The following are excerpts from the book "Essential Fatty Acids in Health and Disease" by Dr. Siguel.
Available from NUTREK, Inc., P.O. BOX 1269, Brookline, MA 02146-0022. $18.95 + $3.95 for S & H.
Blood testing for essential fatty acid (EFA) abnormalities is available from Boston University Medical Center, Dept. of Laboratory Medicine. Your physician may request a blood test and have the blood shipped by mail. Laboratories can request information from 617 638 8602 on how to send blood, or send a self addressed stamped envelope with postage for 4 ounces to EFALAB, P.O. BOX 1269, Brookline, MA 02146-0022.
Research by Dr. Siguel and Lerman, and by researchers at Brigham and Women's Hospital (presented at ASPEN, January, 1995) indicates that EFA abnormalities are quite prevalent in patients with IBD and short bowel syndrome. In the experience of Dr. Siguel, who does the fatty acid analysis, more than 90% of patients have EFA abnormalities, some quite severe. These abnormalities interfere with the ability of the bowel to self-heal, alter the immune function, and are probably a contributory factor to the systemic complications of IBD. Dr. Siguel proposes that EFA abnormalities are the most significant nutritional problem in IBD and short bowel syndrome.
These matters will be discussed later in a future Home Page under development. Likely location = EFAFOOD.COM.
Inflammatory Bowel Disease (Crohn's Disease and Ulcerative Colitis)
There are two major types of inflammatory bowel disease ("IBD"). Crohn's disease primarily affects the ileum, which is the terminal part of the small intestine. Ulcerative Colitis primarily attacks the large intestine. Both diseases cause damage to the cells that line the intestine. The damage makes it more difficult for the body to absorb food. Because the small intestine is one of the major organs involved in the absorption of EFAs and several vitamins (i.e., B12) and minerals, deficiencies of these vitamins, minerals, and EFAs are quite common in Crohn's patients. The diarrhea caused by the malabsorption of food carries with it other minerals and nutrients, often making the disease much worse. In Ulcerative Colitis, the body primarily loses water and a few minerals, but these losses upset the balance of nutrients in the body, and can lead to malabsorption problems in other parts of the intestinal system. Such malabsorption, coupled with increased demand for EFAs to repair the intestinal cells, results in deficiencies of EFAs in practically all patients. Besides increased losses and intestinal repair, the disease itself forces the rest of the body to use up more EFAs, thereby increasing the need for EFAs. It is common for patients with IBD to have wide fluctuations in their plasma EFA levels. Research has shown that EFA abnormalities contribute to the inflammatory process and further deterioration in IBD. My research is finding that EFA abnormalities are probably the most significant nutritional abnormality in Crohn's disease.
When patients with IBD are relatively well fed or receive intravenous lipids, their EFA status improves. When the disease becomes more active, their EFA status gets worse, which in turn causes further damage to the intestine and makes the disease even worse. Most patients have a large whole body deficiency (that is, not enough EFAs in their bodies) and it is difficult for them to eat enough EFAs by mouth to correct this deficiency. Treatment aims to prevent a rapid deterioration of the disease and prevent or correct many of the "systemic" complications (other severe problems that often affect patients with IBD).
Based on my clinical experience, I have concluded that Crohn's disease is caused by an infectious agent. Some physicians think it is a "psychiatric" disorder; others call it an "immune" disorder (even though we do not know what causes immune disorders and many may be caused by infectious agents). I believe it is an infectious disease which is not very contagious, but, nevertheless, is worth taking care to avoid contact with. People with Crohn's disease and their family members should pay particular attention to bathroom use, being certain it is kept as clean and sanitary as possible. However, because the microorganism is primarily in the intestine, together with millions of other organisms, infection is rare. Because there is not enough money for research and, in my opinion, much of the current nutritional and drug research is misguided, the cause of Crohn's disease has not been found. The infectious agent may be found to be somewhat similar to the one that causes tuberculosis. Whatever it is, it is very difficult to identify because the intestine contains too many bacteria.
Crohn's disease produces a severe inflammatory response that in part obstructs the intestine and interferes with the absorption of food. This obstruction causes severe intestinal cramps, particularly after eating regular foods. Traditionally, some physicians and medical textbooks have recommended a diet low in fiber, referred to as a "low residue" diet. I have not found such diets useful. Low residue diets made with whole foods require digestion and still contain significant residue that irritates the cells lining the intestine. The exceptions are specially formulated diets that require practically no digestion and are very easy to absorb (see below). Our research has developed new approaches that could help when used under medical supervision.
Inflammatory bowel diseases, such as Crohn's Disease and Ulcerative Colitis, and short bowel syndrome often caused by surgical removal of a portion of the bowel, have several symptoms and problems that can be classified into major categories:
Diarrhea, due to poor absorption of fat and some other food nutrients , as well as to poor absorption of water and other body secretions such as bile.
Inflammation, because the intestinal cells react to the disease and become inflamed. An inflammatory response often spreads to other parts of the body.
Partial Obstruction of the intestine which interferes with movement of food and causes severe pain. It also causes increased bacterial growth that produces gas and interferes with food absorption.
Malabsorption and malnutrition, because some but not all nutrients are poorly absorbed.
Diarrhea may improve with a diet high in fiber. Some leftovers from digestion, such as bile, produce diarrhea by irritating the intestine and acting as powerful laxatives. Some fibers, such as pectin and gum, may help to bind these food residues and reduce diarrhea.
Cholestyramine (sold under the name QUESTRANTM) has a similar effect when eaten 15 to 30 minutes before each fatty meal. Other types of fiber, such as cellulose, may prevent watery diarrhea by absorbing water in the colon. There are several bulk fiber chemicals that you can buy for similar purposes. A diet with a wide variety of vegetables and fruits, low in animal fat and high in fiber, may also prevent this type of diarrhea. However, caution must be taken if the intestine is obstructed.
Increased intestinal inflammation is the most important characteristic of IBD. It is difficult to detect with conventional blood tests. Many physicians order a wide range of tests to detect or monitor inflammation. Unfortunately, most of those tests are practically useless. If you feel sick, you are sick even if the test is "normal". If you are sick and the test is abnormal, there is little the physician can do that he could not do without the test results. If you feel great, and the test is abnormal, then you may not want to do anything because the test may either be in error or does not reflect your current well-being. In IBD the most important test of the activity of the disease is how you feel. The next most important tests are the nutritional tests that help you to decide how to specifically change your diet to correct nutritional deficiencies or excesses. A fatty acid profile such as the fatty acid profile EFA-SR is very important because it helps you to correct EFA abnormalities, prevent unusual clot formation (which is common in IBD, particularly in patients who require intravenous feeding), and helps your doctor to modify the inflammatory response. Because the balance of EFAs determines the nature and extent of the inflammatory response, your doctor may recommend that you eat more 3 in the form of EPA or linolenic acid, or more 6 in the form of linoleic or GLA, to drastically change the inflammatory response. This is one situation where EFA derivatives may be indicated and the fatty acid test EFA-SR should be repeated frequently. With frequent monitoring you can plan your optimal diet. Because the cost of frequent hospitalization is extraordinarily high, fatty acid analysis is highly cost-effective even if it only saves you a few days of hospitalization every year. IBD is a very expensive disease to treat, and treatment is rarely effective. Patients and doctors should aim to minimize and prevent complications by correcting nutritional abnormalities.
There is one test which I recommend for most patients with IBD: protein electrophoresis (see section II). This test is inexpensive and uses tiny amounts of blood. With modern technology and the aid of a highly trained specialist, this test measures a wide range of inflammatory proteins and other indicators of health status. Very few physicians are aware of the wide range of applications of this test.
A partial obstruction can get worse with a diet high in fiber. This effect is difficult to predict. However, a diet very low in fiber may actually produce a greater obstruction because when the intestine contracts, there is not enough food inside it to prevent the intestine from contracting so tightly that it obstructs itself. In fact, this is believed to lead to diverticulitis and other problems. Therefore, for each person there is a certain amount of fiber which will help to prevent the pain associated with obstruction and also decrease diarrhea, and a larger amount that will cause an obstruction. Only you can tell by trial and error, and the amount may vary according to the state of inflammation of your intestine.
A partial obstruction is caused by a combination of factors. With IBD, the skin-like tissue that lines the intestine becomes thicker and harder, and the intestine becomes narrow and less flexible. In addition, the cells become inflamed and swollen. Outside the intestine, and inside the abdomen, the intestine becomes twisted because of the force caused by food trying to get through. Twisting the intestine, like twisting a hose, causes a partial obstruction. In obstructed areas, water accumulates because it cannot move fast enough, and there is overgrowth of the bacteria which produce gas. Food cannot pass through quickly enough and keeps pushing against the wall of the intestine, causing pain. The pressure of the food causes the intestine to distend and touch other organs. In IBD, you will notice abdominal distention, an increased urge to urinate (because the bowel is pressing against the bladder), and leg and knee pain as the intestine presses against the sciatic nerve. Sometimes the only symptom of intestinal inflammation and partial obstruction is pain in the knee and diffused leg pain. Many physicians diagnose "arthritis" when the real problem is intestinal inflammation pressing against a nerve. A similar situation occurs with back pain. Severe back pain may indicate a large intestinal infection or inflammation. The treatment for intestinal inflammation consists of bowel rest (intravenous feeding or elemental diet) for several days to weeks until the inflammation subsides and antibiotics if the inflammation is severe. You may need a wide spectrum mixture of intravenous antibiotics, to prevent or treat a hidden abscess. There is a great danger in treating this "arthritis" with steroids, because many times the inflammation is associated with small abscesses. The inflammatory process used by the body to fight the abscess and prevent the bacteria from spreading to other parts of the body can be reduced by steroids. Using steroids could cause a small infection to propagate to other parts of the body.
In treating IBD, we suggest that you start with a small amount of fiber. Try that amount for several weeks. Increase it slowly. If it causes you more pain, then decrease it. Allow time for the body to adapt to it. Modify the fiber composition by trying different foods, ONE AT A TIME so that you can identify any specific food which is not good for you.
Inflammatory bowel disease, such as Crohn's disease, is characterized by diarrhea and malabsorption. Among the major nutrients, carbohydrates are the easiest to absorb, protein is next and fat is the most difficult to digest and absorb. Individuals with inflammatory bowel disease are prone to develop severe deficiency of essential fatty acids. Because fat usually increases diarrhea, the best diet is very low in fat supplemented with one to two tablespoons of a mixture of 3 and 6 oils, both precursors and derivatives.
Malnutrition is a complicated problem. It refers to having adequate body weight and adequate amounts of some nutrients, but having an imbalance in your nutrients. You may have normal or increased weight and look fine, and still be malnourished. To detect imbalances in protein, fat, minerals and vitamins one needs sophisticated blood and urine tests which require a specialist to interpret. Once the imbalance is determined, proper therapy is provided. Malnutrition manifests itself through subtle symptoms, such as muscle weakness, cramps, impaired vision or decreased mental abilities.
Most people with inflammatory bowel disease have nutritional deficiencies caused by poor absorption of some nutrients. (In contrast, most other Americans have nutritional excesses along with deficiencies.) They simply cannot absorb some nutrients. The most common deficiencies involve most vitamins and minerals, and can be corrected easily with oral supplements. Most of the common multivitamins are not appropriate because they do not have vitamins and minerals in the proportion these people need them. They often have too much Iodine and not enough calcium, potassium, B12, Folate and Biotin. In particular, deficiencies of magnesium are quite common and very difficult to correct.
Very thin people with malabsorption diseases need to eat more food because they are not getting enough calories. However, most people do get enough calories, but develop deficiencies of selected vitamins and minerals. Our studies have shown that the most common types of nutritional deficiencies in patients with malabsorption diseases are:
Be careful with supplements. This is not a do-it-yourself-job. If you eat the wrong mixture of supplements you can easily overdose on one. One easy mineral to overdose on is Iodine, which is easily absorbed and found in many foods, salt and vitamin supplements.
To correct existing EFA abnormalities and supply daily requirements, most patients with malabsorption disease would need to take between 1 and 3 tablespoons of oil per day. For some people, this is too much fat, and causes more diarrhea (which can be minimized using cholestyramine and eating 1/2 of the oil in the morning and the rest in small amounts). Do not expect quick results. It often takes years to correct severe EFA deficiency in IBD. People with coronary artery disease or abnormal cholesterol levels associated with excessive weight usually have enough EFAs. Their problem is too much saturated fat which interferes with the proper use of the EFAs. In IBD, most people are thin and do not have enough EFAs in their body. Because IBD patients have fat malabsorption, they cannot eat too much fat and therefore it takes a long time to correct EFA deficiency. Those who can eat and absorb large amounts of fat (i.e., 3 tablespoons per day), may gain quite a bit of weight and should reduce other sources of calories and increase exercise. In severe cases, intravenous feeding with fats is recommended to correct severe absolute (whole body) EFA deficiency (see chapter I.3).
Treatment of Crohn's disease
Treatment of Crohn's disease aims to correct the symptoms. Until we identify the organism that causes the disease, we will not be able to have antibiotics against it. Surgery is to be avoided as long as possible. Even the worst cases, where patients have intestinal fistulas or "holes," or abscesses and infections, can often be treated with total parenteral nutrition and bowel rest for several months, and also with intravenous antibiotics for 10 days followed by oral antibiotics if needed. The disease recurs after surgery practically every time, while the nutritional deficiencies caused by removal of the bowel remain forever.
Treatment should diagnose and correct nutritional abnormalities that are a major factor in premature death in Crohn's disease, as well as the cause of many other health problems. Successful treatment should relieve intestinal inflammation and obstruction, and reduce diarrhea. There is an approach for each one of these problems (which will be discussed at length in another book).
After many years of research, scientists now agree that the best treatment for Crohn's disease is "complete bowel rest," meaning that the bowel should not work digesting food. There are two "foods" available which I consider best for the treatment of Crohn's disease: VivonexTM and TolerexTM. These are powder formulas composed primarily of simple amino acids, small carbohydrates, vitamins and minerals. For this reason they are called "elemental diets" (meaning very simple in chemical composition). They require practically no digestion and are absorbed almost immediately, without requiring much involvement from the intestine. After a period of 2 to 4 weeks on this formula, practically all patients improve drastically. Their nutrition improves because the formula is nutritionally balanced and contains all essential vitamins, minerals and amino acids. (Unfortunately, the exceptions are EFAs; see below.) In addition, the intestinal inflammation subsides. An even better treatment would be exclusive intravenous feeding, known as Total Parenteral Nutrition. However, this treatment is expensive (as much as $30,000 per month), and dangerous because the intravenous lines can get obstructed or infected.
Most people cannot tolerate VivonexTM and TolerexTM by mouth. They must drink it using a tube inserted through the nose into the stomach. The tube is connected to a pump that feeds the solution continuously for 15 to 24 hours per day. Sometimes people drink it slowly with a straw all day long. Drinking it fast causes diarrhea.
To reduce diarrhea, I recommend the use of a product like "QuestranTM" or a similar resin. This type of product binds to bile (one of the substances made by the body which helps with digestion) and prevents it from reaching the large colon where it becomes an irritant that causes diarrhea. "QuestranTM" is also effective in lowering cholesterol (rarely a problem in patients with Crohn's disease) and has been shown to have very few side effects. I suggest you use 1/3 or more of the usual envelopes of "QuestranTM" about 10 minutes before you start to eat any meal that contains fat. You can also add one envelope of "QuestranTM" for each 3 envelopes of VivonexTM or TolerexTM.
Many times in Crohn's disease, the intestinal obstruction gets substantially worse, because of increased inflammation and/or because of "bacterial overgrowth". Bacterial overgrowth means that the bacteria which normally live in the intestine have grown too much. Once out of balance, they cause gas and other problems. There is also a high probability that small abscesses (sores with pus) or tiny infections develop within the intestine. My clinical experience has shown the best treatment to be significant doses of a mixture of antibiotics targeted to the common bacteria found in the intestine. Treatment for about 10 days resolves the problem. This matter must be discussed with your physicians because many doctors refuse to believe that antibiotics work in Crohn's disease, in part because they often use the wrong mixture of antibiotics.
The elemental diets given to Crohn's patients have practically no fat in them. This is done intentionally to facilitate absorption and prevent complications. Because many people must drink the elemental diet with a tube while they are sleeping, it is important that the food leave the stomach very promptly. Otherwise there is danger that it could be regurgitated and enter the lungs. Fat slows the digestion process and increases the time that a food spends in the stomach.
Because elemental diets contain practically no EFAs, and usually zero -3s, you must supplement your diet with soybean oil. Because patients with Crohn's disease develop severe EFA deficiencies, they must be monitored regularly and eat as much oil as they can tolerate. If possible, I suggest two tablespoons per day of soybean oil, one first thing in the morning and one late in the afternoon. Take the oil at least 2 hours before going to bed to prevent food from staying in the stomach too long and regurgitating into the lungs. In the morning the body may produce the largest amount of bile and this could make it the easiest time to absorb the EFAs. Always precede a dose of oil with about 1/3 envelope of QuestranTM. If oral EFAs are not enough, a patient may need to receive periodic Intravenouos lipids.
Many patients will find that a diet very low in fat along with EFA supplements is best for them. Very low, particularly zero fat foods are easy to digest and minimize diarrhea. Oils high in EFAs provide the required essential fats with a minimum of fat intake. Vegetables often decrease diarrhea, but you must be careful not to eat too many vegetables at a time if you have a partial intestinal obstruction. Vegetables are high in fiber and indigestible matter that can worsen an obstruction. If you develop the symptoms of a complete obstruction, which include feelings of nausea, vomiting, and severe, continuous abdominal cramps that seem to occur in cycles (on for a few minutes, off, and then on again), you should be seen immediately by a physician. The on-off-on pain cycle occurs as the intestine tries to push the food through the obstruction.
Short bowel syndrome
Some people have "short bowel syndrome,", meaning that their bowel (intestine) is shorter than normal. Quite often this occurs as a result of an accident or a disease. For example, a person may have had a cancer that required removal of part of the intestine. Or s/he was involved in an accident or shooting which caused him/her to lose part of the intestine. The nutritional deficiencies in short bowel syndrome resemble those of patients with Crohn's disease or Ulcerative Colitis. The type and extent of the deficiency depends on how much of the intestine is missing. Fortunately, the remaining parts of the intestine are not diseased in these patients; consequently, they rarely suffer from obstructions or massive malabsorption in the remaining parts. On the other hand, some patients have lost huge sections of the intestine and have similar symptoms and deficiencies as patients with severe Crohn's disease. In other words, they appear to have severely dysfunctional intestines.
Cystic Fibrosis (CF)
The nutritional problems pertaining to EFA abnormalities in cystic fibrosis (CF) are similar to those in Crohn's disease. "The basic defect in cystic fibrosis increases the metabolism of EFAs and thereby gradually gives rise to EFA deficiency, which is a well documented finding in most cases with this disease." EFA abnormalities and their metabolic products, i.e., different eicosanoids, and EFA deficiency ". . .will cause gastrointestinal symptoms and the sequence of this development will mirror the natural history of the disease". Often, a decrease in total fat, and probably EFA abnormalities, are the first detectable signs of the deterioration characteristic of cystic fibrosis. There is evidence that in CF there is an impairment in the conversion of EFA precursors to their derivatives, as well as biochemical evidence of EFA deficiency. It is recommended ". . .that close monitoring of plasma EFAs be carried out in CF, because of the high incidence of EFA deficiency despite efforts to improve and liberalize fat intake." These authors recommend the analyses of plasma for the detection of EFA abnormalities and cite my research to describe their findings. The authors suggest that correction of EFA abnormalities will assist with easier ". . .control of chest infections, marginally better respiratory function, and perhaps extended survival." These results, together with those of numerous other published articles, provide compelling evidence that the treatment of CF prior to 1994 has ignored fundamental effects of EFA abnormalities on CF.
Correction of EFA abnormalities may require large amounts of oil and could take years unless intravenous lipids are used. Intravenous lipids may be required because of fat malabsorption. These issues also occur in Crohn's disease.
Case study: Cystic Fibrosis and Crohn's disease with EFA Deficiency
35 year old woman with Crohn's disease for over 5 years, partial intestinal resection. She has elevated 20:39 /20:46 (See chapter I.3), and significantly decreased levels of EFAs and derivatives. Both the percent and the absolute quantities of EFAs are decreased, a condition we call Absolute EFA Insufficiency. The purpose of therapy is to achieve normal results as measured by the fatty acid test EFA-SR. Because EFAs are essential for the intestine to repair itself and make more cells, correcting abnormalities of EFAs will minimize complications of the disease and increase bowel healing.
Recommended treatment: Oral soybean oil supplements (15-30 ml/day) plus 200 I.U. Vit. E/day, plus cholestyramine to minimize diarrhea. (Large vitamin E doses are needed due to malabsorption.) A repeat of the fatty acid profile after three months found that EFA levels increased significantly and derivatives were formed. Although there was a marked increase in the percent of PUFAs, due to the severe extent of the deficiency, the patient was still very deficient. We estimated that it would take many years to correct the deficiency using only oral supplements. The patient was then hospitalized for one week to receive a "loading" dose of EFAs with intravenous lipids and extra supplements of trace minerals, vitamins and other minerals. Now at home, she continues on a diet which includes a mixture of regular foods, an elemental diet, and EFA oral supplements. Repeated analyses have shown significant normalization of the fatty acid profile EFA-SR: The 3s have returned to normal but 6s are still deficient. Her oral dose of oils was then changed to 1/2 safflower and 1/2 soybean mixture, to increase the 6/3 ratio.
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