Download May – Supplements and Complementary Therapies May

May – Supplements and Complementary Therapies
May-Supplements and Complementary Therapies
Because there is no conventional cure for IBD, individuals with IBD commonly use complementary or
alternative therapies in an attempt to ameliorate symptoms. In fact, a clinical research study conducted at an
outpatient clinic in a tertiary center demonstrated that a majority of IBD patients (56%) use complementary and
alternative medicine, also known as CAM (Weizman et al., 2012). CAM is a term that refers to a wide array of
practices and products that are not considered part of mainstream medical IBD care.
The four major domains of CAM are:
Mind-Body Medicine (prayer, tai chi, hypnosis, meditation, biofeedback, and yoga)
Manipulative and Body-Based Practices (chiropractic manipulation, massage, and reflexology)
Energy Medicine (biofield therapies and bioelectromagnetic-based therapies)
Biologically-Based Practices (dietary supplements and functional foods)
TIP #1: Be aware that CAM use by your patients is likely, and be sure to encourage them to alert you to any
CAM therapies they are using.
CAM use has been found to be especially prevalent among university-educated individuals and among
individuals who have experienced ineffectiveness and/or unwanted side effects from conventional
therapies; however, adherence rates to conventional treatments were not found to be correlated to
CAM use (Weizman et al., 2012). The level of trust in the health care provider was not found to be
different between CAM users and non-users (Weizman et al., 2012), suggesting that CAM use on the
part of your patient is not a sign of distrust in you as a provider.
Because even innocent-seeming vitamins might contain ingredients that could interact with
medications, it is important to build a bridge of communication that keeps you fully informed of your
patients’ use of CAM.
For more information on CAM modalities in general, to help educate yourself or your patients, see the
National Institutes of Health, National Center for Complementary and Alternative Medicine website at:
http://nccam.nih.gov/
For more information on CAM modalities in the context of IBD, see the CCFA Fact Sheet titled,
Complementary and Alternative Medicine (CAM) at:
http://www.ccfa.org/assets/pdfs/CAM.pdf
TIP #2: Familiarize yourself with the most common forms of CAM, especially those that interest your patients.
For example, probiotics, or supplemental friendly bacteria, were found by Weizman et al. (2012) to be
the form of CAM therapy most commonly used by individuals with IBD. Increasingly, prebiotics are
added to probiotic supplements to help increase the growth of the desired bacterial populations once
these microorganisms have been ingested and are present in the gut. Figure 1 illustrates the
relationship between prebiotics, probiotics, and gut health.
PREBIOTICS
(dietary fiber/
indigestible carbohydrates)
Feed
PROBIOTICS
(friendly
bacteria)
Fermentation
by-products
(short-chain fatty acids)
nourish human cells
Gut
Health
Figure 1: Prebiotics are sometimes combined with probiotics
in supplements known as synbiotics. Probiotics are friendly
bacteria with recognized multifactorial gastrointestinal
benefits, and prebiotics are the source of sustenance required
for probiotics to flourish. Beneficial short-chain fatty acids
produced during fermentation further benefit the gut.
Nurses who are equipped with knowledge of the mechanistic rationale undergirding this popular form of
complementary therapy will be better able to communicate with their patients who are exploring this
route to gut health. Reading articles about probiotics and prebiotics, such as Damakos & Kolios (2008),
will help further your understanding of the scientific rationale for probiotic/prebiotic supplementation for
IBD.
Always be respectful of patients’ decisions to supplement their disease management using reputable
practices/practitioners, whether regarding probiotic/prebiotic supplementation or other complementary
and alternative therapies for IBD—and be ready to have a thoughtful discussion regarding the most
common types of CAM. In order of prevalence, the most common forms of CAM use in IBD are
probiotics, fish oil, naturopathy, massage/relaxation, acupuncture, homeopathy, Chinese herbal
medicine, aroma therapy, and hypnosis (Weizman et al., 2012).
TIP #3: Be mindful of the potential need for you to be proactive regarding the recommendation of supplements.
Intestinal inflammation, pharmaceutical agents, and intestinal resections are some of the conditions that
can predispose individuals with IBD to serious nutritional deficiencies. Careful assessment and
supplementation can help to avoid these deficiencies and maximize health. The potential for subclinical
inflammation puts all patients with IBD at additional risk for nutritional deficiencies; therefore,
assessment of nutritional status is always warranted, and supplementation may be needed even in
cases of clinical remission and the absence of obvious pharmaceutical or surgical risk factors.
Additional considerations include patients on steroids, who especially need supplemental calcium and
Vitamin D, and patients on methotrexate or sulfasalazine, who especially need folic acid
supplementation. Vitamin B12 is absorbed in the terminal ileum; thus, patients with terminal ileal
disease or who have had their terminal ileum resected may need vitamin B12 supplementation.
As they are still in their growth years, children and adolescents with IBD are particularly vulnerable to
nutritional deficiencies. IBD affects the bone health of these young patients—approximately 10-40% of
children with IBD have bone mass deficits at diagnosis, especially those with Crohn’s disease (Breglio
& Rosh, 2013). Vitamin D levels should be monitored yearly and supplemented if low (Pappa et al.,
2011).
For a review of the added requirements for calcium and vitamin D in IBD, see “Bone Loss in IBD,” a
document that can be accessed at: http://www.ccfa.org/resources/bone-loss.html
For a review of other deficiencies common in IBD, see the CCFA Complementary and Alternative
Medicine (CAM) fact sheet at: http://www.ccfa.org/assets/pdfs/CAM.pdf
TIP #4: Always remember to document in the patient’s chart the discussions you have regarding
supplementation and CAM use.
Resources
Complementary and Alternative Medicine Fact Sheet: http://www.ccfa.org/assets/pdfs/CAM.pdf
Extra-Intestinal Complications: Bone Loss: http://www.ccfa.org/resources/bone-loss.html
It’s Up to You: Decisions & IBD Management: http://www.ccfa.org/assets/pdfs/decision-making-slides.pdf
(CAM information starts on page 12)
Managing IBD: Taking Charge of Your Disease: http://www.programs.rmei.com/CCFAmanageIBDVL/
National Center for Complementary and Alternative Medicine: http://nccam.nih.gov/
References
Damaskos D, Kolios G. Probiotics and prebiotics in inflammatory bowel disease: Microflora ‘on the scope’. Br J
Clin Pharmacol. 2008;65(4):453.
Breglio, K. J., & Rosh, J. R. (2013). Health maintenance and vaccination strategies in pediatric inflammatory
bowel disease. Inflammatory Bowel Diseases, 19(8), 1740-1744.
Pappa, H., Thayu, M., Sylvester, F., Leonard, M., Zemel, B., & Gordon, C. (2011). A clinical report on skeletal
health of children and adolescents with inflammatory bowel disease. Journal of Pediatric
Gastroenterology and Nutrition, 53(1), 11.
Weizman, A. V., Ahn, E., Thanabalan, R., Leung, W., Croitoru, K., Silverberg, M. S., . . . Nguyen, G. C. (2012).
Characterisation of complementary and alternative medicine use and its impact on medication
adherence in inflammatory bowel disease. Alimentary Pharmacology & Therapeutics, 35(3), 342-349.
doi: 10.1111/j.1365-2036.2011.04956.x