-IBIS-1.7.6-
tx
digestive system
Crohn's disease/regional enteritis
Nutrition

dietary guidelines

eating principles:
Decrease consumption of refined foods, especially sugar: Individuals with Crohn’s disease are more likely to have a diet higher in sugar than does the average healthy person. Heaton et al found that individuals with Crohn's who changed to a diet low in refined sugar and high in fiber experienced a 79% reduction in hospitalizations compared with a group who made no dietary changes. Brandes et al reported similar findings in comparing those who consumed high amounts of sugar and tyose who consumed lrelatively low amounts.
(Grimes. Lancet 1976;1:395; Brandes JW, Lorenz-Meyer H. Z Gastroneterol. 1981;19(1)1-12; Mayberry JF, Rhodes J. Gut 1984;886-899; Heaton KW, et al. Brit Med J 1979;2(6193):764-766.)
High complex carbohydrate, high fiber diet: Crohn's Disease is virtually nonexistent in cultures consuming primitive diets, the incidence of Crohn's disease is on the increase in cultures which have shifted onto a Western diet. In looking at the modern Japanese diet, Shoda et al have reported that a diet high in animal fats and protein can be associated with higher risk for developing Crohn's disease. Fats from fish have not been implicated and, in fact, can be beneficial.
(Shoda R, et al. Am J Clin Nutr 1996;63:741-745.)
• When transitioning diet, it is important to be very careful not to aggravate the condition; hence, refined and easy to digest foods have a valuable role to play initially. As the person stabilizes, fiber and unrefined foods are important to continue the health of the colon.
• Elimination/rotation diet, rotation diet, rotation diet expanded
• Correct nutrient deficiencies
• Provide adequate calories

• The treatment of childhood Crohn's is difficult because the patient must consume enough calories and protein for proper growth. On the other hand, increasing the amount of protein tends to aggravate allergic sensitivities. It is important to monitor growth in a child with Crohns as chronic colitis can have an effect on the absorption of many critical nutrients.
• Be careful 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 is 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

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

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, cooked carrots, okra, steamed and mashed parsnips, 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, 132.)
• Carrot and apple
• Carrot and spinach (Walker, 132.)
• Carrot, beet, and cucumber (Walker, 132.)
• Papaya (Jensen, 61; Airola, 63.)
• Raw cabbage (Airola, 63.)
• Celery juice and apple (Shefi)

specific remedies:
• Pour boiling water over 15 g dried powdered apple and serve twice daily (Yin-fang, Cheng-jun, 45.)

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. Riordan et al found that dairy, cereals and yeast are the most likely aggravating dietary factors. Research by Wantke et al indicates that individuals with Crohn's are more likely to have a diminshed ability to break down histamines. In addition there may be some lectin incompatibilities so doing specialized blood typing may be helpful.
(O'Maorain, et al. Arch Disease Childhood 1983;53:44; Jones. Lancet July 27, 1985; 2;177-180; Nutrit Res Newsletter Oct., 1984; Nanda, et al. Gut 1989;30:1099-1104; Frieri, Claus, Boris et al. Annals of Allergy 1990;64, 345-351; Riordan AM, et al. Lancet 1993;342:1131-1134; Gaby AR. Nutr Healing January 1998:1,10-11.)
Factors that promote translocation across damaged mucosal barrier:
a) Changes in bacterial flora
b) Impaired host deficiency mechanisms
c) Trauma
d) Endotoxemia
e) Protein calorie malnutrition
f) Long term treatment with cortisone (Marz, 381, 1997.)
• 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.

Therapeutic considerations:
• Researchers in the National Coop Crohn's Disease Study observed 77 patients who received placebo therapy in a 17 week study. 20 of the patients with active bowel disease went into remission after the 17 weeks. Of these 20 patients, 70% (14) remained in remission after 1 year and 45% (9) remained in remission after 2 years (about 12% of the original 77). In patients having no previous history of steroid therapy, 41% achieved remission after 17 weeks. In addition, 23% of this group continued in remission after 2 years as compared to 4% of the group with prior history of steroid therapy.

Cortisone and NSAIDs:
Increased permeability and an increase the number of food reactions were related to cortisone and NSAIDS. (Marz, 377, 1997.)

supplements

Elemental diet: This treatment has been especially effective in stabilizing acute situations. ENFOOD®, produced by Dr. Gislason in Vancouver, B.C. Canada,has a formula that is relatively palatable. In the U.S., Tolerex and Vivonex T.E.N.® (Sandoz) are less tasty elemental formulas; the latter has added branched chain amino acids and glutamine to enhance its effectiveness. Prior to 1990 in the literature the current Tolerex was Vivonex. This formula can be added to other nutrients as mentioned below. It is best to add these nutrients in a couple at a time to minimize any risk of reaction.
(Marz, 378, 1997; Teahon, et al. Gut, 1133-37, 1990; Giaffer MH, et al. Lancet 1;816-19, 1990; Sanderson IR, et al. Arch Dis Child 1987;62(2):123-127.)
Multivitamin/-mineral: Individuals with Crohn's are at significant risk for nutrient depletion due to impaired absorption. Broad-spectrum nutrient support is advisable, especially given the key roles that zinc, folic acid, and vitamin B12 play in repairing damaged intestinal cells. (Imes S, et al. J Am Dietet Assoc 1987;87:928-930.)
Vitamin A and Beta carotene: 50,000-75,000 IU per day. While vitamin A plays a central role in the growth and repair of the cells comprising the intestinal mucosa, results in clinical studies have been mixed. Supplementation with vitamin A at these levels should only be undertaken with supervision by a qualified healthcare professional. Caution is advised when supplementing with vitamin A as it can cause problems if there is liver involvement. Supplementation with vitamin A at levels higher than 10,000 IU per day is generally contraindicated in women who are or might become pregnant.
(Dvorak AM. Lancet 1980;i:1303-1304; Skogh M, et al. Lancet 1980; i:766; Wright JP, et al. Gastroenterology 1985;88:512-514.)
Vitamin B12 IM 1000µg, every 2-3 weeks. Often damage to the ileum leads to malabsorption. Many patients with Crohn's feel much better with B12. (Marz, 380, 1997.)
• Vitamin C 1 g per day
• Vitamin D: Deficiencies are common due to malabsorption associated with Crohn’s; this can significantly increase the risk of bone degeneration. Driscoll et al have reported positive outcomes in treating risk of individuals with Crohn's who subsequently developed osteomalacia. Evaluation by a healthcare professional trained in nutritional therapies would be appropriate to determine correct dosage.
(Driscoll RH, et al. Gastroenterol 1982;83:1252-1258; Harris AD, et al. Gut 1985;26:1197-1203; Leichtmann GA, et al. Am J Clin Nutr 1991;54:548-552.)
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 is associated with a reduced risk of colon cancer
(Lashner, et al., Gastroenterol, 1988;19 (5 part 2); 1989; 49:127-131; Elsborg, Larsen. Scand J Gastroenterol. 14:1019-24, 1979; Hodges, et al. J AM Diet Assoc. 1984;84(1):52-58.)
Magnesium (Galland L. Magnesium 1988;7:78-83.)
• Selenium: Depletion is common in Crohn's and supplementation may be beneficial.
(Rannem T, et al. Am J Clin Nutr. 1992 Nov;56(5):933-937.)
Zinc picolinate (and Copper): 30-50 mg zinc per day; additionally supplementing with 2–4 mg of copper daily will balance out depleting effects of the zinc. Zinc deficiency is common in Crohn’s disease
(Sandstead HH. Nutr Rev 1982;40:109-112.)
Lactobacillus acidophilus re-establishes flora critical to healthy intestinal micro-ecology; dairy-free product preferrable for most.
(Bennet, Brinkman. Lancet Jan, 21, 1989.)
Saccharomyces boulardii, range from 250 mg three times daily to 500 mg taken four times daily, especially valuable for diarrhea due to Crohn’s disease.
(Plein K, Hotz J. Z Gastroenterol 1993;31:129-134; Bleichner G, et al. Intensive Care Med 1997;23:517-523.)
Essential Fatty Acids, particularly Omega-3 oils. 2-3 g EPA/DHA three times daily. The best food sources of EPA and DHA are salmon, herring, mackerel, albacore tuna, and sardines. Mate et al conducted a two-year study on the benefits of a diet containing 3.5-7 ounce of fish rich in omega-3 fatty acids and found a significantly lower rate of recurrence of Crohn’s in those eating fish regularly as compared to another group eating a diet low in such fish. Other research by Belluzzi et al indicates that an enteric-coated, “free fatty acid” form of EPA/DHA may be most effective when taking Omega-3 oils in supplemental form.
(Lorenz R, et al. J Intern Med Suppl 1989;225:225-232; Mate J, et al. Gastroenterology 1991;100:A228; Belluzzi A, et al. Dig Dis Sci 1994;39:2589-2594; Lorenz-Meyer H, Bauer P Nicolay C, et al. Scand J Gastroenterol 1996;31:778-785; Belluzzi A, et al. N Engl J Med 1996;334:1557-1560.)
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 fatty acids into arachidonic acid.
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.
(Mochizuki, et al. JEPN 1984;8:638-646.)
Note: many enteric formulas contain 35-50% fat.
Arginine: 3 g per day (Siefter, et al. Surgery 1978;84:224-230.)
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, et al. JPEN 9:608-17, 1985. Marz, 1997;380.)
Butyrate enema: can do a series. Can also take orally.
(Breuer R. Med World News December, 1991; Harig JM, et al. N Engl J Med 1989;320:23-28.)
Cod liver oil enema: can also do a series of these combining with butyrate
Glycyrrhiza (Licorice) has anti-fungal and anti-inflammatory activity
Lipase: May facilitate improved absorption, especially fat-soluble vitamins.
(Hegnhoj J, et al. Gut 1990;31:1076-1079.)
• Liquid chlorophyll
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, et al. Lancet 1986;1:207-208; JAMA 1979;242:1169; Lancet June 16, 1969: 1270.)
N-Acetylated glucosamino sugars: 800 mg three times daily, bipasses the rate limiting step in mucopolysaccharide synthesis by providing preformed N-acetylated glucosamines. (Burton AF, Anderson FH. Am J Gastroenterol. 1983 Jan;78(1):19-22.)
• Alfalfa tabs: rich in minerals
• Chlorella

» drug interaction:
Prednisone/prednisolone:
- causes Sodium retention
- causes reduced activation of Vitamin D; 1,25(OH)2D3 can be measured to determine if supplementation necessary, with low levels can use calcitriol
(Travato, 1991; 44:1651-1658; Tuttle, 1982;126:1161-1162)
- causes increased urinary excretion of Zinc, Vitamin K and Vitamin C
(Buist, 1984; 4 (3):114.)


footnotes

Belluzzi A, Brignola C, Campieri M, Pera A, Boschi S, Miglioli M. Effect of an enteric-coated fish-oil preparation on relapses in Crohn’s disease. N Engl J Med 1996;334:1557-1560.
Abstract: BACKGROUND: Patients with Crohn's disease may have periods of remission, interrupted by relapses. Because fish oil has antiinflammatory actions, it could reduce the frequency of relapses, but it is often poorly tolerated because of its unpleasant taste and gastrointestinal side effects. METHODS: We performed a one-year, double-blind, placebo-controlled study to investigate the effects of a new fish-oil preparation in the maintenance of remission in 78 patients with Crohn's disease who had a high risk of relapse. The patients received either nine fish-oil capsules containing a total of 2.7 g of n-3 fatty acids or nine placebo capsules daily. A special coating protected the capsules against gastric acidity for at least 30 minutes. RESULTS: Among the 39 patients in the fish-oil group, 11 (28 percent) had relapses, 4 dropped out because of diarrhea, and 1 withdrew for other reasons. In contrast, among the 39 patients in the placebo group, 27 (69 percent) had relapses, 1 dropped out because of diarrhea, and 1 withdrew for other reasons (difference in relapse rate, 41 percentage points; 95 percent confidence interval, 21 to 61; P < 0.001). After one year, 23 patients (59 percent) in the fish-oil group remained in remission, as compared with 10 (26 percent) in the placebo group (P = 0.003). Logistic-regression analysis indicated that only fish oil and not sex, age, previous surgery, duration of disease, or smoking status affected the likelihood of relapse (odds ratio for the placebo group as compared with the fish-oil group, 4.2; 95 percent confidence interval, 1.6 to 10.7). CONCLUSIONS: In patients with Crohn's disease in remission, a novel enteric-coated fish-oil preparation is effective in reducing the rate of relapse.

Belluzzi A, Brignola C, Campieri M, Camporesi EP, Gionchetti P, Rizzello F, Belloli C, De Simone G, Boschi S, Miglioli M, et al. Effects of new fish oil derivative on fatty acid phospholipid-membrane pattern in a group of Crohn's disease patients. Dig Dis Sci. 1994 Dec;39(12):2589-2594.
Abstract: Fish oil has been recently proposed as a possible effective treatment in inflammatory bowel disease (IBD); however, a lot of annoying side effects (ie, belching, halitosis, diarrhea, etc) affect patient compliance. We carried out a study of patient tolerance in a group of Crohn's disease (CD) patients with a new fish oil derivative consisting of 500-mg capsules of eicosapentaenoic-docosahexaenoic (EPA 40%-DHA 20%), a free fatty acid mixture (Purepa), and we also evaluated its incorporation into phospholipids, both in plasma and in red cell membranes. Five groups of 10 CD patients in remission received nine Purepa capsules daily in four different preparations (A: uncoated, B: coated, pH 5.5; C: coated, pH 5.5, 60 min time release; D: coated, pH 6.9) and 12 x 1-g capsules daily of a triglyceride preparation (Max-EPA, EPA 18%-DHA 10%), respectively. We coated three of the four Purepa preparations in order to delay the release of contents in an attempt to minimize the side effects. After six weeks of treatment, the group taking Purepa capsules, coated, pH 5.5, 60 min time release (group C) showed the best incorporation of EPA and DHA in red blood cell phospholipid membranes (EPA from 0.2 to 4.4%, DHA from 3.7 to 6.3%), and no side effects were registered, whereas in all other groups side effects were experienced in 50% or more of subjects. This new preparation will make it possible to treat patients for long periods.

Belluzzi A, Boschi S, Brignola C, Munarini A, Cariani G, Miglio F. Polyunsaturated fatty acids and inflammatory bowel disease. Am J Clin Nutr. 2000 Jan;71(1 Suppl):339S-42S. (Review)
Abstract: The rationale for supplementation with n-3 fatty acids to promote the health of the gastrointestinal tract lies in the antiinflammatory effects of these lipid compounds. The first evidence of the importance of dietary intake of n-3 polyunsaturated fatty acids was derived from epidemiologic observations of the low incidence of inflammatory bowel disease in Eskimos. The aim of this paper was to briefly review the literature on the use of n-3 fatty acids in inflammatory bowel disease (ulcerative colitis and Crohn disease), the results of which are controversial. The discrepancies between studies may reside in the different study designs used as well as in the various formulations and dosages used, some of which may lead to a high incidence of side effects. Choosing a formulation that lowers the incidence of side effects, selecting patients carefully, and paying strict attention to experimental design are critical when investigating further the therapeutic potential of these lipids in inflammatory bowel disease.

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.

Bleichner G, Blehaut H, Mentec H, Moyse D. Saccharomyces boulardii prevents diarrhea in critically ill tube-fed patients. A muticenter, randomized, double-blind placebo-controlled trial. Intensive Care Med. 1997 May;23(5):517-523.
Abstract: OBJECTIVE: To assess the preventive effect of Saccharomyces boulardii on diarrhea in critically ill tube-fed patients and to evaluate risk factors for diarrhea. DESIGN: Prospective, multicenter, randomized, double-blind placebo-controlled study. SETTING: Eleven intensive care units in teaching and general hospitals. PATIENTS: Critically ill patients whose need for enteral nutrition was expected to exceed 6 days. INTERVENTION: S. boulardii 500 mg four times a day versus placebo. MEASUREMENTS AND RESULTS: Diarrhea was defined by a semiquantitative score based on the volume and consistency of stools. A total of 128 patients were studied, 64 in each group. Treatment with S. boulardii reduced the mean percentage of days with diarrhea per feeding days from 18.9 to 14.2% [odds ratio (OR) = 0.67, 95% confidence interval (CI) = 0.50-0.90, P = 0.0069]. In the control group, nine risk factors were significantly associated with diarrhea: nonsterile administration of nutrients in open containers, previous suspension of oral feeding, malnutrition, hypoalbuminemia, sepsis syndrome, multiple organ failure, presence of an infection site, fever or hypothermia, and use of antibiotics. Five independent factors were associated with diarrhea in a multivariate analysis: fever or hypothermia, malnutrition, hypoalbuminemia, previous suspension of oral feeding, and presence of an infection site. After adjustment for these factors, the preventive effect of S. boulardii on diarrhea was even more significant (OR = 0.61, 95% CI = 0.44-0.84, P < 0.0023). CONCLUSIONS: S. boulardii prevents diarrhea in critically ill tube-fed patients, especially in patients with risk factors for diarrhea.

Brandes JW, Lorenz-Meyer H. Sugar free diet: a new perspective in the treatment of Crohn disease? Randomized, control study. Z Gastroneterol 1981;19:1-12.

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.

Burton AF, Anderson FH. Decreased incorporation of 14C-glucosamine relative to 3H-N-acetyl glucosamine in the intestinal mucosa of patients with inflammatory bowel disease. Am J Gastroenterol. 1983 Jan;78(1):19-22.
Abstract: The synthesis of glycoproteins was investigated in intestinal mucosa from patients with inflammatory bowel disease (IBD) and from those with various other conditions. The incorporation into acid-insoluble macromolecules of the amino sugar glucosamine, the first and committed metabolite in the biosynthetic sequence, and its immediate derivative, N-acetyl glucosamine was determined. Tissue was incubated with 1-2 nmol 14C-glucosamine and 3H-N-acetyl glucosamine and the simultaneous incorporation of both isotopes was measured. Bowel tissue from areas microscopically uninvolved in active disease process was examined. Values for the incorporation of both substrates into acid-soluble constituents were similar for both IBD and non-IBD groups, as was also the incorporation of 3H into acid-insoluble constituents. The incorporation of 14C, however, when expressed relative to that of 3H in each individual patient, i.e., 14C/3H, was distinctly different in IBD cases. In 26 non-IBD samples this ratio ranged from 0.04-0.26 with a mean of 0.097 +/- 0.009. In nine cases of Crohn's disease values ranged from 0.013-0.06 with a mean of 0.039 +/- 0.011 (p less than 0.01); in nine cases of ulcerative colitis values were 0.007-0.06 with a mean of 0.031 +/- 0.006 (p less than 0.01). It is concluded that the step involving the N-acetylation of the amino sugar is relatively deficient in patients with IBD and this could reduce the synthesis of the glycoprotein cover which protects the mucosa from damage by bowel contents.

D'Adamo P. Eat Right For Your Type. Putnam, NY, 1996.

Driscoll RH, Meredith SC, Sitrin M, Rosenberg IH. Vitamin D deficiency and bone disease in patients with Crohn’s disease. Gastroenterol 1982;83:1252-1258.

Dvorak AM. Vitamin A in Crohn’s disease. Lancet 1980;i:1303-1304. (Letter)

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.

Frieri, Claus, Boris, et al. Preliminary investigation on humoral and cellular immune responses to selected food proteins in patients with Crohns disease. Annals of Allergy 1990;64, 345-351.
Abstract: 11 Crohns patients were studied and 7 were revealed to have positive skin test to milk, wheat and soy protein. 5 of these had both allergic symptoms and Crohns disease and 4 had complaints of food allergy. 6 patients had elevated sIgG4 to several food proteins in spite of negative sIgE reactions. The antigen most frequently associated with elevated sIgG4 levels was egg protein and the highest sIgG4 levels to eggs and milk protein occurred in skin test negative patients.

Gaby AR. Commentary. Nutr Healing January 1998:1,10-11. (Review)

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.

Giaffer MH et al. Controlled trial comparing elemental and polymeric diet as primary therapy for active Crohns disease. Lancet 1990;1;816-819.
Abstract: 30 patients with active Crohns received either Vivonex (elemental diet) or Fortison, a polymeric (protein-containing) diet. 75% of the patients on the elemental diet improved significantly compared to 36% of the patients on the polymeric diet (p=0.03) after 10 and 28 day assessments.

Harig JM, et al. Treatment of diversion colitis with short-chain fatty acid irrigation. NEJM 1989;320:23-28.

Harris AD, Brown R, Heatley RV, et al. Vitamin D status in Crohn’s disease: association with nutrition and disease activity. Gut 1985;26:1197-1203.

Heaton KW, Thornton JR, Emmett PM. Treatment of Crohn’s disease with an unrefined-carbohydrate, fibre-rich diet. Brit Med J 1979;2(6193):764-766.

Hegnhoj J, Hansen CP, Rannem T, Sobirk H, Andersen LB, Andersen JR. Pancreatic function in Crohn's disease. Gut. 1990 Sep;31(9):1076-9.
Abstract: We investigated exocrine pancreatic function in a population of patients with Crohn's disease in order to correlate the pancreatic function with clinical and laboratory variables. A total of 143 patients affected by Crohn's disease and 115 control subjects were studied. All had a Lundh meal test. As a group patients with Crohn's disease had significantly decreased activity of both amylase (p less than 0.02) and lipase (p less than 0.001) in duodenal aspirates. In patients with Crohn's disease enzyme activities were not correlated to duration of disease or to extent or localisation of previous bowel resection. The lowest enzyme values were found in patients with the most extensive bowel involvement, and they were significantly lower (p less than 0.05) than in patients with disease confined to the terminal ileum. The differences between enzyme values in other subgroups of patients were not significant. For the patient group as a whole no correlation was found between disease activity and enzyme values, but for the most uniform group of patients, those with terminal ileitis, pancreatic function was significantly lower (p less than 0.05) in patients with moderate and severe disease compared with patients with mild disease. Thus at least two factors seem to be responsible for impaired pancreatic function in Crohn's disease: firstly disease activity and secondly localisation or extent of disease.

Hodges, et al. Vitamin and iron intake in patients with Crohns disease. J Am Diet Assoc. 1984;84(1):52-58.
Abstract: Mean daily intake of folate was below RDA for 23 male and 24 female patients. Serum folate was low in 21% of males and 26% females.

Imes S, Plinchbeck BR, Dinwoodie A, et al. Iron, folate, vitamin B-12, zinc, and copper status in out-patients with Crohn’s disease: effect of diet counseling. J Am Dietet Assoc 1987;87:928-930.

Immune complexes containing food proteins in normal and atopic subjects after oral challenge and effect of sodium cromoglycate on antigen absorption. Lancet 1969;June 16: 1270.

Jewell DP, Truelove SC. Circulating antibodies to cow's milk proteins in ulcerative colitis. Gut. 1972 Oct;13(10):796-801.
Abstract: IgG and IgM antibodies to cow's milk proteins were found to be increased in patients .

Jones VA, Dickinson RJ, Workman E, Wilson AJ, Freeman AH, Hunter JO. Crohn's disease: maintenance of remission by diet. Lancet. 1985 Jul 27;2(8448):177-180.
Abstract: 20 patients with active disease received either an unrefined carbo fiber-rich diet or a diet which excluded specific foods to which a patient was intolerant (via provocative testing). 7 of 10 patients on the exclusion diet remained in remission for 6 months compared with 0 of 10 on the unrefined diet. In an uncontrolled study, an exclusion diet allowed 51 of 77 patients to remain well on the diet alone for periods of up to 51 months, with an annual relapse rate of less than 10%.

Leichtmann GA, Bengoa JM, Bolt MJG, Sitrin MD. Intestinal absorption of cholecalciferol and 25-hydrocycholecalciferol in patients with both Crohn’s disease and intestinal resection. Am J Clin Nutr 1991;54:548-552.

Lorenz-Meyer H, Bauer P Nicolay C, et al. Omega-3 fatty acids and low carbohydrate diet for maintenance of remission in Crohn’s disease. A randomized controlled multicenter trial. Study Group Members (German Crohn’s Disease Study Group). Scand J Gastroenterol 1996;31:778-785.

Lorenz R, Weber PC, Szimnau P, et al. Supplementation with n-3 fatty acids from fish oil in chronic inflammatory bowel disease - a randomized, placebo-controlled, double-blind cross-over trial. J Intern Med Suppl 1989;225:225-232.

Mate J, Castanos R, Garcia-Samaniego J, Pajares JM. Does dietary fish oil maintain the remission of Crohn’s disease: a case control study. Gastroenterology 1991;100:A228. (Abstract)

Mayberry JF, Rhodes J. Epidemiological aspects of Crohn’s disease: A review of the literature. Gut 1984;886-899.

McDonald PJ, Fazio VW. What can Crohn’s patients eat? Eur J Clin Nutr 1988;42:703-708.

Mochizuki H, Trocki O, Dominioni L, Ray MB, Alexander JW. Optimal lipid content for enteral diets following thermal injury. JPEN J Parenter Enteral Nutr. 1984 Nov-Dec;8(6):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 R, James R, Smith H, Dudley CR, Jewell DP. Food intolerance and the irritable bowel syndrome. Gut. 1989 Aug;30(8):1099-1104.
Abstract: Two hundred patients (156 women) with the irritable bowel syndrome were treated with dietary exclusion for three weeks. Of the 189 who completed this study, 91 (48.2%) showed symptomatic improvement. Subsequent challenge with individual foods showed that 73 of these 91 responders were able to identify one or more food intolerances and 72 remained well on a modified diet during the follow up period (mean (SD), 14.7 (7.98) months). Of the 98 patients who showed no symptomatic improvement after three weeks of strict exclusion only three were symptomatically well at follow up (mean (SD), 12.48 (8.09 months). There was no close correlation between response and symptom complex. There was a wide range of food intolerance. The majority (50%) identified two to five foods which upset them (range 1-14). The foods most commonly incriminated were dairy products (40.7%) and grains (39.4%).

Nutrit Res Newsletter Oct., 1984.
Abstract: 10 patients were given 0.75 mg prednisone daily for 14 days, while 11 patients were given a protein free elemental diet. At the end of 4 weeks 8/10 steroid patients and 9/11 diet patients were in remission. At 3 months, one patient in each group was a treated failure.

O'Morain C, Segal AM, Levi AJ, Valman HB. Elemental diet in acute Crohn's disease. Arch Dis Child. 1983 Jan;58(1):44-47.
Abstract: 15 patients, aged 6-20, were followed for up to 3 years on a hypoallergenic elemental diet. The diet was associated with remissions in the 14 patients who tolerated it.

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 Feb;31(2):129-134.
Abstract: In a randomized, single-center, double-blind, placebo-controlled pilot study, 20 patients with established Crohn's disease suffering from diarrhea and moderate complaints as measured by the BEST Index, were treated with the yeast preparation Saccharomyces boulardii (S.b.) in a dosage of 250 mg t.i.d., initially for two weeks in addition to the basic treatment. A reduction in the frequency of bowel movements (5.0 +/- 1.4 vs. 4.1 +/- 2.3 evacuations/day, p < 0.01) and in the BEST Index (193 +/- 32 vs. 168 +/- 59, p < 0.05) as compared to baseline was registered. After this initial phase, the patients were allocated in randomized order to the control group (n = 7) receiving placebo, or to the verum group (n = 10) receiving S.b.(250 mg t.i.d.) for 7 weeks, while the basic treatment was maintained. The group treated with S.b. showed a significant reduction in the frequency of bowel movements in the tenth week, to 3.3 +/- 1.2 evacuations per day, and in the BEST Index, to 107 +/- 85. In the control group taking placebo, however, this effect was not observed. By contrast, the frequency of bowel movements and the BEST Index rose again in the tenth week until reaching initial values (4.6 +/- 1.9 evacuations daily and 180 +/- 61, respectively). No adverse drug events were observed. In order to confirm these positive effects of S.b. in patients with Crohn's disease, further controlled multicenter trials in a larger patient population should be performed.

Rannem T, Ladefoged K, Hylander E, Hegnhoj J, Jarnum S. Selenium status in patients with Crohn's disease. Am J Clin Nutr. 1992 Nov;56(5):933-937.
Abstract: Twenty-seven of 66 patients with Crohn's disease had reduced concentrations of selenium and glutathione peroxidase in plasma and erythrocytes. When the patients were subgrouped according to the length of resected small bowel, a significant reduction of selenium and glutathione peroxidase in both plasma and erythrocytes was only found in patients with a resection > 200 cm. A highly significant correlation between selenium and glutathione peroxidase was found in plasma (r = 0.81) as well as in erythrocytes (r = 0.62), but no correlation was observed in the control group. A statistically significant correlation was also found between plasma selenium and the Harvey-Bradshaw score (r = -0.44), body mass index (wt/ht2) (r = 0.47), and plasma albumin (r = 0.29). Patients with a small-bowel resection > 200 cm appear to be at risk of developing severe selenium deficiency. These patients should have their selenium status monitored and probably receive selenium supplementation.

Riordan AM, Hunter JO, Cowan RE, et al. Treatment of active Crohn’s disease by exclusion diet: East Anglian Multicentre Controlled Trial. Lancet 1993;342:1131-1134.

Sanderson IR, et al. Remission induced by an elemental diet in small bowel Crohns disease. Arch Dis Child 1987;62(2):123-127.
Abstract: 15 children with active Crohns randomly received either Flexical (elemental diet) or IM ACTH followed by oral prednisolone along with suphasalazine. The elemental diet proved to equally effective in improving the condition according to a series of evaluations, including growth (which was actually greater in the elemental diet) over the course of 6 months.

Sandstead HH. Zinc deficiency in Crohn’s disease. Nutr Rev 1982;40:109-112.

Shoda R, Masueda K, Yamato S, Umeda N. Epidemiologic analysis of Crohn’s disease in Japan: increased dietary intake of n-6 polyunsaturated fatty acids and animal protein relates to the increased incidence of Crohn’s disease in Japan. Am J Clin Nutr 1996;63:741-745.

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 J. Inflammatory bowel disease: another possible effect of the allergic diathesis. Ann Allergy. 1981 Aug;47(2):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.

Skogh M, Sundquist T, Tagesson C. Vitamin A in Crohn’s disease. Lancet 1980; i:766. (Letter)

Souba WW, Smith RJ, Wilmore DW. Glutamine metabolism by the intestinal tract. JPEN J Parenter Enteral Nutr. 1985 Sep-Oct;9(5):608-617. Review)

Stefanini GF, Bazzocchi G, Prati E, Lanfranchi GA, Gasbarrini G. Efficacy of oral disodium cromoglycate in patients with irritable bowel syndrome and positive skin prick tests to foods. Lancet. 1986 Jan 25;1(8474):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.

Teahon K, Bjarnason I, Pearson M, Levi AJ. Ten years' experience with an elemental diet in the management of Crohn's disease. Gut. 1990 Oct;31(10):1133-1137.
Abstract: 96 of 113 patients with acute Crohns disease who were treated with an elemental diet at Northwick Park Hospital in Harrow Middlesex, UK between 77 and 88. The elemental diet was found to be a safe and successful treatment for acute Crohns disease with remission rates comparable to those achieved with steroids.

Teahon K, Somasundaram S, Smith T, Menzies I, Bjarnason I. Assessing the site of increased intestinal permeability in coeliac and inflammatory bowel disease. Gut. 1996 Jun;38(6):864-869.

Use of cromolyn in combined GI allergy. JAMA 1979;242:1169.

Wantke F, Gotz M, Jarisch R. Lancet 1994;343:113. (Letter)

Wright JP, Mee AS, Parfitt A, Marks IN, Burns DG, Sherman M, Tigler-Wybrandi N, Isaacs S. Vitamin A therapy in patients with Crohn's disease. Gastroenterology. 1985 Feb;88(2):512-514.
Abstract: Vitamin A therapy has been claimed in isolated reports to be of benefit to patients with Crohn's disease. To investigate this further, 86 patients were entered into a long-term double-blind study of vitamin A, 50,000 U twice daily, as compared with placebo. After a mean of 14.1 mo of treatment there was no significant difference between the groups as measured by a variety of activity indices (including the National Cooperative Crohn's Disease Activity Index), the number of acute attacks, and the surgical rate. No toxic effects of vitamin A were observed during the study. In this study vitamin A has not been shown to be of benefit to patients with Crohn's disease who are in remission.

Wright, Truelove SC. 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.