We’ve focused often on SIBO and IBS on the podcast so we’re going to take a look at another gastrointestinal disorder – Inflammatory Bowel Disease (IBD). This week, Dr. Ruscio interviews Dr. Steven Sandberg-Lewis, ND who specializes in the treatment of IBD.
If you need help with IBD, click here.
Dr. R’s Fast Facts
- There are many different faces of Inflammatory Bowel Disease (IBD). There are several different types consisting of different characteristics and symptoms.
- Research is demonstrating a strong link between SIBO and Crohn’s disease.
- Certain types of fiber may benefit patients with IBD while many types of fiber tend to exacerbate symptoms.
- The best marker for IBD can be evaluated through a simple stool test.
- According to Dr. Sandberg-Lewis, the best diet for IBD is the Specific Carbohydrate Diet (SCD).
- There are many treatment options for patients with IBD, including diet, immune-modulating herbs, probiotics, elemental diet, fecal transplant, and pharmaceuticals.
- Dr. Sandberg Lewis finds the best immune-modulating herbs to be boswellia and curcumin, along with several others.
- VSL-3 and Lacto-Prime Plus are effective probiotics for many patients with IBD.
Dr. Steven Sandberg-Lewis bio…..2:42
Inflammatory Bowel Disease (IBD) defined…..4:50
Symptoms associated with IBD…..6:17
Differentiation between IBD, IBS and SIBO…..8:29
Fiber and IBD…..11:20
Testing for IBD…..18:22
Calprotectin test to predict IBD relapse…..22:38
Supplementing with folate…..24:49
Treatment of IBD – diet…..29:27
Treatment of IBD – probiotics and inflammation modulating botanicals…..32:09
Treatment of IBD – elemental diets…..40:45
Treatment of IBD – fecal microbiota transplant and helminthic therapy…..46:05
Treatment of IBD – prescription medications…..51:39
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Inflammatory Bowel Disease with Dr. Steven Sandberg-Lewis
Welcome to Dr. Ruscio Radio, discussing the cutting edge in health, nutrition, and functional medicine. To make sure you’re up to date on this and other important topics, visit DrRuscio.com and sign up to receive weekly updates. That’s D-R-R-U-S-C-I-O.com.
The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor.
Now, let’s head to the show!
Hi, everyone. Welcome to Dr. Ruscio Radio. We have a very exciting episode ahead with Dr. Steven Sandberg-Lewis, as he discusses the topic of inflammatory bowel disease, or IBD. He’ll go into the different types of IBD, how to test for IBD, and different treatment options available for patients with inflammatory bowel disease. Here are your fast facts. There are many different faces of inflammatory bowel disease. There are different types, consisting of different characteristics and symptoms. Research is demonstrating a strong link between SIBO and Crohn’s disease. Certain types of fiber may benefit patients with IBD while many types of fiber tend to exacerbate symptoms. The best marker for IBD can be evaluated through a simple stool test. According to Dr. Sandberg-Lewis, the best diet for IBD is the Specific Carbohydrate Diet. There are many treatment options available for patients with IBD, including diet, immune-modulating herbs, probiotics, elemental diet, fecal transplant, and pharmaceuticals. Dr. Sandberg Lewis finds the best immune-modulating herbs to be boswellia and curcumin, along with several others. VSL#3 and LactoPrime Plus are effective probiotics for many patients with IBD.
All right, I think you’re really going to enjoy this episode, so let’s get started.
Dr. Michael Ruscio: Hey, folks. Welcome to Dr. Ruscio Radio. This is Michael Ruscio, and I am here with Dr. Steven Sandberg-Lewis, who is a very well respected naturopath and very, very intelligent, cutting-edge guy in the realm of IBD, and so I thought he would be the perfect person to bring on to really dive into this topic. Steven, welcome to the show.
Dr. Steven Sandberg-Lewis: Thanks.
Dr. Steven Sandberg-Lewis Bio
DrMR: Can you tell people a little bit about your training? I know that you’re a clinician, and you’re also an educator. Can you tell people a little bit about you, your training, and what you’re doing?
DrSSL: Sure. I graduated in 1978 from what at that time was called the National College of Naturopathic Medicine. Now it’s called the National College of Natural Medicine, and soon it’s going to be renamed because we’ve become a university. Anyway, that’s a lot of detail on the school, but it was 1978, so I’ve been in full-time practice since that time. I guess I’m going on 38 years this summer, and I have been a full-time professor at the College for the last 20 years, teaching gastroenterology and pathology and other courses related to cases. And I’ve been in the clinic about 22 hours a week, supervising student doctors and also seeing private patients, and my total focus in my practice is GI digestive disorders. I’d say, at this point, about 20 percent of my practice is inflammatory bowel disease, and I am currently in the process of writing a book on inflammatory bowel disease with two other naturopathic doctors that are also acupuncturists that have a very strong focus in their practices on inflammatory bowel disease.
DrMR: You have a really great breadth of experience, both academic and clinical, to pull from for this topic, which is why I thought you would be the perfect gentleman to bring on to discuss this.
Inflammatory Bowel Disease (IBD) Defined
DrMR: Can you tell us a little bit about what inflammatory bowel disease is?
DrSSL: Inflammatory bowel disease is the term for a group of disorders that we think are mostly associated with a less than ideal reaction of the immune system to the microbiome in the small and large gut. The most common ones people have heard of are Crohn’s disease and ulcerative colitis, but there are also several types of inflammatory bowel disease that are more recently recognized called microscopic colitis, and that includes lymphocytic colitis and collagenous colitis. Those are conditions that if a patient with frequent, urgent diarrhea were to have a colonoscopy, the exam looks completely normal on the colonoscope. It’s only when they’re biopsied that the microscopic analysis shows inflammatory bowel disease, and that’s why it’s called microscopic colitis.
Symptoms Associated With IBD
DrMR: You’ve already bridged on some of the common symptoms. Frequent bowels or diarrhea, sometimes bloody diarrhea, I know, are some of the key symptoms. Can you expand a little bit upon what the symptoms typically look like?
DrSSL: Yeah. On the scope of all these different conditions, for microscopic colitis, the most typical presentation is just urgent, frequent, watery, nonbloody stools, which can be a condition that just totally affects a person’s entire life and makes it almost impossible to function until it’s under control.
DrSSL: Crohn’s disease is interesting in that it can present as almost any kind of symptom, but the most typical symptoms are either constipation or diarrhea. Almost always there’s abdominal pain, belly pain, but it can be purely constipation and no diarrhea at all, and there doesn’t have to be any blood in the stool, unlike ulcerative colitis, which typically is bloody diarrhea and there may be pain.
DrMR: That’s why I think it’s important, that if someone maybe has SIBO and they’ve been treated and their constipation hasn’t fully responded, one of the next things that we’ll do is start the investigative process for IBD because that certainly can be a cause of constipation. I think it’s underappreciated, the manifestation of Crohn’s disease as constipation, because we’re so typically used to associating it with diarrhea, but I’m glad you made that point, and I think it’s important for both patient and doctor to be aware that if you’ve treated for something like SIBO and you haven’t responded or your lab values have responded but maybe your symptoms haven’t, then looking into IBD, in my opinion, would be a next very intelligent step.
Differentiation Between IBD, IBS, and SIBO
DrMR: Steven, how do you kind of interplay between these two, and how do you differentiate between the two in clinical practice?
DrSSL: Well, Crohn’s disease has a much stronger correlation with SIBO, and one of my coauthors for the book that we’re writing on inflammatory bowel disease recently published an article called The IBS in IBD. It’s one of the things that the three of us that are writing this book are going to discuss at the SIBO symposium this June, and that is, let’s say, take it from the other side, someone that we already know has Crohn’s disease, but they’re having a series of what look like flares of Crohn’s disease, but they don’t respond to any of the typical medicines that their gastroenterologist gives them. That’s a really important time to look at the possibility that they might have both conditions at the same time—often they do—and then it has to be treated as SIBO in order for the “flare” to get put under control because no amount of immunosuppressive standard treatment for Crohn’s is going to help the SIBO.
DrMR: That’s an excellent point. That is something that has been published in a number of studies, that antibiotics can help induce remission of inflammatory bowel disease, and I think it’s for that exact mechanism why that association has been reported.
DrSSL: Yeah, you see doctors throwing in metronidazole as an antibiotic treatment in patients with Crohn’s or sometimes even with ulcerative colitis. They don’t know the mechanism, but they figure, well, sometimes that works, so let’s try it if other things aren’t.
DrMR: Right. It’s exciting that there have been a few studies showing that herbal antimicrobials can work in the same application. It’s nice to see that being published, and hopefully as we’re learning more about this, people will be worked up for SIBO, should they have IBS-type symptoms in Crohn’s or in ulcerative colitis.
DrSSL: Yeah, and as you can imagine, the typical symptoms of SIBO and Crohn’s can be identical. You don’t have to have blood. You don’t even have to have diarrhea. It could be like a methane SIBO, so it’s a giant crossover there.
DrMR: Yeah, definitely.
Fiber and IBD
DrMR: Now, another point of crossover that I think might be important for us to touch on would be fiber. Oftentimes, especially with the boom of literature we’re seeing regarding the microbiota with how we’re studying different African populations and seeing they have a high-fiber diet, and oftentimes that is extrapolated to suggest that Westerners should be mimicking this very high fiber diet, which I think certainly can be helpful in some cases, but there are other cases where that high-fiber diet may be somewhat detrimental, and IBS and IBD are certainly two of those. What are your thoughts on fiber and how they interface into inflammatory bowel disease?
DrSSL: Well, there are some studies that go back to the 1980s that show that both lowering simple sugar intake as well as increasing soluble fiber intake decrease the number of hospital stays for patients with Crohn’s disease—fewer flares and fewer times in the hospital—but I think that part of the issue with Africa and high-fiber diets is that folks in more rural, less overdeveloped countries, they have something else besides just higher fiber diets. They have ancient flora.
DrSSL: If you look at the average American, by the age of 20, they’ve had 17 courses of antibiotics, and by age 40, they’ve had something close to 30 courses of antibiotics. Plus they’re eating animals that are raised on antibiotics in order to fatten them, and because of all these influences, people just don’t have this immune-modulating ancient flora that has been with the human race for 80,000 to 100,000 years. I think that if you look at any of those tests that are done looking at diversity of flora, for instance—even in the large bowel alone—you find that more primitive cultures have a wide variety of different bacteria and subtypes, and they have some of these ancient flora, but I think we are rapidly killing them and leading to possible—I hope not—but possible extinction of some of these essential microflora that are designed from birth to modulate the immune systems of human beings.
DrMR: That’s an excellent point. Certainly it seems that the earlier the antibiotics are given, the more deleterious they tend to be on the microbiota. There have been a number of very interesting studies that have shown, when they look at the effect that, let’s say, an antibiotic has on later development of asthma or seasonal allergies, the greatest impact is when antibiotics are administered before six months of age. If they’re administered after a year, they have less of a negative effect, and if they’re administered after two years, they have even less of a negative effect. It certainly seems that the timing of the antibiotic makes a really strong impact on this.
One question I’d like to get your clinical kind of take on regarding fiber: I know that there’s evidence supporting both lowering fiber and increasing fiber consumption in inflammatory bowel disease. The general trends seems to be—and this is what I generally do in clinical practice—if someone is flared or highly symptomatic, generally lowering the fiber intake tends to be helpful, and then once someone is in remission, bringing the fiber back in tends to be helpful. Do you follow that general trend? Or are there any pearls you could offer someone who is struggling with IBD and trying to figure out the best way to manipulate their fiber intake for management and/or prevention?
DrSSL: Yeah, I do take people off of fiber during acute flares, and that’s probably the reason that we also tend to take them off any raw fruits or vegetables during the flare. In order to get the fiber back after they’re in remission, depending on whether or not you know that they also have SIBO, you might choose your fibers from the vegetables and fruits that are lower in FODMAPs.
I was recently speaking with Dr. Allison Siebecker. She’s been looking into some sources of fiber that are actually beneficial for folks with bacterial overgrowth, and she was mentioning that there’s one particular form of GOS that actually is beneficial. It’s not the type of GOS that you find in beans that tends to cause gas. She’s just starting to look into that, as well as, of course, the partially hydrolyzed guar gum, which seems to be actually beneficial in SIBO.
Depending on the patient, whether or not you know they have SIBO, you might just use certain kinds of fibers in addition to the low-FODMAP fruits and vegetables.
DrMR: It’s funny that you mention her because we did a recording a few weeks ago, and that will have aired probably a couple of weeks before this one, where we talked about that specifically, which is exciting and it’s something that we’re both looking into, which is seeing if there are any types of prebiotics and any types of fibers that can really be helpful for patients with SIBO. Thank you for bringing that up, and hopefully between her and me, we’ll have something new to report in the next couple of months on that.
Testing for IBD
DrMR: How about ways to test this? We’ve alluded to some already with colonoscopy, but I know there are a number of different markers to test, all the way from antibodies through to more preventative measures like folate. What are some of the best tests to use if someone is trying to sort this out and monitor their IBD?
DrSSL: The test that we use the most is the fecal calprotectin. It’s really the one that shines the most in the research. Occasionally we’ve used fecal lactoferrin or lysozyme, but they don’t have as much evidence behind them. The calprotectin is an inflammatory substance that is produced by white blood cells—neutrophil white blood cells, specifically—in the gut in conditions in which there is major inflammation. That test will show a positive result if the patient has polyps in the colon, if the patient has diverticulitis, if the patient has Crohn’s or ulcerative colitis. It will be positive if they have colon cancer that’s well developed, so a number of bad things that would definitely indicate the need for colonoscopy and biopsy. If we’re not really sure and the patient has never been diagnosed with IBD, we’ll use the fecal calprotectin. And if it’s less than 50, we won’t refer them for colonoscopy because those types of inflammatory conditions are very unlikely. If it’s over 100, we will recommend that, and certainly if it’s 250 or more, that’s an indication of an acute flare.
DrSSL: That’s the most common thing that we use. The antibodies that you talked about, which are the p-ANCA and the ASCA, those blood antibodies, I mostly use those when a patient has already had a colonoscopy and they’ve been diagnosed with what’s called indeterminate colitis. I didn’t mention that before, but that’s when it’s unlikely that a gastroenterologist can differentiate by colonoscopy or biopsy as to whether they have Crohn’s or ulcerative colitis, so they’ll call it indeterminate colitis. That’s when those antibodies are useful, because the ASCA, or anti-Saccharomyces cerevisiae antibody, is something that’s much more common in Crohn’s disease, and the p-ANCA shows up in other autoimmune disorders as well, but in terms of the gut, ulcerative colitis is the thing that’s most likely to do that.
DrMR: Right. I’m assuming you’re running those antibodies in conjunction with inflammatory markers like calprotectin or maybe CRP or ESR to get a gauge of both the antibodies and the inflammatory activity?
DrSSL: Well, the calprotectin I really, like I said, use the most to get an idea of how much inflammation is going on. CRP and fecal leukocyte testing, those are all things that are useful, too, but they’re pretty nonspecific. Yeah, the antibodies, like I said, I pretty much only run them when someone has been already diagnosed with indeterminate colitis and we’re trying to figure out if it’s more like Crohn’s or if it’s more likely to be ulcerative colitis.
Calprotectin Test to Predict IBD Relapse
DrMR: Something else I’d be curious to hear your thoughts on: I’ve read a number of studies showing that calprotectin can predict a pending relapse, and so in my IBD patients, we’ve been screening that every few months to keep tabs on the condition so as to potentially preempt a relapse and know that we have to maybe tighten up the diet or increase probiotics or antiinflammatory herbs or whatever it is that we’re using. I haven’t been using it for that long, so it’s hard for me to have a firsthand clinical sense as to how helpful it is in the real world. Have you used it in that application at all?
DrSSL: Well, I just told that to a patient with ulcerative proctosigmoiditis about an hour ago, that it would be a good idea because her calprotectin level was 500 when we tested it, and she’s starting to come out of the flare now. We were talking about checking it every three to four months, and if we find that the level is high again even though she doesn’t seem to be in a flare, we can take that as an indication that in the next 30 days or so she’s likely to start a flare and that we should get more serious about her treatment.
DrMR: Perfect. Then we’re in agreement on that. Good. I think that definitely could be something nice for people to be aware of. Especially if you’re maybe someone who is trying to come off of a drug therapy and opt for a more natural alternative, I think this can be a really nice marker to run to know if these things are having enough of an effect or if we need to be more aggressive with the natural therapies. Or if you’re monitoring someone who is in remission, and they’re trying to open up their diet and be maybe a little bit less strict with their care, potentially we can head off a pending relapse by monitoring that. Yeah, I think that can be a really nice preventative marker for people.
Supplementing With Folate
DrMR: Now, what about folate? I know you’ve discussed folate being able to predict the neutrophilic hypersegmentation index, if I’m remembering correctly, and that if found to be low, giving folate can help because that can prevent the occurrence of cancer, which is increased in IBD. Can you expand upon that?
DrSSL: Well, I first got interested in it when I read several studies showing that taking sulfasalazine or mesalamine types of drugs for inflammatory bowel disease was a common cause of folic acid deficiency. Thirty years ago, when I was having my IBD patients take folic acid and then retesting their neutrophilic hypersegmentation index to see if it would come down under 10 percent, which is considered ideal, I would often have gastroenterologists get mad at me because they thought it was unnecessary or somehow would affect the treatment they were giving, but now it’s pretty universally accepted that you should have your patient on at least 1 milligram of folic acid daily long term, especially if they are using sulfasalazine-type drugs. That can reduce the risk of colon cancer in those patients, according to some studies, by up to 85 percent or so, which is pretty important.
DrMR: Definitely. Do you prefer folate over folic acid? Are the studies using folic acid? I know many people listening may have heard of the recent criticisms of folic acid, which as I understand it, is only going to be really an issue if people have MTHFR polymorphisms. I’m assuming that these studies were using just folic acid and showing that decrease of colon cancer risk. Is that correct, or was it folate? What did that look like?
DrSSL: Yeah, folic acid in the studies that I have seen. What I tend to do is, if we want to, we’ll just start the patient on the folic acid if their neutrophilic hypersegmentation index is too high, and then we’ll repeat the test in two months and see if it has come down. If it hasn’t, then we might switch to folate, or if they’ve already been tested, we’ll use folate instead. Of course, that’s a tricky thing because some folks that have multiple SNPs and not just the MTHFR SNPs, they’ll really get aggravated if you give them anything like a moderate to high dose of methyltetrahydrofolate, so you have to start with really, really small doses, and so I usually just start with the folic acid and repeat the test. It’s not the kind of thing you have to fix immediately. If two months down the line you haven’t seen any change in the test, you can always switch to a more absorbable or bioactive form.
DrMR: Gotcha. I think you make an excellent point about starting with the folic acid and only moving to the folate if it’s really indicated. I think we sometimes can have an MTHFR-centric view on a lot of things, and you made a great point that there are other polymorphisms that may make more of a difference or impact the need if someone should or should not be taking folate. What I see, anyway, is patients walking in really concerned about one SNP and sometimes missing the bigger picture, so I think you made a great point and brought us back to a very practical clinical decision, which is start with the folic acid and then reevaluate.
Treatment of IBD – Diet
DrMR: Now, regarding treatments, I know there are a number of treatments available. Maybe we could start walking through, starting with diet and then maybe ending with what everyone is hoping to prevent, which would be surgery. Could you start us off with some of the best diets for IBD?
DrSSL: Well, all of us here in Portland that are treating a lot of both ulcerative colitis and Crohn’s and microscopic colitis, we really, really rely on the Specific Carbohydrate Diet. It’s been around since the 1940s, and that’s what it was designed for, as well as to treat celiac disease. We really rely on it. I like to call it my prednisone. It’s fast acting like prednisone, and it also can be used lifelong—unlike prednisone—to help prevent recurrences and to treat long term. For many patients, within three or four days, it can start to get them out of a flare. That’s one of the mainstays.
Often these days, I will use Dr. Siebecker’s SIBO Specific Diet, which, as you know, combines the low FODMAPs with the Specific Carbohydrate Diet. It’s just such a nicely organized diet that I’ll often just give them that rather than just a pure SCD.
DrMR: Sure. Especially because if someone maybe has a touch of SIBO along with the IBD, you kind of cover both your bases with the SCD low-FODMAP diet.
DrMR: I think it’s important to mention, in case people are not aware of this, that there have been studies looking at head-to-head comparisons of different diets, and they’ve found that many of these diets—I know this has been done for elimination diets as well as the SCD, and maybe for the low-FODMAP, but I’m not sure on that one—compared to mesalazine, which is one of the frontline therapy drugs, have shown equivalent results.
Treatment of IBD – Probiotics and Inflammation-Modulating Botanicals
DrMR: I know sometimes we can think that the drugs are more powerful, but in a lot of these cases, there have been a lot of studies showing that diets have been equally as effective as some of the drugs, and there have actually been studies also showing—even well-performed studies, as high as things like meta-analysis, like we’ve talked about being one of the highest levels of scientific evidence—showing that certain antiinflammatory herbs have equivalent effectiveness as some of the frontline antiinflammatory drugs, like mesalazine.
Maybe that as a transition point, Steven, can you take us into what some of your favorite probiotics and/or antiinflammatory herbs are?
DrSSL: I don’t mean to be a snob, but I don’t like the word “antiinflammatory.” I like to use something like “inflammation modulating.”
DrSSL: Because as you know, inflammation is a positive thing if it is in balance, and so I just tend to call them inflammation modulators rather than antiinflammatory.
DrMR: Which I agree with, by the way.
DrMR: I think if we’re going to be technical, I think that’s a much better description.
DrSSL: Yeah. Certainly boswellia and curcumin, or turmeric, are the two that are probably the best studied and probably what you were talking about earlier. I tend to use those in a tincture, a liquid herbal tincture, and this was put together by Dr. Eric Yarnell, who teaches gastroenterology up in Seattle. His formula, he calls it Dr. Yarnell’s Ulcerative Colitis Relapse Prevention Formula, which is a very long name, so we just call it Yarnell’s Formula. It does contain turmeric. It doesn’t actually contain boswellia because he’s a very well-known herbalist and very knowledgeable about herbs, and he’s in the plant savers group that’s trying to prevent extinction of certain herbs, and he believes that boswellia, because you have to take the cambium layer of the bark, you have to cut the bark off the tree in order to get the boswellia, he’s concerned that that’s going to be extinct. So he uses propolis in place of boswellia. He feels that propolis has all the same effects on modulating inflammation that boswellia has, so in his formula, there are those two herbs together with yarrow plant and calendula, which is marigold, and there is some licorice in there. It’s about eight different herbs that we use in a combination that help to prevent relapse. That’s one of the formulas I’ll use.
Some patients we actually have on boswellia as a straight capsule, one ingredient, and also on turmeric as a single-ingredient capsule or just as the powder in their food. Definitely those are the most common botanicals that I use.
DrMR: Gotcha. In terms of probiotics, again, many of these probiotics have been shown to be as effective as the frontline therapy drugs, the 5-ASA class drugs. Do you have some probiotics in particular that you like?
DrSSL: I mention to patients about VSL#3 just because it has been one of the targets of studies, and I pretty much check in with them because patients have usually tried a probiotic or two or three or four, and probiotics are as individual as the microbiome itself. I find that people will take one, and they get no response. They’ll take another one, and they’ll get worse. They’ll take a third one, and they’ll have a miracle from it. It’s very, very individual, so generally I just tell people, “If you’ve already found one that you really feel a difference from, use that. If you haven’t, start with probiotics that have no prebiotics in them. Start with that.” We have certain ones that we like to use. Should I mention brand names of things?
DrMR: Yeah, that’s fine.
DrSSL: I tend to start out with something like LactoPrime Plus, which is made by Klaire Labs. That particularly removes the cognitive dissonance that might occur when I put a patient on a Specific Carbohydrate Diet and then they read the label of something that I gave them to take and it says that it has inulin in it or it has maltodextrin or something that they will find is a real problem, and they’ll have to call me and clarify, “Did you really mean this?” The nice thing about that particular product, LactoPrime Plus, is that it says right on there, “SCD compliant.” It has no inulin. It has no FOS. It has nothing else that we would tend to have them avoid.
DrMR: A question about that: When I’ve kind of picked apart some of the probiotic studies, what I’ve generally seen is that the amount of prebiotic in most probiotics is what many consider somewhat negligible, like maybe 400 to 500 milligrams, whereas most of the prebiotic studies are using at least 1000 milligrams, or 1 gram, and in many cases they’re using 3 to 5 grams or even higher. So I’ve been of the belief that the amount of inulin or other prebiotics in most probiotics is so small that it’s almost negligible. Would you agree with that?
DrSSL: Especially if it is just in the base, and there they don’t even tell you how many milligrams it is. I don’t think that’s a problem for 99 percent of patients, but I see so many patients in a week. If I’m seeing 40 patients in a week, if I’m going to get a phone call from half of them and some of them are going to call me three times, I will just do whatever I need to do to avoid that!
DrMR: Sure. Understandable.
DrSSL: It just makes my life easier.
DrMR: Understandable. And you make a great point, which is if it’s just in the base, then it’s usually a small amount, around 400 to 500 milligrams. I’ve actually spoken with the Chief Medical Officer of Klaire Labs, and we actually had him on the podcast a number of months ago, and we talked about this. But to your point—and a very important clarification point, I think—that’s if it’s just in the base. If you see something in terms of the main ingredients and you see inulin listed, you will usually see it in terms of a dose next to it, at least 1000 milligrams or higher. If you see inulin listed as a main ingredient or if you can get a specific readout on the milligrams, I would say 1000 milligrams is something you want to be under. If you see much above 1000 milligrams, then you’re getting into murky waters where you may have a reaction.
So we’ve talked about diet, we’ve talked about probiotics, we’ve talked about folic acid and folate, and we’ve also spoken briefly about some of the herbal antimicrobials or antibiotics that have been shown to induce remission.
Treatment of IBD – Elemental Diets
DrMR: Now, what about something like the elemental diet? I know there’s been some great literature on different types of elemental diets or semi-elemental diets or even what’s known as polymeric diets. We’ll gloss over the distinguishing factors between those, but generally speaking, an elemental or a semi-elemental diet is a liquid diet that you’ll consume for anywhere from a number of days to a number of weeks. Some initial research has shown it to be a very effective therapy in SIBO. There’s definitely a wealth of literature showing it can be very effective in treating IBD, and from what I’ve gathered, in many European countries, it’s kind of one of the major frontline interventions for IBD, which is some type of liquid elemental or semi-elemental diet. What’s your experience with using it?
DrSSL: My experience is that they are very effective, especially in, say, a flare of Crohn’s. They are also quite effective in helping people gain weight when they’re cachectic and underweight with diseases like this. The problem is that a fully hydrolyzed protein elemental diet is so bitter that it will make a lot of patients nauseous just to try to drink a half a cup of it. So usually if a patient has lost enough weight and they’re so reactive, sometimes the best way to do this is to put in a nasogastric tube, and the patient just feeds directly into their stomach. They can put on weight. You can feed kids during the night when they’re asleep, and they can sometimes still eat food during the day, or you can just completely use the elemental diet. But it really is problematic because it tastes so bad.
DrMR: Right. That’s a good chance to maybe clarify some of the differences—at least as I understand them—between the elemental diet, semi-elemental diet, and polymeric diets. To put it simply, elemental diets are fully broken down, and much of the classification has to do with the size of the protein molecule. In an elemental diet, the proteins are pretty much amino acids, and as Steven put it, they’re very bitter. They do not taste good at all. In fact, just to try it, I tried one of the prescription versions of this known as Vivonex Plus, and I had one of my friends also taste this, and I thought he put it very aptly. He said, “This tastes like you’re drinking postage stamp glue.” That’s pretty dead on. I can pretty much choke down anything, and even this I was like, whoa, this would be tough.
Now, if we go one level up in terms of molecular size of the protein molecule, we have partially digested or partially hydrolyzed whey, in many cases. This is what we see in a semi-elemental diet or even maybe a little bit less digested in what’s known as a polymeric diet. When you increase the molecule size or make the molecules a little bit bigger, there’s a little bit higher of a chance of reactions, yes; however, in much of the literature that I’ve reviewed, they tend to work equally as well in many cases, according to many of the studies, but what you gain there with that increased molecule size is quite a bit of palatability, quite a bit of taste. So the difference in transitioning from a fully elemental diet to a semi-elemental diet, in terms of taste, tends to be fairly large. From what I’ve seen in reviewing the literature, the clinical effectiveness is similar, and we’ve been using some of these semi-elemental diets in the clinic for the past few months, and we’ve been seeing really good results, both in palatability and tolerability. Yes, there’s an occasional reaction, but for the most part, they seem to be pretty well tolerated.
Steven, have you experimented with any of the semi-elemental or polymeric versions?
DrSSL: I did years ago, but I haven’t done that in the last five or six years, so I’m glad that you’re still getting some good reactions with them. I’ve used some high-glutamine, D-limonene, rice-based protein, not fully hydrolyzed, supplements in the past that I saw good results with, but like I said, I haven’t done that much in the last five years or so.
Treatment of IBD – Fecal Microbiota Transplant and Helminthic Therapy
DrMR: What about FMT? We have a doctor that specializes in FMT coming on the show soon, and I’m going to be curious to get his take in terms of the effectiveness in IBD. I’ve been following the published literature regarding FMT, or fecal microbiotal transplant therapy, in IBD, and the wave of studies coming out in the past six months all tend to agree on it being fairly favorable and having a pretty low side effect profile. Is FMT something that you have referred for or used with IBD?
DrSSL: Yes. Is that Mark Davis that you’re going to have?
DrMR: Yes, actually Mark Davis and then another clinician who is in Australia, where the regulations aren’t as tight and they can use FMT and not potentially get in trouble for using it other than treating Clostridium difficile infections.
DrSSL: Yeah, it’s really unfortunate that the FDA decided two or three years ago that FMT could only be used for C. difficile and it would be investigational for any other use. Mark Davis did his first FMT treatment with an ulcerative colitis patient when he was a student of mine on my shift at NCNM, and then he has gone on to really become one of the leading experts. He and I wrote up a very detailed research proposal once the FDA said that it would have to be under research, and unfortunately none of the local investigational review boards, institutional review boards that oversee research, were willing to have anything to do with a study that had the FDA looking over their books.
DrSSL: They just thought that would bring a level of scrutiny that they did not want to bring into their institutions, so we got shot down after Mark did a lot of work writing that up. It was really unfortunate. He can tell you what the present state is, but Dr. Borody in Australia, who treated over a hundred cases that were published, he found about a 40 to 50 percent rate of… you might say “cure” with quotations because that’s not really a word that’s used with IBD.
DrSSL: But basically patients that had been intractable with their disease—fulminant, very severe disease—on many medications that weren’t working and then up to 15 to 20 years published remission, not on a diet, no special diet, no medication, and no symptoms—as good as a cure gets for IBD. He had, like I said, close to 40 or 50 percent of his patients respond that way. When I’ve discussed this with Dr. Davis, he using a slightly different protocol, he found about a 20 to 25 percent rate of similar response and maybe another 20 percent of patients that had quite a good response, but not quite so perfect clearing of their disease. I think it’s extremely promising, and as more research gets done, I think it’ll be added to the list with C. diff and it’ll become a pretty standard option.
Another thing, of course, would be the helminthic therapy, which Mark Davis can talk about, too.
DrMR: Right, and that’s something I’ve also been following. Thank you for mentioning the helminthic therapy, or essentially just inoculating oneself with worms that we used to think were not healthy but are starting to learn that they actually have some immune-modulating or inflammation-modulating effects. Do you have any experience with that, Steven? From what I’ve seen in the literature, it seems like FMT may be a little bit more effective, but I haven’t seen a ton published lately in terms of follow-up studies after the first cropping of studies in this area. Any thoughts or comments on that?
DrSSL: Yeah, I have to say that until I get to that chapter of the book and start doing the research on it, whenever a patient brings it up or I bring it up, I just give them Mark Davis’ name and email and just say to talk to the expert. I’m not totally up on that.
DrMR: All right. Well, I’ll do the same when we have him on the show because he should be coming on in the next month or two. It’s very cool that he was a student of yours when he did his first FMT. That must have been a cool thing to be part of.
Treatment of IBD – Prescription Medications
DrMR: We’re kind of coming to the end of our time here, but just briefly I want to bring up that there are a few drugs that are frontline therapies. Prednisone, as you mentioned earlier, is one. Of course, that can’t be used frequently or for long term because of long-term side effects. There’s a family of drugs known as the 5-ASA drugs, and this includes things like mesalazine, and there are stronger drugs that carry a higher side effect profile, like TNF-alpha inhibitors like Humira. This is the dialogue that you’ll probably get with your more conventionally trained doctor in a conversation with you about these drugs, so I suppose people can get an education on these there, but is there anything that you would like to mention about these drugs before we come to a close?
DrSSL: Well, as you would probably guess, these drugs don’t do anything that actually has to do with the cause. They just shut off a mechanism, which can save a person’s life, so they have value—great value—when there’s nothing else to choose from. But they’re all immunosuppressive medications of different types, and that also includes things like 5-mercaptopurine and other classes that are just different versions of suppression of the immune system.
The prescription drug that I offer all of my patients with IBD is low-dose naltrexone, and there are a number of studies that have been done now, mostly with Crohn’s—they’re starting to do some with ulcerative colitis, too—and I’ll have to say that if that medication doesn’t work, it’s usually not going to do much in terms of side effects. The occasional patient will have trouble sleeping, and they’ll never take it beyond a week or so. I’d say that’s one in 10 or 12 patients that might have that problem, maybe less. But the thing I love about low-dose naltrexone is it does not suppress immunity. It works by raising endorphin levels and thereby having an effect on TNF-alpha and other inflammatory cytokines to modulate the immune response and, I believe, also to increase the regulatory T cells, which are so important with autoimmune disease. Again, like the Specific Carbohydrate Diet, I often will see responses even within a few days for the better. It’s something that I continue to prescribe and rely on pretty heavily, and I just love the mechanism by which it works, rather than an immunosuppressive medicine.
DrMR: Sure. That’s a great point.
DrMR: Well, is there anything else that you’d like to leave the listener with before we conclude?
DrSSL: Yeah. I would like to just cap this off by saying that we talked about all these different mechanisms, and we talked about different agents, but the microbiome, which seems to be a key piece of this whole inflammatory response and normally the protection from this whole set of conditions, is greatly influenced by emotions and unresolved emotions and states of mind, and it goes the other way, too. I think the microbiome has dramatic effects on preventing or changing patterns of anxiety, depression, changes in mental functioning, and so especially if a patient has had traumatic brain injury or they have a tendency to store up emotions and not express them, and I think that’s a common belief and notation in patients that have inflammatory bowel disease. They have as many feelings as anybody else, maybe more, but often they don’t express them outwardly, and I think that we should keep that in mind—stress and coping and the ability to complete an emotion rather than carry it around long term, unresolved. I think that that’s another very important piece of this whole thing because it affects biochemistry so dramatically and so fast that it’s just a shame when you’re having to work around these things instead of being able to actually go to the bullseye and make some positive change. I wouldn’t write that part off in these conditions.
DrMR: Certainly. I think you make a great closing point, and that’s why I think most of us in functional and naturopathic medicine always harp on starting with diet and lifestyle as kind of the foundations from which we do everything else. I think that’s a great point to bring us to a close.
Dr. Sandberg-Lewis, if people want to find out more about you or see you or follow your work, where can they find you?
DrSSL: Well, I have a terrible website. I wouldn’t want anybody to go to it. I’ve ignored it for eight years. So probably just go to NCNM.edu, which is the National College website, and then also my private office, which right now is in flux because I’m actually moving my private office March 1, but right now we have a website for the SIBO Center, so either NCNM.edu or SIBOcenter.com would be ways to find out more. And you could just google me and wade through that mess.
DrMR: All right. Well, thank you very much, sir, for taking the time, and I’ll look forward to seeing you at this year’s SIBO Symposium.
DrSSL: OK, Michael. It’s been fun.
DrMR: All right, thanks again.
DrMR: Bye bye.
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