November 28, 2017 at 10:11 am #1256Debbie LewisParticipant
Idiopathic T1 diabetes – no islet cell destruction, no antibodies
Inflammatory bowel disease
Eosinophilic gastrointestinal disease
Allergic duodenitis of uncertain aetiology
Father African Mother Caucasian
Novorapid Insulin 15-20 units p/d
Levemir 9 units p/d
Nalcrom/ sodium cromoglycate
Breastfed for 2.5 years
++ febrile convulsions
blood in stools, increase in drinking, diagnose T1 diabetic (no islet cell destruction), ++ weight loss
Following diabetes diagnosis he has had ongoing digestive issues which were managed through diet (dairy/g/f diet, no soy, well cooked vegetables etc.). Tried number of supplements over extended periods – probiotics, aloe vera, psyllium husk, FOS, fish oil, sach boul with some success but ongoing underlying issues.
came to clinic after 6 months of daily diarrhoea, stomach ache, fatigue, poor appetite and ongoing headaches.
Severe problems with motion sickness and car travel which can last for several days after journey.
All beneficial bacteria 4+
Commensal – 4+ alpha & gamma strep
Dysbiosis – none
Yeast – none
Parasites – none
Lactoferrin 942 <7.3
Calprotectin 579 <50
Lysozyme 2450 <600
White blood cells – few
SIgA 178 51-204
Pancreatic function, SCFAs – normal
Vit D 124 >50
Negative coeliac screen
WCC 11 4.5-13
CRP 3 <5
ESR 10 <10
Intervention – May 2017
Digestive enzymes, glutamine, Biocidin Advanced Formula Liquid (Potent Broad-Spectrum Botanical Combination), fish oil and probiotic.
FODMAP diet 6 weeks with reduced grains and legumes, focused on slow cooked meats, bone broth, fermented vegetables. Fish oil and multi vitamin & turmeric gave pain and stomach ache.
Moved diet towards SCD – some improvement in energy but continuing diarrhoea, bloating and nausea.
September 2017 – endoscope and colonoscopy. H-pylori negative
Diagnosis of ulcerative colitis, elevated eosinophils in GI tract, increased duodenal intraepithelial lymphocytes but negative tTG. Consultant recommended gluten free diet (which he has been on for 5 years) and potentially Humira injections if further progress is not seen in lowering inflammation.
Recent review in clinic – daily diarrhoea or constipation, ongoing fatigue and stomach ache, nausea, burping.
Family have tried to maintain SCD – except for g/f school lunches.
Discussed SIBO test but consultant not willing and difficult to do at home due to fasting period.
I am concerned that the fast transit time is leading to deficiencies despite the diet changes the family have made. They have tried many supplements to assist with this in the past with little long term affect and ongoing levels of inflammation.
His HbA1C is high and the family have tried a pump but the child is not happy to have it.
I am wondering whether there is a missing component to address around the immune issues/diabetes/gut which need considering. Whether prioritising stabilising blood sugars with a low carb diet is a priority and what supplements may be appropriate given the number the child has taken and palatability. I am considering whether smoothies with powdered nutrients may be more appropriate.
The child is currently feeling very fed up with intervention, supplements and dietary restrictions.
Posted By Debbie Lewis 28/11/17
March 18, 2019 at 10:16 am #1257Carrie Decker, NDModerator
Thank you for contributing this case here. It will be seen, likely soon, if the new medications Nalcrom (sodium cromoglicate) and Salofalk (mesalamine) are helpful for this young man, as from his comprehensive stool analysis it looks very much like he is in an active phase of inflammation, typical of active inflammatory bowel disease (IBD).
Balancing blood sugar definitely is important, particularly for long term health in the type 1 diabetic. Given the poor absorption of nutrients, chromium is one mineral to definitely consider as a minimal support for blood sugar balance. Two different liquid formats available, which might be more tolerated by this young man, are detailed in the suggestions. At this point, with some of his labile symptoms and being already on insulin, the only other primary intervention directed at blood sugar (aside from reducing carbohydrate intake in the diet) would be for his paediatric endocrinologist to work with the family and this young man on refining his insulin dosing regimen. It is likely that a longer acting insulin to help support a more controlled basal glucose is in order.
Anderson RA. Chromium in the prevention and control of diabetes. Diabetes Metab. 2000 Feb;26(1):22-7. https://tinyurl.com/yd4xjdrr
That said, other interventions which help to address the inflammatory state in his gut as well may have a positive impact on his glucose control. Blood sugar can be very labile in individuals who experience infections and inflammation, as both are stressors on the body.
In a fairly large group of patients with IBD, a number of patients had tried a gluten-free diet (GFD) and a significant amount found improvements with this dietary change. 65.6% of all patients who tried a GFD had some improvement of their symptoms and 38.3% reported fewer or less severe IBD flares. There also are studies showing that a high-carbohydrate/refined sugar diet has detrimental effects on individuals with a high activity of Crohn’s disease. The combination of these findings is what often leads patients with IBD to select a gluten-free, low-carbohydrate diet such as the Specific Carbohydrate Diet or an Autoimmune Paleo Diet.
Herfarth HH, et al. Prevalence of a gluten-free diet and improvement of clinical symptoms in patients with inflammatory bowel diseases. Inflamm Bowel Dis. 2014 Jul;20(7):1194-7. http://tinyurl.com/kjqks5p
Brandes JW, et al. [Sugar free diet: a new perspective in the treatment of Crohn disease? Randomized, control study]. Z Gastroenterol. 1981 Jan;19(1):1-12. http://tinyurl.com/jo8oysd
Given the eosinophilic related inflammation and absence of pathogens found on the CDSA, it would be worthwhile to consider the possibility of allergies, food sensitivities, histamine intolerance, and mast cell activation syndrome. Many of these things can be related, and it may be an overlapping issue. A recent review of the success of dietary interventions for eosinophilic esophagitis found that of the dietary interventions that many tried, the removal of cow’s milk, wheat, egg, and soy led to remission of more than 60% of the children. Although his diet has been restricted to avoid many of these things, I don’t see a distinct period in which eggs were also removed so this would be something to consider.
Kagalwalla AF, et al. Efficacy of a 4-Food Elimination Diet for Children With Eosinophilic Esophagitis. Clin Gastroenterol Hepatol. 2017 Nov;15(11):1698-1707. https://tinyurl.com/ycs6okjq
There are various supplements which can be helpful to help balance out the Th1:T2 imbalance, reducing histamine, as well as stabilizing mast cells. Although it may be a problem in part due to diminished histamine breakdown, particularly in the small intestinal brush border where the diamine oxidase (DAO) enzyme is present, there also may be systemic issues with histamine, particularly given the eosinophilic and allergic diagnosis. Headaches, nausea, diarrhoea, and sensitivity to motion all may be related to excess histamine.
Manzotti G, et al. Serum diamine oxidase activity in patients with histamine intolerance. Int J Immunopathol Pharmacol. 2016 Mar;29(1):105-11. http://tinyurl.com/gqx5acg
Whenever there is damage to the intestinal mucosa, DAO levels are potentially reduced; thus, following a diet in which histamine intake from foods is minimized may be of benefit for a period of time. This includes aged and fermented products, as histamine levels increase with these processes. Vitamin B6, vitamin C, magnesium and copper are cofactors necessary for the proper function of DAO, while many of the other B vitamins, vitamin C, and magnesium are necessary for histamine breakdown by the primary enzyme via which it is metabolised, histamine methyl transferase (HMT). Methylation support (S-adenosyl methionine (SAMe), trimethylglycine, or methylated forms of B12 and folate) also may be necessary for individuals with genetic variants of genes associated with methylation.
Some things which support reduction of histamine are quercetin and other flavonoids, vitamin C, and bromelain. Quercetin helps to reduce allergic response, stabilising mast cells in the body, and improving intestinal permeability. Vitamin C, as was mentioned, also supports the breakdown of histamine in addition to other anti-allergic effects. As zinc deficiency can contribute to an imbalance in the Th1 to Th2 response, favouring allergy, it also should be considered given the likelihood of dietary deficiencies. Diindolylmethane (DIM) also can be helpful, as it has been shown to induce a regulatory T cell response, reducing the Th2 allergic response.
Lee EJ, et al. Quercetin and kaempferol suppress immunoglobulin E-mediated allergic inflammation in RBL-2H3 and Caco-2 cells. Inflamm Res, Oct 2010; 59(10): 847-54. http://tinyurl.com/o4a6ztp
Pearce FL, et al. Mucosal mast cells. III. Effect of quercetin and other flavonoids on antigen-induced histamine secretion from rat intestinal mast cells. J Allergy Clin Immunol. 1984 Jun;73(6):819-23. http://tinyurl.com/pvuj9z6
Shaik YB, et al. Role of quercetin (a natural herbal compound) in allergy and inflammation. J Biol Regul Homeost Agents, Jul 2006; 20(3-4): 47-52. http://tinyurl.com/puakgfx
Suzuki T, Hara H. Quercetin enhances intestinal barrier function through the assembly of zonula [corrected] occludens-2, occludin, and claudin-1 and the expression of claudin-4 in Caco-2 cells. J Nutr. 2009 May;139(5):965-74. https://tinyurl.com/ycdnp2sx
Johnston CS. The antihistamine action of ascorbic acid. Subcell Biochem. 1996;25:189-213. http://tinyurl.com/ztscr8r
Chang HH, et al. High dose vitamin C supplementation increases the Th1/Th2 cytokine secretion ratio, but decreases eosinophilic infiltration in bronchoalveolar lavage fluid of ovalbumin-sensitized and challenged mice. J Agric Food Chem. 2009 Nov 11;57(21):10471-6. https://tinyurl.com/y94e6s55
Huang Z, et al. 3,3′-Diindolylmethane alleviates oxazolone-induced colitis through Th2/Th17 suppression and Treg induction. Mol Immunol. 2013 Apr;53(4):335-44. https://tinyurl.com/ydxzrfbj
Sprietsma JE. Zinc-controlled Th1/Th2 switch significantly determines development of diseases. Med Hypotheses. 1997 Jul;49(1):1-14. https://tinyurl.com/ydbohp67
Tocotrienols have been shown to reduce the allergic response by stabilizing mast cells. Luteolin, a flavonoid found in certain botanicals including perilla leaf, has been shown to have vasculature-stabilizing and anti-histamine effects, inhibiting IgE-mediated histamine release from mast cells. Boswellia extracts also have been observed to act as mast cell stabilizers. Boswellia also acts to inhibit leukotriene synthesis, which may play a role in allergic symptoms.
Tsuduki T, et al. Tocotrienol (unsaturated vitamin E) suppresses degranulation of mast cells and reduces allergic dermatitis in mice. J Oleo Sci. 2013;62(10):825-34. https://tinyurl.com/yctv4fgs
Kimata M, et al. Effects of luteolin and other flavonoids on IgE-mediated allergic reactions. Planta Med. 2000 Feb;66(1):25-9. https://tinyurl.com/y74rraws
Seelinger G, et al. Anti-oxidant, anti-inflammatory and anti-allergic activities of luteolin. Planta Med. 2008;74(14):1667-77. https://tinyurl.com/ybmrgojg
Gupta I, et al. Effects of Boswellia serrata gum resin in patients with bronchial asthma: results of a double-blind, placebo-controlled, 6-week clinical study. Eur J Med Res. 1998;3(11):511-4. https://tinyurl.com/ybzvh6os
For patients that struggle to get adequate protein in their diet, I find that protein powders are very beneficial. I personally like to use a pea protein powder in my practice as it is quite hypoallergenic. Pea protein has an excellent array of amino acids, including high levels of BCAAs (branched chain amino acids). This can be taken as a snack in a liquid or used to make a smoothie. When individuals make smoothies I always emphasise that it should not just be full of fruit and liquid but should include a protein and a fat source so it is a more balanced and complete meal/snack. Fats can include nut butters, coconut milk, avocado. Usually people find that they enjoy their smoothie much more when it is more complete and don’t have an energy crash later in the day, which also of course is very important for the diabetic patient.
Butyrate has been shown to promote healthy large intestinal flora and protect the mucosa from mechanical and chemical damage, as well as improve tissue integrity. Unfortunately, it does have a poor smell. Some feel that this is improved by keeping the supplement in the freezer, however as the smell may lead to poor compliance it may not be something you chose to start with. A thorough article about the use of SCFAs for the management of colonic inflammation has been written by Michael Ash, and can be found on the Nutri-Link Clinical Education website http://tinyurl.com/odk2g3u.
There are several discussions on the Clinical Education group about many of these topics specifically. Please do use the search function found by the magnifying glass in the upper right-hand corner of the page when you are in this group to look for previous discussions concerning topics such as “IBD,” and “Mast Cell” or “Histamine Intolerance” for further information. A discussion about the topic of Histamine Intolerance can be found here: https://tinyurl.com/yatw6ddx, while a discussion about Mast Cell Activation Syndrome can be found here: https://tinyurl.com/ybl2zlty.
Topical castor oil to the abdomen and right upper quadrant of the liver are very supportive for supporting gastrointestinal healing. Dr. Todd Born recently wrote about the many benefits of castor oil which can be read here – http://tinyurl.com/kqsrfga. I generally instruct clients to use a simplified castor oil pack by simply massaging castor oil into the region, applying a cotton cloth to protect other garments from the oil, and using the body heat to draw the oil internally. A warm water pack may also be applied for a period of 15 – 20 minutes.
The following supplements are suggested for you to consider in light of your relevant expertise and intimate understanding of the needs of your client or patient. They may be used in isolation or as part of a multi supplement strategy, but at all times the consideration of their use should be tied into the specific needs of the individual you are responsible for. Of course, with a sensitive client, it always is prudent to make changes and introduce new supplements gradually.
Support for reduction of Th2/Th1 imbalance, mast cell stabilization, and reduction of histamine:
Quercetin Bioflavonoids (ARG) or Quercetin 300 (ARG): 2 capsules 30 minutes before meals one to three times daily. http://tinyurl.com/795l5qo Supports reduction of histamine.
Aller Aid L92 (ARG): 1 capsule twice daily. http://tinyurl.com/jpcpr29 For support with reduction of allergies, and related inflammation. Contains Lactobacillus acidophilus L-92, vitamins A and C, Boswellia, and Luteolin.
Liquid Mineral 2 Zinc (BB): 15 – 30 drops (15 – 30mg) once daily with food. https://tinyurl.com/yazwx757
Pea Protein Isolate (BRC): 2 scoops with 8 oz of liquid or in a smoothie. http://tinyurl.com/oub565t
Chromium liquids available:
Aqueous Chromium (BRC): 1 – 2 drops (150 – 300mcg) daily. https://tinyurl.com/yap4dv2z
Liquid Mineral 5 Chromium (BB): 2 – 3 drops (200 – 300mcg) daily. https://tinyurl.com/y8n7x9xo
You also may want to consider a more comprehensive liquid multivitamin:
Aqueous Multi Plus (BRC): 1 Tbsp with breakfast and lunch. http://tinyurl.com/mbtyy69
Please consider these suggestions in light of the other clinical information pertaining to this individual. I hope this information is helpful, and if you have any further questions or information specific to the problems this individual is experiencing, please do provide feedback.
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