๏The use of Cannabis for more than 6 months at any time for IBD symptoms
was a strong predictor of requiring surgery in patients with Crohn's disease
(odds ratio = 5.03, 95% confidence interval = 1.45-17.46) after correcting for
demographic factors, tobacco smoking status, time since IBD diagnosis, and
biological use.
๏Similar cannabis survey study in hepatitis C patients that found that daily cannabis
use was associated with nearly seven times the odds of worse hepatic fibrosis.
Storr M, Devlin S, Kaplan GG, Panaccione R, Andrews CN. Cannabis use provides symptom relief in patients with inflammatory bowel disease but
Ishida JH, Peters MG, Jin C, Louie K, Tan V, Bacchetti P, Terrault NA. Influence of cannabis use on severity of hepatitis C disease. Clin Gastroent

Coconut & Crohns ๏Anecdotal stories of
coconut oil, macaroons,
shredded coconut, ‘young
coconut milk’ reducing
CD symptoms
๏Basson study in
rats/mice, lauric and
myristic fatty acid-rich
coconut oil with anti-
inflammatory effects,
changes in gut
microbiome
๏Limited risk
Basson AR, Chen C, Sagl F, Trotter A, Bederman I, Gomez-Nguyen A, Sundrud MS, Ilic S, Cominelli F, Rodriguez-Palacios A. Regulation of In

PBD & Ulcerative Colitis
๏Ninety-two cases were studied, of which 51 were initial episodes and 41 were relapses
๏Varied severity and location
๏31 mild, 48 moderate, 13 severe
๏15 proctitis, 22 left-sided colitis, 55 extensive colitis
๏Lacto-ovo-semivegetarian diet (PBD) together with medication
๏Fish once a week and meat once every 2 weeks.
๏Cumulative relapse rates at 1- and 5-year follow-up (Kaplan-Meier analysis) were 14% and 27%,
respectively, for the initial episode cases, and 36% and 53%, respectively, for relapse cases.
๏At long-term follow-up (6 years 4 months), PBDS was significantly higher than baseline PBDS (p <
0.0001)
๏The cumulative relapse rate at 1 year was reported to be around 50% (44%–51%) in Norway,
Netherlands, and Denmark
๏The European Collaborative Study Group of Inflammatory Bowel Disease (EC-IBD) reported it to be 28%
๏PBD 14% cumulative relapse rate is far better than those reported.
Chiba M, Nakane K, Tsuji T, Tsuda S, Ishii H, Ohno H, Watanabe K, Obara Y, Komatsu M, Sugawara T. Relapse Prevention by Plant-Based Diet

Diet & IBD: Remains Murky
๏Active CD (six studies), inactive CD (seven studies), active UC (one study) and inactive UC
(four studies)
๏Issues:
๏Inadequately powered
๏High in bias
“The effects of dietary interventions on CD and UC are uncertain.
Thus no firm conclusions regarding the benefits and harms of dietary interventions
in CD and UC can be drawn.
There is need for consensus on the composition of dietary interventions in IBD
and more RCTs are required to evaluate these interventions.”
~Cochrane Database of Systematic Reviews
Limketkai BN, Iheozor-Ejiofor Z, Gjuladin-Hellon T, Parian A, Matarese LE, Bracewell K, MacDonald JK, Gordon M, Mullin GE. Dietary interve

Keto Diet & UC: Possible Correlation
Onset of Ulcerative Colitis during a Low-Carbohydrate Weight-Loss Diet a
Mitsuro Chiba, MD, PhD, Perm J. 2016 Winter; 20(1): 80–84.
Long-term intake of dietary fat and risk of ulcerative colitis and Crohn's dis
A high intake of dietary long-chain n-3 PUFAs (Omega 3 FAs) may be as

Fats in IBD
๏UC: Increase n-3 PUFA/ Omega 3 FA: Fish oils,
flax and chia seeds, walnuts
๏CD: Limit trans-unsaturated fats: Meat, whole
milk, and milk products, cakes, cookies,
crackers, icings, margarines, and microwave
popcorn
๏Seems like good dietary advice for everyone
Long-term intake of dietary fat and risk of ulcerative colitis and Crohn's disease. Ananthakrishnan AN1, Khalili H, Konijeti GG, et al. Gut. 2014 May

Curcumin- yellow stuff in root
Turmeric - the plant itself
Curcumin is a natural phenol found in the
large-leafed herb curcuma longa L.
(common names Turmeric, Indian
Saffron). The rhizome (underground stem)
of the turmeric plant contains up to 5%
curcumin, in combination with essential
oils and other compounds. Turmeric has
been used for various medicinal uses in
both Indian (Ayurvedic) and Chinese
medicine systems for thousands of years
(Joshi 1983). Only recently has modern
medicine begun to critically evaluate
turmeric and its extracts and antioxidant,
anti-inflammatory, antiplatelet,
cholesterol lowering, antibacterial and
antifungal effects have been identified.
Curcumin may also induce apoptosis and
inhibit carcinogenesis (Basile 2009; Lee
2009; O’Sullivan-Coyne 2009).
Kumar S, Ahuja V, Sankar MJ, Kumar A, Moss AC. Curcumin for maintenance of remission in ulcerative colitis. Cochrane Database Syst Rev. 201

Curcumin & Quiescent UC
๏N=89 (49 male) with quiescent ulcerative colitis, defined by clinical, radiographic,
endoscopic, and pathological criteria
๏Randomised to either curcumin 2 g/day (n = 45) or placebo (n = 44)
๏All patients were receiving maintenance therapy with sulfasalazine or
mesalamine at entry and continued to receive these medications throughout the
study. Other medications were stopped four weeks before starting the study.
The interventions were administered for six months with an additional six
months of follow-up.
๏The primary study outcome was the proportion of patients relapsing at 6 and 12 months
defined as an ulcerative Clinical Activity Index (CAI) score of more than four; secondary
outcomes included CAI and Endoscopic Index (EI) scores before and after treatment
and adverse events
Hanai H, Iida T, Takeuchi K, Watanabe F, Maruyama Y, Andoh A, et al. Curcumin maintenance therapy for ulcerative colitis: randomized, multic

Quiescent Ulcerative Colitis
๏4% patients in the curcumin group relapsed at six months
๏18% patients in the placebo group relapsed (RR 0.24, 95% CI 0.05 to 1.09; P = 0.06).
๏There was no statistically significant difference in relapse rates at 12 months (off
curcumin 6 months)
๏22% curcumin patients relapsed at 12 months
๏32% of placebo patients (RR 0.70, 95% CI 0.35 to 1.40; P = 0.31)
๏The clinical activity index (CAI) at six months
๏Curcumin group verses placebo group (1.0 + 2.0 versus 2.2 + 2.3; MD -1.20, 95% CI -
2.14 to -0.26)
๏Endoscopic index (EI) at six months was significantly lower
๏Curcumin group than in the placebo group (0.8 + 0.6 versus 1.6 + 1.6; MD -0.80, 95% CI
-1.33 to -0.27)
Hanai H, Iida T, Takeuchi K, Watanabe F, Maruyama Y, Andoh A, et al. Curcumin maintenance therapy for ulcerative colitis: randomized, multicen

Curcumin: A Hot Topic
Anti-Inflammatory Effects of Curcumin in the Inflammatory Diseases: Status, Limitations and
Countermeasures. Peng Y, Ao M, Dong B, Jiang Y, Yu L, Chen Z, Hu C, Xu R.
Drug Des Devel Ther. 2021 Nov 2;15:4503-4525. doi: 10.2147/DDDT.S327378. eCollection
2021.PMID: 34754179
Nano-Derived Therapeutic Formulations with Curcumin in Inflammation-Related Diseases.
Quispe C, Cruz-Martins N, Manca ML, Manconi M, Sytar O, Hudz N, Shanaida M, Kumar M,
Taheri Y, Martorell M, Sharifi-Rad J, Pintus G, Cho WC.
Oxid Med Cell Longev. 2021 Sep 15;2021:3149223. doi: 10.1155/2021/3149223. eCollection
2021.PMID: 34584616
A triple-blind, placebo-controlled, randomized clinical trial to evaluate the effect of curcumin-
containing nanomicelles on cellular immune responses subtypes and clinical outcome in
COVID-19 patients. Hassaniazad M, Eftekhar E, Inchehsablagh BR, Kamali H, Tousi A,
Jaafari MR, Rafat M, Fathalipour M, Nikoofal-Sahlabadi S, Gouklani H, Alizade H, Nikpoor
AR.Phytother Res. 2021 Nov;35(11):6417-6427. doi: 10.1002/ptr.7294. Epub 2021 Sep 19.
PMID: 34541720

UC flare & acute dietary changes
Diet modifications that 69% of UC study subjects found helpful for the 4-6
weeks during and after a flare of UC:
1. Eat little and often (four to six times a day)
2. Drink lots of fluids
3. Decrease intake of fat
4. Decrease simple carbohydrates
5. Decrease high-fiber foods
๏These five simple steps during a flare LOWERED their SCCAI by 1.3
points
๏No diet modifications RAISED their SCCAI by ~0.88
Kyaw MH, Moshkovska T, Mayberry J. A prospective, randomized, controlled, exploratory study of comprehensive dietary advice in ulcerative c

Smoking (Tobacco) & Ulcerative Colitis
๏UC predominantly a disease of ex-smokers and nonsmokers
๏First noted by Samuelsson in 1976
๏Smoking protects against the development of UC
๏Also lessens severity of UC
๏In a cohort of smokers with UC, over half-indicated smoking improved their
disease and none felt smoking had a detrimental effect on their UC.
๏Similarly, in a group of ex-smokers with refractory UC, 14 out of 15
achieved prolonged clinical remission without steroids, following resumption
of low-dose smoking.
Lunney PC, Leong RW. Review article: Ulcerative colitis, smoking and nicotine therapy. Aliment Pharmacol Ther. 2012 Dec;36(11-12):997-1008. do
Green JT, Rhodes J, Ragunath K, et al. Clinical status of ulcerative colitis in patients who smoke. Am J Gastroenterol 1998; 93: 1463–7. CrossrefC
Calabrese E, Yanai H, Shuster D, et al. Low-dose smoking resumption in ex-smokers with refractory ulcerative colitis. J Crohns Colitis 2012; 6: 756

Smoking (Tobacco) & Ulcerative Colitis
๏Question of less colectomy
๏Current cigarette smoking in UC patients increased the risk of articular and
dermatological EIMs, whereas no such increase was observed in ocular or
hepatobiliary complications.
๏Current / previous smoking has also been shown to reduce primary sclerosing
cholangitis
๏Why? Unclear
๏Nicotine?
๏Carbon monoxide
๏Effect on gut microbiota
Lunney PC, Leong RW. Review article: Ulcerative colitis, smoking and nicotine therapy. Aliment Pharmacol Ther. 2012 Dec;36(11-12):997-1008. d

Smoking (Tobacco) & Crohns Disease
๏ Smoking and Crohn's disease (CD):
๏OR current smokers / lifetime nonsmokers 2.0 (95% CI:
1.65–2.47)
๏OR ex-smokers / lifetime nonsmokers 1.80 (95% CI: 1.33–
2.51)
๏Risk of smoking to the development of CD is greater to women (3x)
than it is to men
Lunney PC, Leong RW. Review article: Ulcerative colitis, smoking and nicotine therapy. Aliment Pharmacol Ther. 2012 Dec;36(11-12):997-1008.
Persson PG, Ahlbom A, Hellers G. Inflammatory bowel disease and tobacco smoke--a case-control study. Gut. 1990 Dec;31(12):1377-81. doi: 10

Smoking (Tobacco) & IBD Phenotype
๏87 sibling pairs with IBD who were discordant for smoking status at
diagnosis
๏23 sibling pairs were also discordant for disease type – one developed
UC and the other CD
๏In 21 out of the 23 cases, CD developed in the active smoker and
UC in the nonsmoker.
๏Other studies have also confirmed the association of smoking with CD and
nonsmoking with UC in the context of IBD phenotype expression within
families
Bridger S, Lee JC, Bjarnason I, Jones JE, Macpherson AJ. In siblings with similar genetic susceptibility for inflammatory bowel disease, smokers te

SVD & Crohns Disease
๏22 adult CD patients who achieved clinical remission either medically (n = 17) or surgically
(n = 5) and consumed an SVD during hospitalization were advised to continue with an
SVD (Semi Vegetarian Diet— lacto ovo + weekly fish x 1 + meat q2 weeks
๏SVD was continued by 16 patients (compliance 73%)
๏Remission was maintained in 15 of 16 patients (94%) in the SVD group vs two of six
(33%) omnivores
๏Remission rate with SVD was 100% at 1 year and 92% at 2 years.
๏SVD showed significant prolongation in the time to relapse compared to that in the
omnivorous group (P = 0.0003, log rank test).
๏C-reactive protein was normal at the final visit in more than half of the patients in remission
who were taking an SVD, who maintained remission during the study (9/15; 60%), who
terminated follow-up (8/12; 67%), and who completed 2 years follow-up (7/10; 70%).
Mitsuro Chiba, Toru Abe, Hidehiko Tsuda, Takeshi Sugawara, Satoko Tsuda, Haruhiko Tozawa, Katsuhiko Fujiwara, Hideo Imai. Lifestyle-related d

SVD & Crohns Disease
Chiba M, Ishii H, Komatsu M. Recommendation of plant-based diets for inflammatory bowel disease. Transl Pediatr. 2019 Jan;8(1):23-27. doi: 10.2
IFX infliximab (Remicade)
ADA adalimumab (Humira)
Half ED half elemental diet

SVD & Ulcerative Colitis
Chiba M, Ishii H, Komatsu M. Recommendation of plant-based diets for inflammatory bowel disease. Transl Pediatr. 2019 Jan;8(1):23-27. doi: 10.2

Sour Cherry & Rat UC
Whole Tart Cherry Improves Disease Activity Index in Rat
Model of Dextran Sulfate Solution – Induced Ulcerative Colitis
by Downregulating the Janus 1 And Janus 3 Kinases and TNF -
Alpha
Johana Alexandra Coronel, Louisiana State University LSU Digital Commons
LSU Master's Theses Graduate School 4-4-2018

Sour Cherry & Inflammatory Markers
๏37 men and women between the ages of 65⁻80 were randomly assigned
to consume 480 mL of tart cherry juice or control drink daily for 12 weeks.
๏Plasma levels of CRP, MDA, and OxLDL decreased numerically by 25%,
3%, and 11%
๏ Commercially available Montmorency tart cherry concentrate (King Orchards, MI, USA) was
used in this study. A detailed description for preparing beverages and nutrient composition of
tart cherry juice and control drink : 68 mL of Montmorency tart cherry concentrate was diluted
with 412 mL of water. Control drink was prepared by mixing unsweetened black cherry
flavored Kool-Aid (Kraft Foods, Chicago, IL, USA) with water. The control drink was matched
for energy and sugar content with similar color, sugar content, acid, and flavor as the tart
cherry juice. Participants were instructed to consume 240 mL of the beverage in the morning
and 240 mL in the evening for the entirety of the 12-week intervention.
Chai SC, Davis K, Zhang Z, Zha L, Kirschner KF. Effects of Tart Cherry Juice on Biomarkers of
Inflammation and Oxidative Stress in Older Adults. Nutrients. 2019 Jan 22;11(2):228. doi:
10.3390/nu11020228. PMID: 30678193; PMCID: PMC6413159.

Mindfulness/Yoga & IBD
๏Review of six studies of mindfulness or meditation in IBD
๏Strongest effects in quality of life and anxiety/depression
๏Inconsistent or minimal changes in perceived stress, disease-related outcomes
๏A total of 100 IBD patients [ulcerative colitis (UC) n = 60 and Crohn's disease (CD) n = 40] in
clinical remission phase of disease
๏Yoga group that underwent an 8-week yoga intervention (physical postures, pranayama,
and meditation) 1- hour/day in addition to standard medical therapy (UC, n = 30; CD, n =
20)
๏Control group (UC, n = 30; CD n = 20), which continued with standard medical therapy
๏After the 8-week yoga intervention, fewer UC patients reported arthralgia.
๏The number of patients reporting intestinal colic pain in the control group was higher.
๏State and trait anxiety levels were significantly reduced in patients with UC.
Gastroenterol Clin North Am. 2017 Dec;46(4):859-874. doi: 10.1016/j.gtc.2017.08.008. Epub 2017 Oct 3. Mindfulness-Based
Interventions in Inflammatory Bowel Disease Megan M Hood , Sharon Jedel
Int J Yoga Therap. 2015;25(1):101-12. doi: 10.17761/1531-2054-25.1.101. Effect of Yoga-Based Intervention in Patients with
Inflammatory Bowel DiseasePurnima Sharma , Gopal Poojary , Sada Nand Dwivedi , Kishore Kumar Deepak

Exercise & IBD
Review article
“While some data support physical activity as having a protective role in the
development of IBDs,
the findings have not been robust.
Importantly, studies of exercise in patients with mild-to-moderate IBD activity
show no danger of disease or symptom exacerbation. Exercise has
theoretical benefits on the immune response, and the limited available data
suggest that exercise may improve disease activity, quality of life, bone
mineral density, and fatigue levels in patients with IBDs.
Overall, exercise is safe and probably beneficial in patients with IBDs.”
Clin Exp Gastroenterol. 2017 Dec 22;11:1-11. doi: 10.2147/CEG.S120816. eCollection 2018.Exercise in patients with inflammatory bowel dis

IBD & High Fiber
๏ Meta-analysis on IBD and fiber indicates that fiber may
have a slightly beneficial impact on UC
๏ No evidence that fiber should be limited (except in
cases of a bowel obstruction)
๏ Study of patients in remission with CD showed that the
people with the highest quartile of fiber had a 40% lower
risk of a CD flare compared with the people in the lowest
quartile of fiber intake
Brotherton CS, Martin CA, Long MD, Kappelman MD, Sandler RS. Avoidance of fiber is associated with greater risk of
Crohn's disease flare in a 6-month period. Clin Gastroenterol Hepatol. 2016;14(8):1130-1136

UC in Rats, exercise & fatty diet
๏Experimental colitis in rats, fed high or low fat rat chow, and either
exercised on a rat wheel 5 days a week vs sedentary
๏Non-exercising fatty meal rats had more colon damage and
inflammatory molecules in their blood streams compared to low
fat diet rats.
๏The fatty diet rats who exercised accelerated the healing of the
colitis and lowered the inflammatory bloodstream molecules.
Bilski J, Mazur-Bialy AI, Brzozowski B, Magierowski M, Jasnos K, Krzysiek-Maczka G, Urbanczyk K, Ptak-Belowska A, Zwolinska-
Wcislo M, Mach T, Brzozowski T. Moderate exercise training attenuates the severity of experimental rodent colitis: the importance
of crosstalk between adipose tissue and skeletal muscles. Mediators Inflamm. 2015;2015:605071. doi: 10.1155/2015/605071. Epub
2015 Jan 5. PMID: 25684862; PMCID: PMC4313673.

Probiotics & IBD: S boulardii
๏S boulardii (Florastor)
“The number of studies of S. boulardii as treatment for IBD is limited.
Furthermore, the existing trials have small populations
and short duration.
We do not have enough evidence to prove the effect of
S. boulardii in IBD.”
Sivananthan K, Petersen AM. Review of Saccharomyces boulardii as a treatment option in IBD. Immunopharmacol Immunotoxicol. 2018 Dec;40(6

Probiotics & IBD: e Coli Nissle 1917
E Coli Nissle 1917
Scaldaferri F, Gerardi V, Mangiola F, Lopetuso LR, Pizzoferrato M, Petito V, Papa A, Stojanovic J, Poscia A, Cammarota G, Gasbarrini A. Role a

Probiotics & IBD: VSL#3
๏Not cost effective in pediatric UC
“VSL#3 may be effective in inducing remission in active UC.
Probiotics may be as effective as 5-ASAs in
preventing relapse of quiescent UC.
The efficacy of probiotics in CD remains uncertain, and more evidence
from RCTs is required before their utility is known.”
Park KT, Perez F, Tsai R, Honkanen A, Bass D, Garber A. Cost-effectiveness analysis of adjunct VSL#3 therapy versus standard
medical therapy in pediatric ulcerative colitis. J Pediatr Gastroenterol Nutr. 2011 Nov;53(5):489-96. doi:
10.1097/MPG.0b013e3182293a5e. PMID: 21694634.
Derwa Y, Gracie DJ, Hamlin PJ, Ford AC. Systematic review with meta-analysis: the efficacy of probiotics in inflammatory bowel
disease. Aliment Pharmacol Ther. 2017 Aug;46(4):389-400. doi: 10.1111/apt.14203. Epub 2017 Jun 27. PMID: 28653751.

Crohns Disease
Yes:
Vitamin D3
High Fiber
? SVD (Semi-Vegetarian Diet)
? Coconut
No:
Cannabis (Increased surgery 5x
for use >6 months)
Tobacco (especially women)
Trans-unsaturated fats
S boulardii

Ulcerative Colitis
Yes:
Curcumin/Turmeric
5 steps in flare management
?SVD (Semi Vegetarian Diet)
? Omega 3 FAs
?Tobacco (aargh)
?Tart cherry
? High fiber
?Low fat diet/exercise (rats!)
?VSL#3 (cost)
No:
?Keto Diet
e Coli Nissle 1917

The ‘Embrace IBD’ Song
Homage to
“Addicted to Love”
Robert Palmer 1986

Here comes a flare, you're not at home
Quickly your bowels are not your own
You have cramps, you're feeling weak
Crave spasm drugs before your shriek?
Belly hurts, you can't eat
There's no doubt, this flare is deep
You've no control, good health concede
More pharma meds are all you need?

You hope new fancy drugs mean you're immune to a
flare...oh no
It's closer to MY truth to make you lifestyle aware
You know ya gotta embrace it
Embrace IBD

You see the signs, approaching flare
CDAI tells you it's there
Your colon bleeds on tissue swipe
Looser stools down your drainpipe
You've got one job
Flares can be saved
Low scores are what you crave
There is control that's left for you
Lifestyle aware is what you do

Might as well embrace it, take your Vitamin D
…avoid cannabis please
…with a macaroon spree
…eat a SVD
…with some tart cherries
…yes, embrace IBD

Find me!
PLRaymond@RxForSanity.com
Slide deck available at SlideShare.net PatriciaRaymond

Holistic Management as an Adjunct in IBD: Encourage your patient to own their disease

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