Chronic Kidney Disease – A plant-based diet prevents and treats CKD

Printable version: Chronic Kidney Disease – full article

Abstract

Interest in the dietary treatment of chronic kidney disease has been growing as its incidence has been increasing. Chronic Kidney Disease (CKD) is now the 8th leading cause of death in the United States and its treatment consumes substantial amounts of medical resources and money.

Several lines of epidemiological research have shown a lower risk of chronic kidney disease among vegetarians. It also shows a substantially increased risk among omnivores, especially those who eat red and processed meats.

Although the practice started long ago, research on the use of a low-protein plant-based diet to treat chronic kidney disease diet has intensified in recent years. This research has shown that a low-protein vegetarian diet is safe and efficacious at both treating and slowing the progression of chronic kidney disease.

Treatment with a low-protein vegetarian diet, often supplemented with keto analogues, has been shown to reduce acidosis, phosphotemia, uremia, proteinuria and to slow progression. Research shows that this treatment does not result in malnutrition. Research has also shown that larger amounts of plant protein than animal protein can be consumed, without deleterious effects.

Treatment with a low protein vegetarian diet also has the advantage of preventing and treating common comorbidities such as type 2 diabetes and coronary artery disease.

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The Prevention and Treatment of Type 2 Diabetes Mellitus with a Plant-Based Diet – published

We are delighted to announce that our comprehensive review article on the prevention and treatment of Type 2 Diabetes Mellitus with a Plant-Based Diet was recently published in the peer-reviewed Endocrinology and Metabolism International Journal.

Here’s the published article as a pdf.

Review Article

The Prevention and Treatment of Type 2 Diabetes Mellitus with a Plant-Based Diet

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Open Letter to Editor, JACC

Open Letter To the Editor-in-Chief, Journal of the American College of Cardiology

October 27, 2017

 

Dear Dr. Fuster,

In your recent update to the Expert Consensus Decision Pathway, (1) no specific mention was made of a safe and efficacious non-statin therapy, the plant-based diet.

Vegetarian and vegan diets can be very efficacious in reducing serum cholesterol and, importantly, LDL. Studies have shown that those following a plant-based diet have significantly lower total cholesterol and LDL levels. (2)
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Published in Endocrine Practice

This is a letter we just had to write. We sent a fully documented Letter to Editor of Endocrine Practice Journal, concerning a published algorithm for the treatment of Type II Diabetes. We were delighted that our letter was published – see Published Letter to Endocrine Practice – in their June 2017 issue, along with a Response from authors of the algorithm.

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The Prevention and Treatment of Crohn’s Disease with a Vegetarian Diet

We are delighted to announce that this article was published in the peer-reviewed journal, Advanced Research in Gastroenterology and Hepatology, Feb 16, 2018.

Here is the pdf of the published article

Abstract

Epidemiologic studies show that IBD is prevalent in wealthy nations where dietary westernization usually occurs. Dietary westernization is characterized by increased consumption of animal protein, animal fat, and sugar. An epidemiological study found that the risk of Crohn’s disease reduced by 70% in females and 80% in males following a vegetarian diet.

Treatment with medications, though efficacious to a degree, all have significant adverse reactions. Many of these medications will also be contraindicated in a significant number of patients.

Treatment is aimed at inducing remission. A semi-vegetarian diet has been shown to achieve a 100% remission rate at 1 year and 92% at 2 years. Plant-based diets are rich in phytochemicals that help reduce inflammation by modifying several inflammatory mechanisms.

A study of treatment with infliximab and a plant-based diet showed a remission rate of 96%, substantial reduction in CRP and CDAI and improvements in mucosa healing. This study shows that combining infliximab with a plant-based diet results in a strong clinical response.

Plant-based diets promote a more favorable gut microbial profile that is anti-inflammatory. Naturally occurring substances in plant foods, having anti-inflammatory bowel actions include phytochemicals, antioxidants, dietary fibers, and lipids. Many of these natural products exert their beneficial action by altering cytokine production.

The plant-based diet has no adverse reactions or contra-indications and is affordable, so physicians can initiate therapy with a plant-based diet immediately, and prescribe it as a prophylaxis for all patients at risk of Crohn’s disease.

 

Introduction

Crohn’s disease is difficult to treat and can be frustrating for both the patient and their physician. Safer and more efficacious treatments are needed for this disease.

The current standard treatment for Crohn’s disease involves medication to manage symptoms and induce remission, and when necessary, bowel resection. Medications used in the treatment of Crohn’s disease include the following:

  • 5-Aminosalicylic acid derivative agents (eg. mesalamine rectal, mesalamine, balsalazide)
  • Corticosteroids (eg. prednisone, methylprednisolone, budesonide)
  • Immunosuppressive agents (eg. mercaptopurine, methotrexate, tacrolimus)
  • Biologics (eg. infliximab, adalimumab, certolizumab pegol, natalizumab, vedolizumab)
  • Antibiotics (eg. metronidazole, ciprofloxacin)
  • Antidiarrheal agents (eg. loperamide, diphenoxylate-atropine)
  • Bile acid sequestrants (eg. cholestyramine, colestipol)
  • Anticholinergic agents (eg. dicyclomine, hyoscyamine, propantheline)

These medications, though efficacious to a degree, all have significant adverse reactions. Many of these medications will also be contraindicated in a significant number of patients.

Most patients with Crohn’s disease require surgical intervention during their lifetime, as it plays an integral role in controlling the symptoms and treating the complications of Crohn’s disease, but operative resection is not curative. Because of the high rate of disease recurrence after segmental bowel resection, the guiding principle of surgical management of Crohn’s disease is preservation of intestinal length and function. (1)

Mean annual costs for Crohn’s disease are about $8265. 31% of costs were attributable to hospitalization, 33% to outpatient care, and 35% to pharmaceutical claims. The annual dollar cost for Crohn’s disease in the United States is $3.6 billion. (2) It can reasonably be concluded that Crohn’s is both difficult and expensive to treat.

Symptoms of Crohn’s disease may subside with total parenteral nutrition or total enteral nutrition, but it is well known to flare up after the resumption of meals. Therefore, the food in patient’s meals are thought to be an etiologic factor in gut inflammation. (3)

While parenteral nutrition is possible, nutrition taken orally is to be preferred if it won’t cause a flare up, or even better, if it can prevent flare ups and induce remission. This is what a vegetarian diet seems to accomplish.

Prevention

The etiology of Crohn’s disease is unknown. Genetic, microbial, immunologic, environmental, dietary, vascular, and psychosocial factors have been implicated, as have smoking and the use of oral contraceptives and nonsteroidal anti-inflammatory agents (NSAIDs).

Epidemiology shows that IBD is prevalent in wealthy nations (4, 5, 6) where dietary westernization inevitably occurs (7, 8). Dietary westernization is characterized by increased consumption of animal protein, animal fat, and sugar. Diets rich in animal protein and animal fat cause a decrease in beneficial bacteria in the intestine (9, 10).

However, the risk of Crohn’s disease was found to be reduced by 70% in female and 80% in male young people following a nearly vegetarian diet. (11)

Treatment

Treatment is aimed at inducing remission.  An important and well-designed study published in 2010, using a semi-vegetarian diet, achieved a 100% remission rate at 1 year and 92% at 2 years. (12)

A more advanced study published in 2017 examined whether a substantial improvement of the relapse-free rate in Crohn’s Disease could be obtained by incorporating three recently developed concepts in medicine: biologics, a plant-based diet and window of opportunity. This was followed by maintenance of remission with a plant-based diet, rather than further use of biologics with or without immunosuppressants. (13)

Patients were treated with infliximab and a plant-based diet. The primary end point was clinical remission at week 6. Secondary end points were normalization of C-reactive protein (CRP) concentration at week 6 and mucosal healing. Crohn Disease Activity Index (CDAI) score was also evaluated. (13)

All patients in this study who completed the protocol achieved remission at week 6. Remission rates by intention-to-treat and per protocol analysis were 96% and 100%, respectively. The rates of CRP normalization at week 6 were 92% among adults with a new diagnosis, 82% among children with a new diagnosis and 67% among relapsing adults. The mean CDAI score was significantly decreased from 314 before treatment to 163 after the first week. The scores were further decreased chronologically: 115, 98, 82, 74, and 63 at weeks 2, 3, 4, 5, and 6, respectively. Mucosal healing was achieved in 46% patients. This study has shown that a plant-based diet can improve the efficacy of biologics such as infliximab. (13)

Plant-based dietary patterns may promote a more favorable gut microbial profile. Such diets are high in dietary fiber and fermentable substrate (i.e. non digestible or undigested carbohydrates), which are sources of metabolic fuel for gut microbial fermentation and, in turn, result in end products that may be used by the host (i.e. short chain fatty acids such as butyrate). These end products may have direct or indirect effects on modulating the health of their host. (14)

The naturally occurring substances in plant foods having anti-inflammatory bowel actions include phytochemicals, antioxidants, microorganisms, dietary fibers, and lipids. The literature indicates that many of these natural products exert their beneficial action by altering cytokine production. Specifically, phytochemicals such as polyphenols or flavonoids are the most abundant, naturally occurring anti-inflammatory substances. The effects of lipids are primarily related to the n-3 polyunsaturated fatty acids. The effects of phytochemicals are associated with modulating the levels of tumor necrosis factor α (TNF-α), interleukin (IL)-1, IL-6, inducible nitric oxide synthase, and myeloperoxide. The anti-IBD effects of dietary fiber are mainly mediated via peroxisome proliferator-activated receptor-γ, TNF-α, nitric oxide, and IL-2, whereas the effects of lactic acid bacteria are reported to influence interferon-γ, IL-6, IL-12, TNF-α, and nuclear factor-κ light-chain enhancer of activated B cells. These results suggest that the anti-IBD effects exhibited by natural products are mainly caused by their ability to modulate cytokine production. (15)

Studies, conducted using in vivo and in vitro models, provide evidence that pure polyphenolic compounds and natural polyphenolic plant extracts can modulate intestinal inflammation. (16)  Polyphenols may thus be considered able to prevent or delay the progression of Crohn’s disease, especially because they reach higher concentrations in the gut than in other tissues. (17)

While not perfect, of all the laboratory markers, C-Reactive Protein (CRP) is the most studied and has been shown to have the best overall performance. CRP is an objective marker of inflammation and correlates well with disease activity in Crohn’s disease. (18)  It is produced as an acute phase reactant predominantly in the liver, in response to stimulation by interleukin (IL)-6, TNF-α and IL-1β, which are produced at the site of inflammation. (19)

Adipocytes in hypertrophied mesenteric adipose tissue produce and secrete significant amounts of adiponectin, which may be involved in the regulation of intestinal inflammation associated with Crohn’s disease. Furthermore, adiponectin concentrations in hypertrophied mesenteric adipose tissues of Crohn’s disease patients correlated inversely with serum CRP levels (r = −0.51, p = 0.015) (20)  There is a good correlation between CRP and other measures of inflammation such as the Crohn’s Disease Activity Index, radioactive labelled fecal granulocyte excretion and fecal calprotectin. (21, 22, 23)

Plant-based diets have been shown to increase adiponectin in diabetics, and reduce CRP in both diabetics and patients with coronary artery disease, and may well be doing the same in Crohn’s disease patients. (24, 25, 26)  This improved profile of cytokines may be part of the therapeutic efficacy of plant-based diets in Crohn’s disease.

Discussion

To put the efficacy of a vegetarian diet into perspective one must compare it to standard treatments. Overall, despite the use of oral mesalamine treatment in the past, new evidence suggests that this approach is minimally effective as compared with a placebo, and less effective than budesonide or conventional corticosteroids.  Induction of remission was noted in 52% of Crohn’s disease patients.

Maintenance of remission was reported in 71% of Crohn’s disease patients on azathioprine over a 6-month to 2-year period. Induction and maintenance of remission was noted in 70% of Crohn’s disease patients on methotrexate over a 40-week period. Induction of remission was reported in 32%, 26%, and 20% of Crohn’s Disease patients on infliximab, adalimumab or certolizumab, respectively. Approximately one-fifth of Crohn’s disease patients treated with biologicals require intestinal resection after 2–5 years in referral-center studies. (27)  The adverse reactions of the above medications are well-known, as are the risks and complications of surgery.

The safety and efficacy of a plant-based diet to treat Crohn’s disease would seem quite advantageous. It has no contraindications and no adverse reactions. Therefore, it may be safely combined with standard treatments.

Treatment with a plant-based diet also reduces the risk of common diseases that the Crohn’s patient will face in common with all patients, such as coronary artery disease and type II diabetes mellitus.

Given the substantial advantages more study is warranted. However, given its safety the physician can institute therapy with a plant-based diet immediately.

Finally, every physician should practice prevention. The decreased risk of Crohn’s disease obtained with a plant-based diet is considerable. It is a safe prophylaxis, and should especially be prescribed for patients at risk because of family history or because of cigarette smoking.

Conflict of Interest

The authors have no conflicts of interest to disclose.

 

References

1.

Kornbluth A, Sachar D, Salomon P. (1998) Crohn’s disease. In: Feldman M, Scharschmidt B, Friedman L, Sleisenger M, eds. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/ Management 6th Edition. Vol 2. 6th ed. Philadelphia: WB Saunders Co.Pages 1708–1734
https://www.ncbi.nlm.nih.gov/nlmcatalog/9609349

2.

Kappelman M, Rifas-Shiman S, Porter C, Ollendorf DA, Sandler RS, et al. (2008) Direct Health Care Costs of Crohn’s Disease and Ulcerative Colitis in US Children and Adults. Gastroenterology. 135(6):1907-1913.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2613430/

3.

Chiba M, Ohno H, Ishii H, Komatsu M. (2014) Plant-Based Diets in Crohn’s Disease. Perm J. 18(4):94. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4315368/

4.

Bernstein C, Shanahan F. (2008) Disorders of a modern lifestyle: reconciling the epidemiology of inflammatory bowel diseases. Gut. 57(9):1185-1191. https://www.ncbi.nlm.nih.gov/pubmed/18515412

5.

Whelan G. (1995) Inflammatory bowel disease: epidemiology. In: Haubrich W, Schaffner F, Berk J, eds. Bockus Gastroenterology. Vol 2. 5th ed. Philadelphia: WB Saunders. Pages 1318–1325

6.

Shivananda S, Lennard-Jones J, Logan R, Fear N, Price A, et al. (1996) Incidence of inflammatory bowel disease across Europe: is there a difference between north and south? Results of the European Collaborative Study on Inflammatory Bowel Disease (EC-IBD). Gut. 39(5):690-697. https://www.ncbi.nlm.nih.gov/pubmed/9014768

7.

US Dept of Health and Human Services. (1981) Report of the Working Group on Arteriosclerosis of the National Heart, Lung and Blood Institute. Arteriosclerosis. Vol 2. Philadelphia: WB Saunders https://catalog.hathitrust.org/Record/005871186

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Popkin B. (1994) The nutrition transition in low-income countries: an emerging crisis. Nutr Rev. 52(9):285-298. https://www.ncbi.nlm.nih.gov/pubmed/7984344

9.

Hentges D, Maier B, Burton G, Flynn M, Tsutakawa R. (1977) Effect of a high-beef diet on the fecal bacterial flora of humans. Cancer Research. 37(2):568-571. http://cancerres.aacrjournals.org/content/canres/37/2/568.full.pdf

10.

Benno Y, Suzuki K, Suzuki K, Narisawa K, Bruce W, Mitsuoka T. (1986) Comparison of the fecal microflora in rural Japanese and urban Canadians. Microbiol Immunol. 30(6):521-32. https://www.ncbi.nlm.nih.gov/pubmed/3747865

11.

D’Souza S, Levy E, Mack D, Israel D, Lambrette P, et.al. (2008) Dietary patterns and risk for Crohn’s disease in children. Inflamm Bowel Dis. 14(3):367-73. https://www.ncbi.nlm.nih.gov/pubmed/18092347

12.

Chiba M, Abe T, Tsuda H, Sugawara T, Tsuda S, et.al. (2010) Lifestyle-related disease in Crohn’s disease: Relapse prevention by a semi-vegetarian diet. World J Gastroenterol. 16(20):2484–2495. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2877178/

13.

Chiba M, Tsuji T, Nakane K, Tsuda S, Ishii H, et al. (2017) Induction with Infliximab and a plant-based diet as first-line (IPF) therapy for Crohn disease: a single-group trial. Perm J.21:17-009. https://www.ncbi.nlm.nih.gov/pubmed/29035182

14.

Wong J. (2014) Gut microbiota and cardiometabolic outcomes: influence of dietary patterns and their associated components. Am J Clin Nutr. 100(Suppl 1):369S-77S. https://www.ncbi.nlm.nih.gov/pubmed/24898225

15.

Hur SJ, Kang SH, Jung HS, Kim SC, Jeon HS, et al. (2012) Review of natural products actions on cytokines in inflammatory bowel disease. Nutr Res. 32(11):801-16. https://www.ncbi.nlm.nih.gov/pubmed/23176791

16.

Romier B, Schneider Y, Larondelle Y, During A. (2009) Dietary polyphenols can modulate the intestinal inflammatory response. Nutr Rev. 67(7):363-78. https://www.ncbi.nlm.nih.gov/pubmed/19566597

17.

Biasi F, Astegiano M, Maina M, Leonarduzzi G, Poli G. (2011) Polyphenol supplementation as a complementary medicinal approach to treating inflammatory bowel disease. Curr Med Chem. 18(31):4851-65. https://www.ncbi.nlm.nih.gov/pubmed/21919842

18.

Vermeire S, Van Assche G, Rutgeerts P. (2006) Laboratory markers in IBD: useful, magic, or unnecessary toys? Gut. 55(3):426-431. https://www.ncbi.nlm.nih.gov/pubmed/16474109

19.

Vermeire S, Van Assche G, Rutgeerts P. (2004) C-reactive protein as a marker for inflammatory bowel disease. Inflamm Bowel Dis. 10(5):661-5. https://www.ncbi.nlm.nih.gov/pubmed/15472532

20.

Yamamoto K, Kiyohara T, Murayama Y, Kihara S, Okamoto T, et al. (2005) Production of adiponectin, an anti-inflammatory protein, in mesenteric adipose tissue in Crohn’s disease. Gut. 54(6):789-96. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1774527/

21.

Fagan EA, Dyck RF, Maton PN, Hodgson HJ, Chadwick VS, et al. (1982) Serum levels of C-reactive protein in Crohn’s disease and ulcerative colitis. Eur J Clin Invest. 12(4):351-9. https://www.ncbi.nlm.nih.gov/pubmed/6814926

22.

Saverymuttu S, Hodgson H, Chadwick V, Pepys M. (1986) Differing acute phase responses in Crohn’s disease and ulcerative colitis. Gut. 27(7):809–813. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1433572/

23.

Hammer H, Kvien T, Glennås A, Melby K. (1995) A longitudinal study of calprotectin as an inflammatory marker in patients with reactive arthritis. Clin Exp Rheumatol. 13(1):59-64. https://www.ncbi.nlm.nih.gov/pubmed/7774104

24.

Kahleova H, Matoulek M, Malinska H, Oliyarnik O, Kazdova L, et al. (2011) Vegetarian diet improves insulin resistance and oxidative stress markers more than conventional diet in subjects with Type 2 diabetes. Diabet Med. 28(5):549-59. https://www.ncbi.nlm.nih.gov/pubmed/21480966

25.

Krajcovicova-Kudlackova M, Blazicek P. (2005) C-reactive protein and nutrition. Bratisl Lek Listy. 106(11):345-7. https://www.ncbi.nlm.nih.gov/pubmed/16541618

26.

Chen C, Lin Y, Lin T, Lin C, Chen B, Lin C. (2008) Total cardiovascular risk profile of Taiwanese vegetarians. Eur J Clin Nutr. 62(1):138-44. https://www.ncbi.nlm.nih.gov/pubmed/17356561

27.

Peyrin-Biroulet L, Lémann M. (2011) Review article: remission rates achievable by current therapies for inflammatory bowel disease. Aliment Pharmacol Ther. 33(8):870-9. https://www.ncbi.nlm.nih.gov/pubmed/21323689

The Treatment of Fibromyalgia with a Plant-Based Diet

Introduction

As the physician will already know, fibromyalgia is a disease which is often very difficult to treat. Many patients suffer from fibromyalgia without a fully efficacious treatment. These patients do not have a good quality of life and cannot maintain normal daily activity with currently prescribed treatments. Hence, many fibromyalgia patients inquire about dietary interventions. (1)

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Rheumatoid Arthritis – Prevention and Treatment with a Plant-Based Diet

Introduction

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease of unknown etiology. There is no cure, so long term treatment is indicated. Medication-based therapies comprise several classes of agents, including nonsteroidal anti-inflammatory drugs (NSAIDs), non-biologic and biologic disease modifying anti-rheumatic drugs (DMARDs), immunosuppressants, and corticosteroids. Other standard treatments include physical therapy and surgery.

Surveys have shown that a substantial proportion of people with RA will try complementary and alternative interventions, perhaps reflecting the lack of complete satisfaction with conventional approaches, and also a desire to help themselves. (1)

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