On Malabsorption

This post is the second in a series of posts on vitamin supplementation for people with IBD. See my first post here. I do tend to sprinkle other topics in between posts in a series. This is mainly because I can’t stand to write on any one topic too many days in a row. I need variety. What can I say, Google has shaped my mind. So, without further adieu…

There is a lot out there on malabsorption. My job in this series is to distill it down to the essentials for those with IBD—what do I need to know? View this series as an executive summary on on vitamin supplementation for IBD, this post being the executive summary for malabsorption.

The term malabsorption covers more than 25 diseases and syndromes; I’ve focused here on IBD.

The most common cause(s) of malabsorption is inflammation or lesions of the intestinal mucosa. This inflammation breaks down the mucosal wall, decreasing the gut’s ability to digest and absorb nutrients. Diarrhea associated with IBD also increases transit times, which decreases absorption.

Think of it this way: Your gut is like an energy capture processing center—take food in, use it as efficiently as possible, spit out the waste. With diarrhea, the machinery is moving too quickly. With inflammation, the machinery itself isn’t functioning properly. So your plant is operating at partial capacity.

In the name of making this post as readable and usable as possible, I’m going to rely on bullet lists—remember, executive summary.

Common Symptoms of Malabsorption:

Higher stool volume (because your processing center is working at partial capacity)*

Cramping and abdominal pain, esp. before a bowel movement

Bloating and gas**

Weight loss

Diarrhea

*A normal stool mass averages 100-200 grams per day in an adult. (What is normal?)

**Gas and bloating occur mainly because the flora in the large intestine ferment (feed on) the undigested matter, typically carbohydrates (these leftovers are what the SCD tries to decrease). One product of this fermentation is gas. This is why it is so dangerous for folks with active diarrhea due to IBD to take Imodium. With decreased motility, gas builds up in the large intestine, and puts pressure on the intestinal wall, drastically increasing your chances for toxic megacolon—For more on this, see my post on Imodium.

Below I list some common deficiencies from malabsorption along with (in parentheses) some common symptoms of them. I will go into greater detail on each deficiency as we progress through this series on vitamins. Remember, the goal is to build the case for vitamin supplementation, and to provide the basic tools for choosing a supplement regimen that is right for you and works with your stage of healing IBD.

Common deficiencies associated with Malabsorption (and some frequent symptoms):

Note:   Neither the list nor the parenthetical symptoms are exhaustive. I’ve just hit the major deficiencies and a few of the common symptoms associated with that particular deficiency. These deficiencies are usually more prominent in those with inflammation of the small bowel, as most absorption occurs in the small intestine.

Iron (anemia, lethargy, etc.)

Zinc (loss of taste)

Folate (abnormal red blood cell growth…)

Vitamin B12***

Vitamin B6***

Vitamin A (night blindness, dermatitis)

Protien Calorie Malnutrition

Calcium (bone loss, muscle cramps, heart rhythm irregularities)

Vitamin D (works in synergy with calcium)

Fat malabsorption (soapy stool, vitamin A, D, E deficiency)

Protien (adema of lower extremities)

Vitamin K (blood thinning, increased healing time)

Potassium (affects neuromuscular conductivity…potassium is involved in just about every physiological process you can think of, and some you can’t.)

***Vitamin B deficiencies can alter nerve cell function, and can cause peripheral neuropathy. Both vitamin B6 and B12, and folate deficiencies can accelerate arteriosclerosis (inflammation of the arterial walls (read: heart attack)). B12 deficiency can be one of the first to appear as uptake in the ileum is frustrated by inflammation.

Why can’t I get what I need from a healthy diet, like the SCD?

I went into some of this in my first post.

Dr. Bill Misner, PhD writes about athletes (who typically have a better diet than the average American), [Healthy] “athletes today ingest only 11% of the organic nutrients from their food sources that the athletes of the 1940’s enjoyed.” This is largely due to soil depletion, and modern farming practices such as green harvesting.

Bruce Ames, professor of biochemistry and molecular biology at the University of California, Berkeley, implies that micronutrient deficiency may eventually deteriorate the quality of whole human cell health.

Inadequate dietary intakes of vitamins and minerals are widespread, most likely due to excessive consumption of energy-rich, micronutrient-poor, refined food. Inadequate intakes may result in chronic metabolic disruption, including mitochondrial decay. Deficiencies in many micronutrients cause DNA damage, such as chromosome breaks, in cultured human cells or in vivo. Some of these deficiencies also cause mitochondrial decay with oxidant leakage and cellular aging and are associated with late onset diseases such as cancer.¹

Also remember, your processing center is not functioning properly. The SCD is perfectly nutritious, and in theory, you should indeed be able to get what you need from the food in the SCD. However, with a damaged gut, and if you are on medication, your chances of deficiencies are high. In this series, we’ll look at the major categories of vitamins, some of the causes for specific deficiencies, and what levels of supplementation is recommended for those with IBD.

Onward to Health.

¹REFERENCE: Ames BN, Low micronutrient intake may accelerate the degenerative diseases of aging through allocation of scarce micronutrients by triage, Proc Natl Acad Sci USA, 2006; 103 (47): 17589-94. (Address: Nutrition and Metabolism Center, Children's Hospital of Oakland Research Institute, Oakland, CA 94609, USA). www.ncbi.nlm.nih.gov/pubmed/17101959?dopt=AbstractPlus

Short-shorts: The Gut-Brain Connection, Bugs, and Skinny Diabetics

I read a lot. I read poetry, fiction, non-fiction, research, whatever--And I'll read anything that pertains to Crohn's, Colitis, and the remediation of.

Every so often I come across a series of articles, or read something that I really just want to share in its entirety. That's how I use short-shorts; they're for conveying interesting reading that I thought might help someone, somewhere, somehow.

Mostly though, I just found these interesting, and needed an outlet for my inner geek.

Which has more neurotransmitters, the gut or the brain?

The role of Clostridium Difficile in colitis.

Phenols and Salicylates and the SCD.

For those on the SCD, or considering the SCD, read through pecanbread.com. I wish someone would have told me about their writing on how to succeed on the SCD. It would have saved me lots of mistakes; many of which likely prolonged my symptoms. Browse all the links at the top.

And for oodles of fun, from one of my favorite blogs, The Healthy Skeptic, read about Skinny People and Type 2 Diabetes.

Onward to Health.

Eat your Broccoli!

I got this link from Paul Stocker at eatingscd.com.--Research suggesting that supplementing diets with fibers from broccoli and plantains (plantains are not SCD-legal, but broccoli is SCD-legal) might prevent relapse of Crohn’s disease

Turns out my mom was right. I should have eaten my broccoli. Darn.

Onward to health.

Short-shorts: Imodium (Loperamide) and IBD

Cartoon: www.erstories.net

Imodium (also here) is a popular and (for most) safe drug for relieving symptoms of diarrhea. For people (like me), with IBD, it is not safe. Loperamide slows peristalsis, the natural muscular contractions of the intestine. Peristalsis, this rhythmic movement of the intestine, is what keeps food and waste moving through your gut. Slow down gut motility in people with inflammation, and you can get gas (and fluid, but gas is the biggest problem of the two) build up.

So what? I retain a little gas; at least I’m not running to the bathroom as much. What’s the big deal?

The big deal about the gas (and fluid) build up is that it essentially gets trapped and creates pressure on the already damaged intestinal wall. This increases your risk for toxic megacolon (or here), and resulting sepsis. Toxic megacolon can develop quickly (less than a day), and if it’s not treated immediately (surgery), it will kill you—so don’t mess with it.

When I researched this topic, I found a surprising majority of sites advocating the (responsible?) use of loperamide with IBD. Don't do it. Some people take Imodium under the direction of their doctor. Knowing what I know about the risks, if my doctor told me to take Imodium, I’d have serious questions for him/her.

So, what do I do about all this D, smart guy?

There are natural treatments for diarrhea. See my post on natural diarrheal remedies. Remember, the idea is to get rid of the entire disease, to heal the root problem, not mask the symptoms. Until you take care of the problem, some diarrhea will be a fact of life for those of us with IBD.

Onward to Health.

Tumor Necrosis Factor (TNF) and Natural TNF Inhibitors for IBD Treatment

OK, so if you are on one of these biological treatment agents mentioned below, please don't take this post personally. I don't mean to degrade people who take the drugs, rather to question the use of them given the price (in dollars, and in health) and all we don't know.

Depending on the level of severity of your IBD, allopathic doctors may make use of steroids such as prednisone, azathioprine (Imuran), methotrexate, or 6-mercaptopurine, or a form of mesalamine. TNF inhibitors are typically recommended when all of the above fail.

What is Tumor Necrosis Factor (TNF)?
TNF is a cytokine (chemical means of cellular communication) produced by your immune system that helps regulate immune cells. It helps induce inflammation, inhibit tumor growth, and keeps viruses from reproducing in your body (and more!)--All good things.

Why should I care?
People with Crohn's and Colitis have been shown to have increased blood levels of TNF-alpha (don't get stuck on the names). So what? So...maybe increased levels of TNF in our blood are causing excess inflammation in our guts. The theory goes, "Decrease TNF levels, decrease inflammation in the gut." A little simple for you? Yea, me too. It turns out that other drugs designed to block TNF-alpha have not worked, and some have even been worse than the placebo in studies. Oops. Must be more complicated than that. Newer drugs are focusing higher up on the immune chain with, for example, activated T-cells.

Allopathic Anti-TNF Treatments:
This theory has led to a suite of biological treatment agents for Crohn's and Colitis (among other inflammatory conditions). These treatments target specific parts of the immune system (in this case, TNF) to decrease inflammation. These drugs (such as Infliximab) have been successful at mitigating symptoms for those with moderate-to severe Crohn's, and has also shown efficacy in Colitis, though not as much as in Crohn's.

What's the Problem with these Biological Treatments? There are several:
1. Depending on your dose, Infliximab can cost you between $19,000 and $22,000 per year. Luckily it's usually covered under major medical insurance! But what if you have a lifetime spending cap on your insurance? Start treatments at 25 years old, live to 75, and you've spent $1.1 million on this one treatment alone. Hope you don't get cancer, or have a child who needs long-term care. Also hope you don't have to change insurance companies...ever (pre-existing condition, anyone?)

2. All of these drugs work to disrupt the immune system. While I understand that IBD is seen in the medical community as an autoimmune disease, we don't understand the full implications of disrupting the immune system over the long-haul. It's just too complex. I take that back, we do know one major implication: If you take these drugs, your immune system will not function the way it was designed. The medical counter-argument is that it's already malfunctioning. Maybe, maybe not. Since we don't know the etiology of IBD, maybe our immune system is doing what it's supposed to do, and if we find the causative agent (such as a bacteria or yeast) we can return things to normal.

3. People who take Infliximab have a much higher risk of cancer (aren't we at a high enough risk already?), and people with background exposure to, for example, TB have actually been infected by TB after starting the drug.

***By tying the hands of our immune system we open ourselves to myriad other health problems. Given the high cancer risk of people (like me) with IBD, shouldn't we want to have an immune system that is able to fight off cancer, virus, bacteria, and other nasties? Have doctors (and patients) appropriately weighed the costs and benefits of prolonged immune suppression for IBD? With all we don't know about the immune system and suppressing it in very specific ways, can we accurately assess them? Are the benefits of (potentially) reducing inflammation (for an unspecified amount of time) worth reducing our body's defenses against, cancer, TB, flu, viruses, food poisoning, etc?

4. Since your body produces antibodies to them, drugs like Infliximab can produce such violent anaphylactic reactions as to endanger your life.

The Natural Response to IBD:
There are a suite of natural treatments for IBD out there (I may someday outline them in one post or a series of posts). It may be true that the only thing that can help you is a TNF inhibitor, but doctors fail in calling TNF inhibition a last resort when they haven't tried or are unwilling to try effective natural treatments such as probiotic therapy, antibiotics (there are natural antibiotics and anti-fungals you can use), and changes in diet first. These treatments are gentle, without side effects, and they cost oodles less than $22,000 per year.  Most doctors are sincere, wonderful people who have dedicated their life to helping people. Doctors, however, are required to practice 'within the standards of the community', so if natural treatments are not the standard of the community it makes it difficult for doctors to (1) find respected, professional training to learn about natural or non-conventional treatments, and (2) it makes it hard for them to be respected in their community if they go off the radar, so to speak.

With that said, there are some natural anti-TNF compounds you can try.

Natural Anti-TNF Compounds:
There is recent, promising research that TNF or the effects of TNF can be inhibited by a number of natural compounds, including curcumin (a compound present in turmeric), and catechins (in green tea). I've included references (in lieu of links) below. I actually take both, curicumin (500-1000mg/day) and catechins in the form of green tea extract (300-600mg/day, catechins).

These natural TNF inhibition agents will not be as strong or as targeted as Infliximab, but they are found whole in our natural food chain, which gives me rest. Combine these with probiotic treatment and the Specific Carbohydrate Diet, and I think you've got a good natural treatment protocol started.

If you are someone who likes to follow the references, start with the Gulcubuk and the Lantz papers.

References for Natural Anti-TNF Compounds:
Siddiqui AM, Cui X, Wu R, et al. (July 2006). "The anti-inflammatory effect of curcumin in an experimental model of sepsis is mediated by up-regulation of peroxisome proliferator-activated receptor-gamma". Crit. Care Med. 34 (7): 1874–82. doi:10.1097/01.CCM.0000221921.71300.BF. PMID 16715036.

Okunieff P, Xu J, Hu D, et al. (July 2006). "Curcumin protects against radiation-induced acute and chronic cutaneous toxicity in mice and decreases mRNA expression of inflammatory and fibrogenic cytokines". Int. J. Radiat. Oncol. Biol. Phys. 65 (3): 890–8. doi:10.1016/j.ijrobp.2006.03.025. PMID 16751071.

Gulcubuk A, Altunatmaz K, Sonmez K, et al. (February 2006). "Effects of curcumin on tumour necrosis factor-alpha and interleukin-6 in the late phase of experimental acute pancreatitis". J Vet Med a Physiol Pathol Clin Med 53 (1): 49–54. doi:10.1111/j.1439-0442.2006.00786.x. PMID 16411910.

Lantz RC, Chen GJ, Solyom AM, Jolad SD, Timmermann BN (June 2005). "The effect of turmeric extracts on inflammatory mediator production". Phytomedicine 12 (6-7): 445–52. doi:10.1016/j.phymed.2003.12.011. PMID 16008121.