Chloe: I mean, they’re the only two conditions identified as inflammatory bowel diseases at the moment, ulcerative colitis and Crohn’s disease. And they are quite different in their presentations regarding how it’s viewed from a gastroenterology perspective. However, how we see, symptoms are extremely similar. So it can be really hard when it comes to diagnosis, you know, before going through a colonoscopy to identify what the likelihood is of each.

Some indicators, I guess…well, I’ll kind of take you through the differences between the two, in that ulcerative colitis is only in the large intestine. In contrast, Crohn’s disease is anywhere from the mouth to the anus. In saying that 80% of people with Crohn’s disease have the disease in their terminal ileum. So in their proximal or sorry, the distal part of the small intestine. That’s the predominant place that we see Crohn’s disease, and therefore the symptoms are far more related to things like abdominal discomfort and quite severe cramping.

We tend to see a lot of nutritional imbalances with both Crohn’s and ulcerative colitis. But I would say with Crohn’s disease; it’s a little more frequent except with ulcerative colitis anemia and iron deficiency because blood loss in ulcerative colitis is far more common. The presentation…

Andrew: Got you.

Chloe: …is very different. Sorry, go on.

Andrew: I was just gonna interject. So what about the skip lesions, though, and then the extra gastrointestinal symptomatology?

Chloe: Yeah, so with both, I mean, they’re both autoimmune diseases. And interestingly, this is quite new in regards of autoimmune disease, understanding that they’re both recognised as autoimmune diseases now. So a lot of extraintestinal symptoms with both.

Skip lesions are in Crohn’s disease so that you can see lesions in the mouth, the small intestine, and the rectum with Crohn’s disease with completely healthy tissue in between. Whereas ulcerative colitis goes from the rectum and will only move in a continuous motion, and it’s very much on the surface of the mucosa.

So Crohn’s disease can be very deep lesions, a lot of inflammation in the mucosa. More likely to cause strictures because of the inflammation. Whereas in ulcerative colitis, you’re more likely to see wearing away of the digestive tract in that regard. Extraintestinal symptoms, I feel quite passionate about talking about extraintestinal symptoms because that was a really big thing for myself. And I’ll talk about that later if you like.

But just as like a broad overview, things that they look for a lot nowadays is autoimmune arthritis and inflammation of the eyes are really common in Crohn’s disease and ulcerative colitis, but more so in Crohn’s disease.

Andrew: And you said extra things, but can we just touch on a horrible presentation, pyoderma gangrenosum. How common is that in Crohn’s?

Chloe: Cannot talk to that, Andrew.

Andrew: That’s all right, no worries.

Chloe: Try again.

Andrew: But it can be quite horrible for patients because these lesions erupt from what might appear at first as an innocuous bump, and then it turns into a lump, and then the skin tissue just erodes. And you’ve got these horrible ulcers that look very, very similar to flesh-eating disease or a bedsore, something like that, a decubitus ulcer, something like that. It’s quite dramatic and horrible for the patient to experience. But anyway, sorry, forgive me that hasn’t presented in yourself, so keep going.

Chloe: I have seen ulceration of external tissues in patients with Crohn’s disease, generally when they’re on medication. So I’m interested to kind of understand that role and if it is to do with the disease itself, or if it’s to do with a mixture of the disease out of control with medication as well. So I generally see that when people are on medication, they’re not healing very well. Is this ulceration of the tissue, you know, especially around the lower…I’m pointing to my ankle, you can’t see that, but I’m pointing to my ankle. But with the lower limb, I tend to see that. But no, it’s not what I’ve experienced.

I guess fistulas is something that is probably the hardest thing I’ve seen to resolve in Crohn’s disease. And possibly, I would say one of the scarier of the symptoms because you know, you can have openings…fistula can be an opening between the intestines and another part of the bowel, it can be an opening between the intestines and the urinary tract, or into the vagina, or into the outside skin. And because there’s a fecal matter where the opening is, I find that very distressing for a lot of patients and extremely hard to heal.

Andrew: Not just very distressing what about the safety issues there regarding the risk of peritonitis?

Chloe: Yeah, peritonitis is extremely…it’s something that you know, again alongside medications when you have these immune suppressant medications with Crohn’s disease, because we do need to remember that we’re talking about the gastrointestinal symptoms a lot, but it’s an autoimmune disease. So the medication is suppressing the immune system quite significantly.

And when you have this suppressed immune system, you tend to see it hard to heal bacterial infections. So when you have bacterial infections, peritonitis or even sepsis is quite common in patients who have been on long-term immune suppressant medications.

Andrew: Gotcha. And the other thing I was going to ask about is a weird thing, a differential diagnosis if you like, or a differential between…forgive me, not a diagnosis. Do I say the word pathognomonic? This was way a long time ago, so I don’t know if this is current. But there was an interesting thing about smoking: smoking would exacerbate Crohn’s, but it could actually dampen ulcerative colitis. Is that still current thinking?

Chloe: Yeah, it is. Interestingly, when I was first diagnosed, it was considered to be protective for both. So 20 years ago, ulcerative colitis and Crohn’s disease were thought to be dampened by cigarette smoking. It is a really fascinating topic, and I wonder if it’s just because of the way that it impacts and suppresses the immune system, cigarette smoke. But the way that it irritates the intestines, and we know that cigarette smoke increases zonulin in the small intestine for patients with or without inflammatory bowel disease and with or without celiac disease.

So does that increase intestinal permeability and then increase the likelihood of a flare or even the onset of Crohn’s disease? Whereas you know, we’re talking about zonulin in the small intestine potentially. Maybe that’s why it doesn’t impact negatively ulcerative colitis.

Andrew: You know what, I’m also wondering if there may be…I have no evidence for this. I’m wondering if there may be some link between smoking and the upregulation of the 2-Hydroxy estrogens.

Chloe: I’m not sure.

Andrew: That would lead to an association with a hormonal link, a sex hormone link. Have you heard anything about the sex hormones with any other part of Crohn’s?

Chloe: Yeah, I mean, we know that the incidence of Crohn’s is the two times that we see it being diagnosed is teenage years, and then 50 plus, so yes, and it’s predominantly women. We know there must be some hormonal link, but it’s all very tenuous kind of trying to connect the understanding at the moment. But you know, nicotine was used as a medicine at some stage. We did originally think it was a medication. So is it just the nicotine that is actually impacting ulcerative colitis positively?

Andrew: So yeah, so there’s an interesting one. I wonder if anybody out there, any gastroenterologist, is using nicotine patches as a therapy. Because we certainly don’t want to espouse the use of smoking with the, you know, 100 odd carcinogens that you’re inhaling every cigarette. But I wonder if nicotine alone might have some therapeutic effect. It’d be really interesting to look at.

Chloe: I feel like we’re so far away from being able to utilise nicotine or discuss smoking as a benefit anymore. Even when we’re talking about this now, you know, I haven’t had a gastroenterologist talk to me about a positive link with smoking in 15 years. You know, for the first five years I was diagnosed, it was a conversation. It was something that we could talk about. But it’s because of all the risks with smoking; I just don’t think it’s in favour of even discussing the benefits anymore.

Andrew: No, but that’s why I’m saying. I certainly wouldn’t espouse smoking, but I could espouse nicotine patches. Interesting topic. Anyway, Chloe, tell us a little bit about your journey. So when were you diagnosed, what age?

Chloe: I was 13. I was quite young. I was very sick for a long time before I was diagnosed. I was probably…you know, my mom would say I had Crohn’s disease from birth really, I was very sick as a child. I had chronic otitis media; I had all the risk factors, chronic use of antibiotics. I wasn’t breastfed. I was allergic to cow’s milk. And I was brought up on soymilk formula: chronic ear infections, lots of anxiety as a small kid. And then at 12, I had…very early I got glandular fever, and from then it was a year of severe illness until I was finally diagnosed.

Andrew: Okay, so this takes us into a whole area of infection as a possible etiological factor in Crohn’s disease. Can you take us through this? This is really interesting, very controversial. But Tom Borody, Professor Tom Borody, has done some work on this. Not that it’s accepted, but interesting.

Chloe: Yeah, he’s always pushing the envelope. So when it comes to bacterial infections, I mean, they still use antibiotics frequently for flare-ups of Crohn’s disease. So it’s known, we know that there’s some form of infection there. And the predominant antibiotic that’s used is metronidazole, which is a very broad-spectrum antibiotic.

Professor Borody did propose a similar treatment to H. pylori at one stage, saying that there was going to be a triple antibiotic therapy for Crohn’s disease, which I’ve never seen come to fruition. I’ve never seen anyone trial that in practice when I’ve seen patients with Crohn’s disease. He looks at mycoplasma as a role in Crohn’s. There’s also MAPs bacteria. So Mycobacterium avium paratuberculosis MAPs stands for I’m pretty sure, but I’ll double-check that one for you. The MAPs bacteria…

Andrew: Avium.

Chloe: Yeah, avium. I’m pretty sure it is mycobacteria avium…

Andrew: I will list that one down.

Chloe: Pardon.

Andrew: I will list that one down.

Chloe: It’s MAPs bacteria in milk. And the MAPs bacteria in milk has been shown to cause a gastrointestinal illness in animals. And it’s well known that it causes gastrointestinal illness in animals. The symptoms are extremely similar to Crohn’s disease, and we do know there’s also a link between a dairy allergy or an intolerance to dairy as a child and the development of inflammatory bowel disease later on in life?

So there’s two mechanisms there where we suspect that dairy has a role in Crohn’s disease, although unfortunately, we’re still not seeing mainstream medical professionals recommending a dairy-free diet. You know, everyone’s very afraid of us not getting enough calcium. So it’s not being recommended even though there are multiple links to dairy and Crohn’s disease.

Andrew: Yeah, you could then go with regards to calcium. It was very interesting about…was it Loren Cordain, the Paleo diet and he was talking…I remember setting this up; I had two dietitians sitting next to me who were extremely interested in his comment about people always talking about intake. Still, they never talk about the loss of calcium. And a dairy-free diet certainly might not have the intake of calcium, but it also doesn’t have the phosphate, which causes the leakage of calcium out of your body. So it’s a really interesting thing it’s not just as simple as saying in your mouth equals what you get. We’ve got a talk about net gain and loss.

Chloe: A 100%. I don’t understand why we are encouraging people to keep consuming foods they specifically are not digesting. There is no point to having a food you’re not digesting because you’re not gonna get the nutrients out of that until we heal the gut. So you know, dairy is something that I feel really passionately about that everyone should trial; all IBD patients should trial a dairy-free diet.

And you know, when we’re talking about the MAPs bacteria, I think it’s really important to note that it is present in pasteurised milk. So you can’t just go, “Oh, we pasteurise our milk in Australia. We don’t have the bacteria.” Untrue, we do still have MAPs bacteria in pasteurised milk in Australia.

Andrew: Wow. Okay. Chloe, can I go a little bit back again to your childhood. So you were diagnosed in the days before we had these new treatment options, the monoclonal antibodies, the mAbs. So probably one of the most famous is adalimumab. I think it’s critical that all of these monoclonal antibody names are so hard to pronounce that people are pronouncing them with the trade name pointedly because the generic name is so hard to pronounce. But anyway, that’s another political argument.

But you were diagnosed and managed in the days before the mAbs were out. So can you take us through a little bit of your medical journey? And indeed, is it because of that medical journey that you were drawn towards natural medicine? Is that what drew you?

Chloe: I vehemently rejected natural medicine when I was diagnosed. My poor mom tried her absolute best to get me to take some fish oil and some magnesium, and I thought…I was one of those kids that was like, as a teenager, I said to my mom, “If it was real medicine, my doctors would have told me to take that, mom.” So she finds it very ironic that I did pull 180, and I came back to natural medicine in my 20s.

I credit my gastroenterologist, my pediatric gastroenterologist, with getting into remission very quickly when I had a very severe, extensive Crohn’s disease. So by the time I was diagnosed, I was hospitalised. Originally they were going to hospitalise me for anorexia bulimia, and it wasn’t until my orthodontist… So I was sent to the orthodontist to get my braces removed because of all the ulceration in my mouth.

And when the orthodontist looked at my mouth, I’d had severe abdominal pain for a year, lots of diarrhea, lots of fatigue; I was just quite a mess. And he looked at my mouth, and he was the one who said to my mom, “I think she has Crohn’s disease.”

So when I was finally hospitalised with Crohn’s disease…yeah, it’s quite cool, actually. I still credit how well he noticed that. He had a dental assistant with Crohn’s disease, and so he recognised it. And he could tell by the back of my teeth that I wasn’t vomiting. So, where the ulcers were suspected to be from vomiting, he could tell by the back of my teeth that I wasn’t vomiting at the time.

Andrew: You know what’s interesting there is we’re crediting, you know, your dental practitioner, an orthodox practitioner, but pointedly, it’s because he had a close associate. So he was intimate with the knowledge and the issues of Crohn’s. Whereas people who know about Crohn’s disease they don’t get it until it’s real.

And forgive me, and the reason I’m saying this is because time and time again, I’m seeing and more and more, I’m seeing stories of orthodox physicians who have been struck down by a condition, and oh my god, they can’t believe the journey they’re having. This isn’t what medicine was supposed to be like, you know? It’s really interesting when they’re on the other side of the fence or the lens.

Chloe: Yeah. I always wonder with my gastroenterologists as a child whether they had their own personal experiences. And I kind of wish that I’d had that shared with me at the time. It seemed like a very strange profession to me as a teenager. Why would somebody choose to put a camera in somebody’s bum? Why would you do that? And it made sense to me now that I specialised in Crohn’s disease when I was so far away from that interest as a teenager.

It makes sense to me now that I’m passionate about it. Yes, because I’ve experienced it and because I’ve been misdiagnosed and mistreated for a lot of my time. And I don’t want to say my pediatric gastroenterologist mistreated me because I think they did such a fantastic job. They put me on trials of probiotics from a young age, they used…I was on an NG tube when I was hospitalised and nil by mouth for a few weeks, which put me into remission a lot quicker than they ever expected. So I had a lot of…I’m so grateful to my pediatric gastroenterologists for what they did for me.

However, I found that I was not able to live a full life after I was diagnosed until I discovered naturopathic medicine. I was constantly unwell with, you know, conjunctivitis, viruses, infections, I was on immune suppressants on and off, I had swollen joints, I couldn’t play sport anymore. I was a shell of my former self. And because I was in “remission,” it wasn’t

considered a problem with my medication, and it wasn’t considered a problem with Crohn’s disease anymore.

So it was only when we started to understand the autoimmune perspective of Crohn’s disease that I finally had this “aha” moment years after I was diagnosed that my arthritis was actually related to the Crohn’s disease. And seeking naturopathic help was when I finally got my life back in a lot of ways, my quality of life back.

Andrew: You were mentioning as well the ages of presentation, the common ages of presentation, puberty, and menopause-ish. Those periods are classically periods of higher stress. How much of an impact does stress play on the flare of Crohn’s?

Chloe: I would say that it is…of all the autoimmune diseases, I would say that Crohn’s is one of the most closely linked with stress and flare-ups. I’ve rarely seen…you know, I’d see other patients with autoimmune diseases, and I’ve seen a few teenagers with autoimmune thyroid conditions. And I definitely see a link between stress, but it’s not as strong as it is with inflammatory bowel disease. It is at high-stress periods, those times when people are having their first incidences of symptoms, onset of symptoms, or major flare-ups.

In saying that, it’s…you know, I think we talk about diet a lot as management of Crohn’s disease. But what I really try to stress to my patients is, you don’t need to have this really restrictive diet if you’re managing your stress really well. And that really kind of clicks people into “Oh, okay, I really need to do this because I wanna go out and have a glass of wine sometimes. I wanna go and be able to have dinner with some friends.”

It’s something that if you manage your stress levels, then you know, reducing medication becomes a possibility, reducing supplementation becomes a possibility. And being able to relax your diet becomes a possibility, basically managing stress levels.

Andrew: You know, that’s answered something I was questioning myself about saying because I was thinking, “Hang on, Andrew, are you just seeing something that’s very hard to answer from a causal relationship?” For instance, did the stress cause the flare out, or did the flare-out cause the stress flare-up? But what you’re saying now is that really it is the stress because it allows you to pull back on supplements and possible medication, yeah?

Chloe: Yeah, but isn’t that a great point? Because you know, we see a lot of autoimmune diseases in women, right like it’s four to one, women to men with autoimmune diseases. And women are the ones who when they have symptoms they seek help. When they have symptoms, they are more likely to feel quite anxious about their health. Is that perpetuating a lot of their symptoms, the anxiety of the original symptoms are perpetuating further symptoms in a lot of ways?

And that’s a huge part of my practice is counselling and forcing people to go inward and manage how they’re really perceiving their own health. And how they can help manage their stress levels internally because you can’t always manage your external stresses.

Andrew: And also, isn’t it possibly a telling thing about how lazy men are and just how much women do for everybody else? Men are the caregivers, sorry, women are the caregivers, the cooks, the cleaners, the counsellors of all the family, you know, they’re “There, there, daddy’s got a cold.” You know, women take on a lot, and they give a lot of and from themselves. So, you know, I think there’s a big lesson here for men. But anyway. So can we talk…

Chloe: But how hugely protective has it been? Like how lucky are men to be able to protect themselves from these autoimmune diseases because they can pass the buck in a lot of sense? And it blows my mind that my generation still has this pattern. I grew up in a world where men and women were very equal, and I was able to do all the things that the boys were allowed to, and all the boys were allowed to do the things that the girls were allowed to, yet we still see a total imbalance when people are getting married and having children. In my generation, it’s still so common.

Andrew: Look, we could get off onto a whole podcast here about stereotypes and misogynistic terms, and things like that. Like even things like dowdy. The word dowdy is only used to describe a woman. There’s a funny “8 Out of 10 Cats Does Countdown” episode on that. But anyway, I won’t go there, it’s rude.

But it’s really interesting how stress is the foundation or the rotting foundation of so many conditions. You know, and if you can’t do this, it’s so hard to build upon. So can I go into how your patients present? Because obviously, you know, when somebody’s talking about their own personal journey, that’s one presentation, whereas presentations change from a population level. Tell us about them and how they present. What are their main fears and issues that they come to see you about?

Chloe: Yeah, that’s a great question because I actually find myself to have quite an atypical Crohn. So I enjoy sharing about it, but I have to really detach when I’m practising a lot because I see very different symptoms. Abdominal pain still seems to be predominant, but a food fear and an inability to be able to read through the BS of what is healthy for Crohn’s disease is what people come to see me for.

And the way that I can best describe that is the difference in nutritional information out there for Crohn’s; it’s so vast. So you know, you were talking about a paleo diet which you know, there’s definitely evidence for a simple carbohydrate diet for Crohn’s, which has been very successful in some patients with Crohn’s disease. It’s very similar to a paleo diet.

There’s also a low residue diet where you’re cutting out all your fibres, and you’re allowed things like jelly and milk, and we sort of go and lollies in moderation and high fructose corn syrup because they’re low fibre. And that’s a very mainstream medico-diet approach. So I would say diet and trying to filter through that information is the main thing people come to talk to me about.

And the presentation is just this like…a lot of people are still on medication when they come to see me, they’re usually pre-diagnosed before they come in. And they just don’t feel 100%; they’re tired all the time. They have food intolerances and end up with, you know, three days of diarrhea still, even though their blood work comes back perfect. There’s a lot of malaise, you know, it’s this real, like, you know, “My doctors say I’m fine now, but I just don’t feel fine. Like, I just don’t think that I’m getting the most out of my life.”

Andrew: How do they say that? “My doctor says I’m fine, but I’m not.”

Chloe: Well, isn’t that common though in our industry, Is my blood work is…?

Andrew: But is that because the labs…

Andrew: Yeah. Is that because the labs look normal, so therefore, you must be normal?

Chloe: Yeah. And I think lab work is a really important one that does come back very normalised with medication with Crohn’s disease. And that’s the main way that we check whether medications are working is, you know, has the CRP come down. So you know, if we’re talking about lab work what I’m looking for is, you know, is this person still struggling with anemia? Is it anemia from chronic inflammation? Is it anemia from iron deficiency or B 12 deficiency? Is there high C-reactive protein? Is it high at a low grade? Is it a 5, 6, 7, up to 11? Or is it 70 or 140?

You know, the labs can come back at 4 or 5 CRP, and the doctors will say fine, and we know that that lab range means there’s a low-grade chronic inflammation there. Or it can come back at 70 or 100 with Crohn’s disease as well. So what was the original question?

Andrew: Oh, well…

Chloe: How did we get here?

Andrew: …to follow on from that, I was very interested when I podcasted with Datis Kharrazian with his work on autoimmune conditions, not specifically Crohn’s. He’d set up this panel where he could actually predict whether somebody was going to a flare or a remission. So it wasn’t “You are now,” it’s “You are going to be.” Really interesting stuff.

Chloe: Is this the Prometheus?

Andrew: Oh, I don’t know. Look up Datis Kharrazian.

Chloe: Is he in the US?

Andrew: Yeah.

Chloe: Yeah, there’s an amazing gastroenterologist called Ilana. I wanna say, Gurevich. I’m gonna double-check that. She talks to Prometheus as lab markers. We just don’t have that access to those lab markers. So I use GI-MAP as a microbiome mapping. So I use testing that looks at the thaw test to be able to predict a flare-up or the likelihood of onset of symptoms for the first time as well. Things like…that come back in a stool test is calprotectin.

So in the Prometheus, I talk about calprotectin a lot. Still, it is far more prominent in ulcerative colitis because it shows that distal colonic inflammation, white blood cells increasing in that area more so than small intestinal inflammation. So it tends to come up more so in ulcerative colitis.

We’re also looking at zonulin. So as I spoke to you before, high zonulin levels are higher, seen in Crohn’s patients and ulcerative colitis patients. But more so in Crohn’s patients with that small intestinal inflammation and increased intestinal permeability.

So the other markers that you can look for UCRP, your ESRs, your inflammatory markers in the blood, anemia, and looking at the way that the iron is balanced. So you know, low serum iron, high ferritin, and low hemoglobin is a surefire sign there’s something really very intricate, like a very ingrained inflammatory response going on right now to get to that stage.

Andrew: I actually think it…just you mentioning a few of those I do remember like, I think there was interleukin 1b I’m not sure but CSR sorry, high…

Chloe: High sensitivity CRP?

Andrew: C-reactive protein CRP CSR, where did I get that from? Calprotectin. And I think it was tied in with, as you say, your white blood cells or a full blood count. It was very interesting. I’ll have to look up what he spoke about, but it was really interesting.

Before we move on, I just wanna go back a little bit just to touch on something you said about a low residue diet. I remember gastroenterologists putting people on, as you said, like a nil by mouth but you’re talking fed parenterally, correct parenterally? Whereas I’ve heard of patients being put on a milk, you know, 1.5 calories per mil formula just like an oligoantigenic diet for a couple of weeks. Have you found benefit of that, or is it still, “It’s milk, guys.”?

Chloe: Not yet. A very good question. Elemental diet has a very good role in managing Crohn’s disease and has been shown to be as effective as steroids and other immune suppressant medications to put somebody into remission; it’s really quite incredible. Unfortunately, the mainstream ones do have milk in them. And when I look back at things that are accessible to hospitals, even the parenteral nutrition does have some element of dairy protein in it. The different thing is…

Andrew: Really?

Chloe: …it has all the free amino acids. So you know, you’re breaking down all the free amino acids so that your small intestine doesn’t have to work to actually absorb any nutrition. And that’s why you see…giving the small intestine that break is where you see remission. And I have seen remission even using liquid nutrition with dairy in it as well; I have seen that.

Andrew: Gotcha. Okay. Can we go further into the assessments that you use, Chloe? Perhaps in a sort of more formal… You’re mentioning GI-MAP. What is it that you see or that you’re looking out for to try and predict a flare or even a remission, what are you looking at?

Chloe: So the main things I’m looking for is calprotectin that’s a no-brainer and blood in the stool. So if there’s blood in the stool and high calprotectin, you have to refer. So I just need to kind of really make sure that that’s known that we need to refer if there’s ever blood in the stool. If there’s blood in the stool, it can just be from a small hemorrhoid; unfortunately, that we’re referring for this tiny little hemorrhoid. And anyone who’s had chronic IBS and IBD is going to probably have some form of hemorrhoids at some stage.

So you know, blood in the stool, calprotectin, mucus. Mucus is a really good sign for Crohn’s disease, whereas calprotectin is a better sign for ulcerative colitis or Crohn’s disease in the colon. Other things I look for in terms of bacteria, actually in one of the GI-MAPs, you can actually see the MAPs bacteria. So having a look, if there is MAP bacteria there and klebsiella as well, they’re two really big ones that come up in Crohn’s disease and really help direct nutritional advice if you see klebsiella and MAPs bacteria.

Andrew: Now that’s really interesting. You mentioned klebsiella because Professor Alan Ebringer has done work with ankylosing spondylitis. And he was talking about…I said this incorrectly in another podcast. So what he was talking about was basically an infection in the gut with klebsiella, and there was a cross-reactivity with the immune system for klebs, and that was causing the flare in ankylosing spondylitis and, therefore the tissue destruction. And he put them on a low-carb diet. Now he used antibiotics and certain other agents. Are you familiar with his work?

Chloe: I’m familiar with the treatment for klebsiella in terms of a simple carbohydrate diet is…treats klebsiella.

Andrew: Gotcha.

Chloe: And it should be noted ankylosing spondylitis and IBD, so closely linked, so commonly seen together.

Andrew: Gotcha. This is just falling into place now. I knew he was a good guy. He was such a lovely, quiet gentleman. He was a beautiful, beautiful man, very quietly spoken but plodding along in his own sort of thing being laughed at by the orthodox medicos, and he’s a professor in St. John’s College, I think in one of the unis in England.

Chloe: It’s very cool to see mainstream medicos look at this. He’s actually quite…because Crohn’s disease and inflammatory bowel disease, in general, is not very well understood in its pathogenesis. And where it starts from, there are so many theories out there that there is…and because we’re actually seeing it in pediatric patients more and more. When it goes into pediatric patients, I find there’s a push to look at things that are non-medicated. So looking at parenteral nutrition, elemental diets, probiotics, there’s a lot of research into probiotics and inflammatory bowel disease. There’s research into curcumin, Boswellia, wormwood.

It’s pretty interesting to see, and a lot of the time, it’s actually started by mainstream gastroenterologists that just are so sick of the main treatment protocols they have. And you spoke to the medication that they’re using nowadays, the biologic medications, the ones that work on treatment of necrosis factor-alpha the adalimumab, and things like that. Those medications before that came along what? 10, 15 years ago, the medication protocols for Crohn’s were just really…they were not great. They were not putting people into remission for long periods. And we were just seeing increases in incidence of diagnoses and increases of incidence in surgeries before those medications came along.

Andrew: Gotcha. Now, you said something there that was really interesting. And that was about not the medications. Oh, that’s right. orthodox medicos now looking at natural agents. I was looking at the GESA, the Gastroesophageal Society of Australia. So gesa.org.au, I think it is. And if you look up the practise guidelines for inflammatory bowel disease and then you scroll down and down and down to Crohn’s, turmeric is there.

Chloe: Yeah, it is…

Andrew: The orthodox guidelines.

Chloe: There’s actually research on curcumin and adalimumab and, like, looking at them in a controlled study to tell whether curcumin is a good alternative. All very preliminary research, I am not suggesting that anybody goes out there and takes their patients off these biologic medications and puts them onto curcumin and expects to have a good result. Because coming off those medications, there is a high risk of a big flare-up, so you need to be very careful. The research going into it is incredible.

My wish is that they wouldn’t put people on these medications so quickly. I understand why they’re doing it; it’s because they are seeing that surgery is delayed. So when people use these medications, they’re seeing that they’re staying another five years without surgery. I’m really interested to see how this actually progresses because, clinically, I see more surgery. I’m seeing a lot of people who have ileostomy and colostomy bags already, and that’s completely different treatment protocol again.

But yeah, the research into curcumin is fascinating. Boswellia has been around for about ten years; they’ve been researching Boswellia and comparing it to DMARDs. So this is when DMARDs were used, things like sulfasalazine and mesalazine. They use those to put patients with Crohn’s disease into remission before they had biologics that was quite common. I’m not seeing it as frequently anymore, but they used Boswellia as an alternative and found good results with Boswellia. All preliminary, really small study…

Andrew: Right, so DMARDs…sorry, just for everybody listening or watching DMARDs are disease-modifying anti-rheumatic drugs, correct?

Chloe: Yeah, correct.

Andrew: Yep. So sorry, Chloe, go on, forgive me, I cut you off.

Chloe: That’s okay. So that’s the other one. The other thing that I’m finding there’s a lot of research on is the use of probiotics. So I sort of spoke to that a little bit before there’s like these multi-strain probiotics, and they’re looking at the way that they can modulate the immune system.

And you know, going back to the GI-MAP, we see commonly a decrease in good bacteria, it’s just, is that where it starts? And that’s probably my favourite hypothesis is when we look at the hygiene hypothesis, how we have this really depressed microbiome in our IBD patients. And in our Western societies, we don’t have the diversity in our microbiome anymore. We are using…and our poor children are going to have…of this generation are going to be obsessed with hand sanitiser, and I just fear for their microbiomes. I think about that; I lie awake thinking about this at night. And this is where we see autoimmune diseases.

Andrew: I hear you. It goes further than that with our kids because, in such a litigious society, I mean, monkey bars are out. You can’t play on monkey bars as a kid because kids break legs. Kids have always broken legs, give them a tree, and they’ll break a leg. It’s just really interesting. And the problem is because everybody’s concerned about being sued. That’s it. And so we’re just getting less and less adventurous. I understand risky behaviour. I’m not talking about that. What I’m talking about is normal everyday play in dirt. I mean, it’s almost like you can’t go out and get muddy.

Chloe: I love that. Get them out in dirt, that is…you know, every kid that comes in and uses hand sanitiser as soon as they come in from the dirt, I cry a little inside. But this is something that I think is probably one of the best hypotheses for the development of Crohn’s disease. Is this really depressed microbiome diversity numbers, and you just see it constantly with GI-MAPs.

So you see that akkermansia is decreased, the paracasei is decreased, you see butyrate is low, high incidence of fat malabsorption. So you know that fat’s going through and dysregulating all of the bacteria undigested all that kind of stuff. So it’s really…you know, it’s about building as much as it’s about clearing. And from a mainstream medico, we go around with antibiotics, clear it all out, let’s get rid of the bacteria.

And then, naturopathically, we need to start rebuilding. And this is where the simple carbohydrate diet and the low residue diet, using them at the right times, is really important. And introducing fibres at the right time is really important as well.

Andrew: You know, just a point you made just before about missing microbes. Indeed, I don’t know if you can see it behind me in there. But there’s the book called “Missing Microbes from Dr Martin Blaser. Do I say, doctor or professor? And he addresses indeed this issue about what’s happened to our microbiome in

general compared to the hunter-gatherer tribes around the world. So if anybody is interested in “Missing Microbes,” by Martin Blaser, B-L-A-S-E-R, I think it is.

So Chloe, thank you. Can we go into a few more of the supplements that you employ? I remember you were saying about your mum employing fish oil or trying to get you to take fish oil. What about things like cod liver oil with vitamin A and vitamin D and how they work with you know, what is it FOXP3 and the other one, the yin and yang with [inaudible 00:44:00]?

Chloe: I love fish oil for trying to regulate the immune system, and I think that’s a really important part. So when we’re looking at Crohn’s disease and treatment, it’s about soothing the gut. So we need to make sure that inflammation is soothed on one level. We need to make sure that we’re modulating the immune system on another level. And the other level is actually increasing the way that we digest our food. So there’s almost three different areas to go through.

The way that I really like…the treatment that I think is most important is the immune regulation because that’s where we sort of, you know, talking about, you know, cod liver oil and fish oils regulating T helper. So you know, we’re regulating the immune system because we do think that there is a role of T helper in interleukin ten specifically, dysregulation in Crohn’s disease.

So that means that ongoing we see tumour necrosis factor-alpha in overplay, we see NF-KappaB is dysregulated as well. So by using things that modulate the immune system inflammatory processes like fish oils, vitamin A, vitamin D, we can sort of start from that process.

The thing that I caution, though, is fat malabsorption and using fish oil when there’s fat malabsorption. So I do like to make sure that the steatocrit is over 500, no, not over 500. I’m talking about pancreatic elastase is over 500, and steatocrit is well under the reference range before we go in with fish oil. So using other things before that like curcumin, wormwood, and Saccharomyces boulardii are other ones that have been shown to regulate the immune system as well.

Andrew: Now, you said wormwood?

Chloe: Yes, I love…

Andrew: Why not things like berberine?

Chloe: I love wormwood and it is such an underrated herb. And I’m talking about Artemisia absinthium. So it’s only available in liquid in Australia this wormwood. There is research looking at assisting people coming off corticosteroids, and the steroid-sparing effect of wormwood, and how using them concurrently actually reduces the incidence of needing steroids in the future. It’s a pretty cool little herb there that we just…I don’t think we’re using anywhere near enough.

Andrew: What about combining it with licorice? Do you ever do that for its steroid-sparing effect at all?

Chloe: Definitely, I love using licorice and/or Rehmannia. So depending on what else is going on, you know if I have a teenager, I love licorice. If I have somebody who is in their 50s, 60s who is also on blood pressure medication, I’ll pick Rehmannia.

Andrew: Okay, I have to ask about hemidesmus. Do you ever use it?

Chloe: I used to use it all a lot, actually. I fell out of favour with it just because I wasn’t seeing clinically that it was working as well as wormwood. So it was no other reason. Like, I used to use a hemidesmus Rehmannia combination all the time, and it was just…I definitely was seeing results, but I would just say it kind of fell down the ladder in its clinical improvements. I wasn’t seeing it as well other things.

Andrew: Okay, you mentioned probiotics a few times, do you…? I mean, the original research was on VSL#3, which is a combination of certain bacteria. And the research was mainly in decreasing inflammatory pouchitis.

Chloe: Mm-hm.

Andrew: It wasn’t in really flare and maintenance?

Chloe: It was in…it was actually my own pediatric gastroenterologist who did some research into VSL#3 in the early 2000s and found that it reduced the incidence of…from memory, it was incidence of flare and severity of flare in ulcerative colitis but not in Crohn’s disease. That was the result of that study.

Andrew: That was it, yep. Okay, so probiotics, you’ve said Saccharomyces boulardii. Do you ever use any of the…? Let’s face it; they’re milk-based probiotics, most of them. Do you ever favour them?

Chloe: To be honest, I don’t use…besides probably Lactobacillus rhamnosus GG, I use quite a bit of. I use a lot of Saccharomyces boulardii. I will with ulcerative colitis patients use that multi-strained high-dose probiotic short term. But I would much rather look at trying to increase the bowel flora with fibres when somebody is not in acute flare.

So that’s my main mechanism of improving the microbiome outside of using Saccharomyces boulardii SB. I would hesitate to say almost all my Chron’s patients start with SB. Not everyone responds perfectly to it, but most find that really, really effective is Saccharomyces boulardii at 1,000 milligrams daily.

Andrew: Who’d have thunk that a little bit of…what is it mangosteen fruit skin could give us such a wonderful natural drug. What about you…you were speaking earlier about fat malabsorption. And if we’re talking about malabsorption, what’s the point of giving fats? Don’t we have to look at how we’re digesting those fats?

Chloe: Yes, yes, yes. And this is where patients who have…this is the different diets. So to kind of give you an overview of different diets, if somebody has had Crohn’s disease or ulcerative colitis from a really young age, specifically Crohn’s I should talk to, from a really young age or has…you know, they could have gotten in their 20s, and they’re now in their 50s, or they’ve been misdiagnosed for a really long time. They probably had it for 30 years.

These are the patients who have a lot of damage to the small intestine. These are the patients where you have to heal the small intestine first before you start to reintroduce fats. Because otherwise, it’s like putting oil on a fire and putting oil on a fire; it’s just gonna further aggravate that inflammation because you’re not digesting the fats properly.

When somebody has been diagnosed in just the last few years, they haven’t had symptoms their whole life; they probably had an infection that triggered something, they had a huge stressful experience that triggered something. You know, whatever the trigger was, before that, they didn’t have a lot of symptoms, those people, fish oil. They usually don’t have the fat malabsorption, so that you can go on fish oil really early, and you can do a simple carbohydrate diet really early and get really good results with those people.

Andrew: Chloe, there’s so much more to go into. And we need you delivering seminars to practices. This is such golden information; thank you for sharing it with us. Can I just ask quickly, because we have run out of time, where can praccies find out more, at least in the initial stages, and please, please, please do you have any mentorship that you’re looking at in the future, please?

Chloe: Yes. I feel very passionately about treating Crohn’s disease, as you can obviously tell. But I feel mostly passionately about the fact that you have to really go at it from a different perspective to other autoimmune diseases, so I do offer mentoring to other practitioners. I can do…that’s always accessible.

Andrew: Great. And what about other sort of resources that you really think are worthy of practitioners to learn from?

Chloe: One of my favourites, as I said before, Ilana Gurevich. I don’t know how to use her whole last name. Ilana Gurevich is a US practitioner, and I find her information absolutely invaluable. She talks about the different ways that she reads GI-MAPs as well, and I find that so fascinating. So she’s got some really good podcasts that she’s done with Michael Ruscio.

I also really like…”Neurology COBI” [SP] has some really great resources as well for CBOE, or at the risk of starting another conversation, CBOE. I’m sorry, I shouldn’t start this now. But, you know, looking at CBOE in Crohn’s disease because of the impact on the ileum and the ileocecal valve is really important. So I look at a lot of “Neurology COBI” information.

Andrew: Podcast number two coming up.

Chloe: Yes, sorry.

Andrew: Thank you, Chloe, for taking us through…thanks for taking us this through this, though, today. Seriously it’s been invaluable, really eye-opening. And there are so many more questions that you go hang on, but what does that mean? But thank you so much for sharing; it’s not just your personal journey but also your dedication to your patients. Because it’s clear, it’s clear to see that you have their best…what do you call it?

Chloe: Interests, patient outcome?

Andrew: Their health interests, thank you, their best outcomes in mind. Thank you, Chloe, gosh. But thank you, everyone, for joining us today. And you can find all of these resources, and we’ll put these up on the designsforhealth.com.au website. So thank you very much for joining us today. I’m Andrew Whitfield-Cook. This is “Wellness by Design.”