To ASCA or not to ASCA
Crohn’s Disease (CD) affects hundreds of thousands of individuals across the United States with a prevalence of approximately 200 cases per 100,000 adults. If you are practicing integrative medicine, it is very likely that you are seeing patients with CD. While a comprehensive review of the disease would require multiple textbooks, this article will highlight the clinical value of testing for anti-Saccharomyces cervesiea antibodies ASCA as well as some of general principles of supporting a patient with CD.
While the precise etiology of CD has not been determined, as a subset of the Inflammatory Bowel Disease conditions, it is not difficult to understand that addressing inflammation is of paramount importance. Specifically, Crohn’s Disease is a Type 1 Immunity (TH1) disease in which areas of active inflammation show elevations in IFN-g, IL-12 and tumor necrosis factor (TNF). In the digestive tract, immunological homeostasis is dependent upon the interplay between intestinal epithelial cells, commensal flora and immune cells. There are a variety of effective ways to soothe inflamed epithelial cells. Aloe, slippery elm root (Ulmus fulva), marshmallow root (Althaea officinalis), deglycyrrhizinated licorice root (DGL, Glycyrrhiza glabra) are great demulcents that provide a calming, mucilaginous coat to irritated epithelia.
Repleting nutrient deficiencies are another important consideration for patients with Crohn’s Disease. Individuals with CDs have an increased likelihood of having multiple nutrient deficiencies including zinc, magnesium, folate and vitamin B12 as well as low levels of thiamine, vitamin B6 and vitamin A. With compromised absorption, nutrient deficiencies are to be expected and you may want to consider replenishing via intramuscular or intravenous therapy as an effective adjunct to oral multivitamins.
Addressing the gut microbiome is critical to healing the digestive tract in patients with CD. An imbalance in digestive flora is associated with CD as well as ulcerative colitis, celiac disease and colorectal cancer. Research shows there is a strong correlation between antibiotic exposure and Crohn’s Disease and that exposure during the first year of life is positively correlated with pediatric onset of CD., While supporting healthy flora is central to digestive repair, making sure your patient is not burdened by harmful flora is just as vital. In working with CD patients, I find that many of them experience significant improvement by eliminating Saccharomyces cerevisiea from their diet. I always include ASCA testing in my preliminary blood work in IBD patients. Research shows that between 60-70% of individuals with CD make IgA or IgG antibodies to S. cerevisiea, versus only 10-15% with Ulcerative Colitis and 0-5% in healthy controls. It is also worth noting that ASCAs is associated with proximal disease (gastroduodenal and small intestine involvement) rather than solely colonic disease (P <0.001) and elevated ASCA levels were shown to progress to a more severe phenotype and need for surgical intervention.
Many IBD patients report high stress levels and I don’t want their “path to wellness” to be a pot-holed roadmap of nutritional torture. Running the ASCA lab and showing them the elevated numbers empowers and motivates them to take a big step toward healing their gut. The test is typically covered by insurance, easy to order and offers a great opportunity to remove a significant obstacle to healing their digestive tract. They are not terribly excited when I ask them to eliminate S. cerevisiea from their diet, but they eventually get over the proverbial ‘hump’ and start to feel better. Having a good handout ready is helpful to the process as brewer’s yeast (also called baker’s yeast) is ubiquitous in the western diet.
We all know it is essential to address food sensitivities when working with patients. While many practitioners rely on the Elimination Diet to identify offending foods, this method does have limitations when it comes to identifying potential sensitivities to micro foods like spices or herbs. Even though discussing the merits and limitations of food sensitivity testing is well beyond the limitations of this short article, it does warrant mention here as an important diagnostic tool. While no single test is perfect, they are useful tools that can help you explore sensitivities to potentially hundreds of foods with one blood draw.
One of my patients with CD told me a great story about her experiences with food sensitivities. She had just snuggled onto her couch with a good book and a cup of herbal tea. Within a few minutes, she said she felt a wave of anger. She was very puzzled as she relishes these quiet moments as a mother of two teenage boys. She quickly hopped off the coach and read the ingredients in her new herbal tea blend. She quickly found the offending ingredient; pepper. She has avoided baker’s yeast and her other food sensitivities (identified via specialty labs) for over two years and was able to get off the medications (which she had to take three times a day) and feel great again. This anecdote highlights that food sensitivities are diverse and even the smallest of exposures can have profound effects for patients with CD.
While addressing nutrition and food sensitivities is paramount for these patients, stress management and regular exercise are just as vital. Patients with high stress levels have higher rates of relapse. I use different approaches to explain the importance and ways to address stress management, depending on the patient. With some patients, explaining the physiological effects of chronic stress is motivating while others will have their eyes glaze over if you mention anything technical and just want to know that it will impede their recovery.
Depending on the patient, I will prescribe counseling, breathing exercises, journaling, yoga, mindfulness exercises or CBT. Asking what works for them and what they are willing to try guides the strategy and empowers them toward ownership and leads to better outcomes. Having some fun is also on the agenda. I find that many of my adult patients do not have hobbies or do things that they enjoy on a regular basis. While loving the biochemistry and physiology of medicine, it is also important to support the whole person and include recommendations that support the mind, body and spirit in all of our patients.
By Tina Beaudoin, ND
Dr. Tina Beaudoin is a licensed Naturopathic Doctor and Senior Medical Educator with Emerson Ecologics. She enjoys seeing patients in her private practice in Manchester, NH, and has been serving as the President of the New Hampshire Association of Naturopathic Doctors since 2012.
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