Tag Archives: IBD

More Butyrate Series, Part 8: Clostridium butyricum and Ulcerative Colitis, Irritable Bowel Syndrome, and Antibiotic Associated Diarrhea

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Clostridium butyricum, a soil-based probiotic used commonly in Asia, colonizes the gastrointestinal (GI) tract of about 10-20% of the human population. Although it does produce butyrate in the GI tract, studies show it creates beneficial effects independently of butyrate too. I do not endorse Clostridium butyricum supplements. I became interested in learning about them because I’m interested in the effect of butyrate on slow colon motility. When I started reading about Clostridium butyricum, it sounded like a nice little probiotic, to the point that I have expanded Part 8 of my Butyrate Series much more than I anticipated in order to elaborate on Clostridium butyricum. (See the first post of Part 8 here.)

I’d like to highlight studies on Clostridium butyricum’s use for GI diseases in this and the next post (or two). Please, remember, I am NOT recommending this probiotic for anyone. I just enjoy reading, researching, and compiling information on niches I am learning about. Do NOT use anything on this blog as medical advice, even if I seem nice, honest, and have certain initials after my name. Anyone on the internet can feed you a line.

By all means, if you think Clostridium butyricum sounds right for you, print off the studies I cite, highlight important points, and hand them to your healthcare provider to see what they think. Although most of the information I have read about Clostridium butyricum, both scientifically and anecdotally, has been positive, I have read tidbits where it made some people worse. (Please pay attention. The Clostridium butyricum probiotics I have found have lactose in them and potato starch, which I know many readers are sensitive to.)

And, as always, please help me with typos or incorrect information. And because it’s more important than anything, be kind and gracious from your heart to all. This world is hurting.  And…now back to science.

Ulcerative colitis

Clostridium butyricum (Bio-Three brand) promoted remission in refractory ulcerative colitis patients, particularly if they started the study with low fecal Bifidobacteria counts.

Twenty refractory ulcerative colitis patients received Bio-Three, nine tablets daily for a month.

  • Nine of the 20 (45%) patients went into remission
  • Two of 20 had a positive response but not full remission
  • In total, 55% had clinical and endoscopic improvement.
  • Nine had no response or worsened. (One of 20 became worse.)
  • 10 of the 20 patients also received 100 grams of “fiber,” which seemed to make no difference in any parameter.
  • Response to the probioitic was not correlated with initial severity of disease symptoms. A person with “terrible” ulcerative colitis symptoms could do–or not do–as well on the probiotic as someone with “mild” symptoms .
  • Patients’ fecal biomes were able to be categorized into three distinct clusters, and those in the clusters with lower Bifidobacteria seemed to respond better to the probiotic and had improved fecal microbiota profiles after therapy.

Source: Clinical effectiveness of probiotics therapy (BIO-THREE) in patients with ulcerative colitis refractory to conventional therapy. Yukiko Tsuda, Yasushi Yoshimatsu, Hiroshi Aoki, Kentaro Nakamura, Masaki Irie, Katsuyuki Fukuda, Nobuo Hosoe, Nobuo Takada, Koji Shirai & Yasuo Suzuki. Scandinavian Journal of Gastroenterology. Vol. 42 , Iss. 11, 2007.

Clostridium butyricum (Bio-Three brand) maintained clinical remission better than placebo did in already controlled ulcerative colitis patients over the course of a year, although the results were not statistically significant.

Of forty-six patients, half received three tablets of Bio-Three three times daily and the other half received placebo doses instead.

  • At three months, the relapse rates in the probiotic therapy group was 0% compared to 17.4% for placebo.
  • At six months, the relapse rate in the probiotic group was 8.7% compared to 26.1% in the placebo group.
  • At 9 months, the relapse rate in the probiotic group was 21.7% compared to 34.8% in the placebo group.
  • At 12 months, the remission rate was 30.5 % in the probiotic group and 43.4% in the placebo group.
  • Fecal flora was analyzed and three clusters of bacterial profiles were identified: cluster I, cluster II, and cluster III. Cluster II has the highest levels of Bididobacteria and benefitted the least from the addition of the probiotic. Cluster I had the lowest level of Bifidobacteria and benefitted the most from the addition of the probiotic, which seems, among other things, to shift the flora to be more consistent with a cluster II bacterial profile. Cluster III was somewhere in the middle for Bifidobacteria.
  • The butyrate to acetate ratio was higher in patients who relapsed. The researchers suggest that the colonic cells are not able to uptake butyrate properly so it persists in the fecal matter.

Source: Yoshimatsu Y, Yamada A, Furukawa R, Sono K, Osamura A, Nakamura K, Aoki H, Tsuda Y, Hosoe N, Takada N, Suzuki Y. Effectiveness of probiotic therapy for the prevention of relapse in patients with inactive ulcerative colitis. World J Gastroenterol. 2015; 21(19): 5985-5994.

[So why not just take Bifido? I think one has to think about the whole climate of the GI tract. Clostridium butyricum would not directly inoculate Bifido. I’d like to think it creates bacteriocins (its own natural antibiotics) and pH changes that can then allow Bifido to properly reproduce and thrive as indicated. Like bringing in hummingbirds by planting geraniums and butterfly bushes. I can put hummingbird food out in winter and bring them, but I haven’t really provided them an environment to prosper. It’s all about cultivating an environment for cure to effect itself–not about taking the magic pill for cure. That’s why food is key.]

Treating ulcerative colitis patients who had food allergies with Clostridium butyricum (420 mg twice daily, brand not mentioned) plus specific immunotherapy for a year reduced the need ulcerative colitis medication.

[Aside: If you have ulcerative colitis, has your healthcare professional suggested food allergy for your consideration?]

Eighty patients with food allergy (diagnosed by skin testing) associated ulcerative colitis were divided into four groups: placebo, Clostridium butyricum only, specific immunotherapy only (SIT), or Clostridium butyricum with specific immunotherapy together. Using Clostridium butyricum alone or specific immunotherapy alone non-significantly reduced the need for ulcerative colitis medication. However, using the treatments together significantly impacted and reduced the need for medication for ulcerative colitis.

The study also investigated the cellular differences and immune response differences among the placebo group, the food allergy ulcerative colitis group, and the non-food allergy ulcerative colitis group. There were marked, significant differences among the groups, reflecting the significance of food allergy on the cellular response of the body. This study found that food allergy associated ulcerative colitis has unique cellular and immune response differences. [It reinforced in my mind the need for inflammatory bowel patients to modify their diets, especially looking at the top 8 allergenic foods.]

Source: Specific immunotherapy plus Clostridium butyricum alleviates ulcerative colitis in patients with food allergy. Bin La. Fan Yan. Dong Lu. & Zhenlv Lin. Scientific Reports 6, Article number: 25587 (2016).

Taking Clostridium butyricum (Miya-BM, three tablets three times daily) after total proctocolectomy with ileal pouch anal anastomosis for ulcerative colitis seemed to decrease the risk of pouchitis compared to placebo over a two-year period.

Nine patients received the probiotic and eight patients received a placebo; however only seven of the probiotic patients completed the study. Only 1 of the probiotic recipients developed pouchitis, whereas 4 of the placebo patients did. The difference was not statistically significant. Miya-BM was the probiotic. It is the same strain and made by the same manufacturer as the Miyarisan Miyairi CBM 588 I mentioned in the last post. However, the label for the Miyarisan Miyairi CBM 588 tablets that I see have 270 mg compared to the 20 mg mentioned for this study. I’m not sure how to compare that for equivalent dosing among Clostridium butyricum probiotics.

As mentioned in the other studies above, Bifidobacteria increased with use of the Clostridium butyricum. (It also increased in the placebo arm, but the placebo was lactose, which the researchers feel may have allowed Bifidobacteria to increase.) It was also found that Escherichia coli also decreased with Clostridium butyricum use. One last interesting parameter to point out is the effect of Clostridium butyricum on AST and ALT values (“liver function tests”). Clostridium butyricum significantly reduced AST and ALT values compared to placebo.

Source: The effect of Clostridium butyricum MIYAIRI on the prevention of pouchitis and alteration of the microbiota profile in patients with ulcerative colitis. Yasueda, A., Mizushima, T., Nezu, R. et al. Surg Today (2016) 46: 939.

Irritable Bowel Syndrome (IBS)

Although Clostridium butyricum is commonly used in Asia for diverse indications, which I assume includes general symptoms of abdominal discomfort, bloating, and diarrhea (aka, irritable bowel syndrome), I did not readily find irritable bowel studies using Clostridium butyricum. I’ll present what I did find.

A new 2018 study on mice concluded that Clostridium butyricum may exert a beneficial action on visceral hypersensitivity of IBS by inhibiting low grade inflammation of colonic mucous through its action on NLRP6.

NLRP6 is thought to help stabilize the intestinal epithelium to allow repair. In this mouse study, Clostridium butyricum (dose: 1.25×10^9 CFU once daily for 7 days) increased NLRP6 while inflammatory IL-18 and IL-1B were decreased. Inflammatory infiltration into the colonic mucosa was decreased in the mice who received the probiotic. Mice who received Clostridium butyricum had less visceral sensitivity.

Source: Kejia Zhao, Leimin Yu, Xi Wang, Yibo He, Bin Lu; Clostridium butyricum regulates visceral hypersensitivity of irritable bowel syndrome by inhibiting colonic mucous low grade inflammation through its action on NLRP6, Acta Biochimica et Biophysica Sinica, Volume 50, Issue 2, 1 February 2018, Pages 216–223.

In a 2013 Chinese study, two groups of irritable bowel patients received the same dietary information and were maintained on common drug treatments. However, in addition, one group received Clostridium butyricum 500 mg twice a day for a month. At the end of the month, the researchers reported a significant improvement in symptoms of the Clostridium butyricum group.

The study is a Chinese study, and I cannot find it any more than I reference.

Source: http://en.cnki.com.cn/Article_en/CJFDTOTAL-GLYZ201303005.htm.
Zhu Ya-bi, Li Hong-guang, Wang Chang-xiong, Wang Wang-yue. Effects of clostridium butyricum in adjuvant treatment of patients with irritable bowel syndrome. The Chinese Journal of Pharmacology. 2013.

To prevent antibiotic associated diarrhea

In children who required antibiotics, Clostridium butyricum (MIYAIRI) decreased the frequency of antibiotic-associated diarrhea. The probiotic was effective in both prophylactic prevention of diarrhea and also in treatment of antibiotic-associated diarrhea.

Study participants were divided into three groups: antibiotic only, antibiotic with Clostridium butyricum started half-way through the duration of antibiotic, and antibiotic with Clostridium butyricum given at the start of antibiotic dosing. The dose of Clostridium butyricum CBM was 1-4 grams daily of 10^7 CFUs in the form of a dissolvable powder. When the dose was higher than 3 grams, the beneficial effect of the Clostridium butyricum on loose stools was statistically significant: 83% versus 49%. Stool studies also showed that a more normal microbial flora was preserved with concomitant use of the probiotic.

Source: SEKI, H., SHIOHARA, M., MATSUMURA, T., MIYAGAWA, N., TANAKA, M., KOMIYAMA, A. and KURATA, S. (2003), Prevention of antibiotic-associated diarrhea in children by Clostridium butyricum MIYAIRI. Pediatrics International, 45: 86–90.

In a small study of 19 patients being treated for Helicobacter pylori with amoxicillin and clarithromycin, Clostridium butyricum (Miyairi CBM 588) at increasing doses eliminated diarrhea and/or soft stools. (A “regular” dose of 6 tablets of 10^7 CFUs showed a decrease in diarrhea, but a double dose of 12 tablets seemed to prevent diarrhea completely.)

Source: Efficacy of Clostridium butyricum preparation concomitantly with Helicobacter pylori eradication therapy in relation to changes in the intestinal microbiota. Kyoto Imase, Motomichi Takahashi, Akifumi Tanaka, Kengo Tokunaga, Hajime Sugano, Mamoru Tanaka, Hitoshi Ishida, Shigeru Kamiya and Shin’ichi Takahashi. Microbiology and Immunology. Volume 52, Issue 3, Version of Record online: 8 APR 2008.

Closing

I’ll have more coming on leaky gut, anxiety, pathogenic gut infections, and more!

Terri

Before You Give Up On Your Diet

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By NMajik at en.wikipedia (Own work (Original caption: “Source: Self”)) [Public domain], via Wikimedia Commons

By NMajik at en.wikipedia (Own work (Original caption: “Source: Self”)) [Public domain], via Wikimedia Commons

This is the last post in my little Specific Carbohydrate Diet series. The Specific Carbohydrate Diet (SCD) is just a real food diet, with some added food tweaks that good observers throughout history have discovered reverse disease and promote healing. It is not the holy grail of diets, although for some patients, it is the cure they were looking for. (You may prefer the word “control” instead of the word “cure,” since these patients will probably never be able to go back to DiGiorno pizza.) I definitely suggest the SCD for Crohn’s and ulcerative colitis as a starting point diet because there is research behind it. (See here for a short summary of the evolution of the SCD diet with references.)

When I used a form of SCD for my gastrointestinal issues (not inflammatory bowel disease), I ran into a few issues and the diet stalled for me, even regressed. I don’t give up easily when I think there’s a way to accomplish something, and so I played around with the diet and I read what other people trying the diet were saying. I’ve compiled a little list of things to try if SCD is not working for you.

Remember, nothing here on my site is medical advice and should always be investigated and explored. Talk with your doctor and maybe get a referral to a dietitian for help. This is the internet. Believe nothing. Question everything.

Eliminate “pesky” foods that are allowed on the diet: nuts, peanut butter, eggs, dairy. Foods that we know cause life-threatening allergies can also cause other immune reactions in the body that aren’t nearly so serious. Even though they aren’t life threatening like true allergy, they still can cause bad, uncomfortable immune reactions, especially at the interface of the gut lining (but not limited to the gut lining).

Common food allergens like nuts, peanuts, dairy, and eggs are notorious for more than just anaphylaxis and hives! If you read research studies, you’ll see them coming up again and again for things like migraines, eosinophilic esophagitis, and eczema! I feel like medical doctors only communicate the life-threatening aspect of these foods (which is super important, of course), and ignore their involvement in so many other disease states. So people walk around treating their problems with creams, puffers, and pills, when they could be investigating their diet.

The Specific Carbohydrate Diet allows eggs, almonds, nuts, peanut butter, homemade yogurt, cheeses and butter. All good foods! But also all known top allergens that can perpetuate illness in susceptible people.

(Coconut is not necessarily a top 8 common allergen, but I’ve read of many SCD’ers having trouble with it, particularly the flour. I’d add it to the “pesky” list.)

How do you know which “pesky” to take out? Well, you can start with the one you have a sneaky suspicion about. Or you can see if your doctor will order you an IgG blood panel (which has such variable results for people), although you need to know up front that many conventional medical doctors disapprove of them. Or you can eliminate them all, and slowly bring them back in one at a time.

Whatever you do, be smart and make sure you’re getting any nutritional deficits accounted for!

Cut down on baked goods. When people switch to the SCD, they often, understandably, try to recreate the diet they had been eating: muffins, breads, pancakes, and cookies. ALL of these things can be made on the SCD and are super tasty! However, the ingredients for them come from the “pesky” category (almond flour, eggs, butter, and so on), so they really shouldn’t be routine food fare. They also come with a big whop of sugar; yes, I know it’s honey, but fructose in excess has its own negative effects. Baked goods are great as a transition to ease families into eating more real, wholesome foods. If my kids hadn’t had a baked good, I would  have had some runaways.

In any area of the diet you may be lapsing and skimping in, get strict again. Get back to eating only the legal foods with “no exceptions.” It’s so easy to let products back into our kitchens. A little guar gum here. A little BHT there. Some maltodextrin there. Some modified food starch. And then you’ve walked down the slippery slope and fallen. Crash and burn for a few little ingredients that really weren’t even that important to you!

Studies indicate that emulsifiers may cause problems for inflammatory bowel disease, so if you’re struggling, get the “small stuff” back out!

Alternatively, perhaps the idea of “being strict” is sabotaging adhering to the diet well, and adding in a few select real, whole, foods, like rice and/or potato may be helpful in overall adherence to the diet.

Even though certain foods are not allowed on the diet, that doesn’t mean that a person’s body and disease will not tolerate them. Yes, it’s best to adhere to the diet as it is written, but it is VERY likely that adjustments will have to be made. Remember, the diet is not magic. It can’t prophesy exactly what your body will and will not tolerate. If adding in a food that may not be problematic anyhow is the price to pay for keeping on the diet instead of giving up completely, it’s worth a trial! Make sense? (But do talk with your healthcare provider who is overseeing your diet. They might have some other tips they’d like you to try first.)

Elaine Gottschall, the author of the diet, did not intend for The Specific Carbohydrate Diet to be a forever diet. She advocated moving off the diet once symptoms were well-controlled.

Read about FODMAP foods. Foods have natural sugars and molecules that we don’t absorb and that feed our gut bacteria. It’s actually a good thing. But sometimes, guts that are compromised need a break from these too, or else they’ll have painful bloating, gas, diarrhea, and/or constipation.  FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. FODMAP foods can cause pain outside of actual inflammatory disease and would be worth exploring. I have noticed that many people suggest cutting down on fruit if the SCD isn’t working well for you, and I can see where certain fruits will exacerbate a FODMAP condition. Here’s a good site with FODMAP information. Just click on the symbol, and it brings up a nice handout.

Take away the power struggle. When it comes to kids, they MUST understand the diet and their bodies. Kids usually make good decisions when they’re given good information and see the impact of certain foods on their bodies. Make it a point to understand the diet and read the book, then paraphrase it and explain it to your child. Kids need empowered, not controlled. Sometimes our fears lead to a strong need to control, but kids will buck this. Well, at least mine do!

The mind-body idea. We KNOW that there is a BIDIRECTIONAL process between the brain and the gut and conversely, the gut and the brain. It works from the bottom up. And the top down. If you’re ready to take it beyond diet and supplements, maybe it’s time to move inward. Google things like mindfulness and IBD. Or hypnotherapy and IBD. See what you think. This area has definitely piqued my interest. It takes me months and years to write, so you’ll definitely want to read in this area before I get any posts up on it!

Well, that’s it for today. I’m sure there are other tweaks. I think the best tweak is to know you’re going to be okay. Know that nothing can get you, because you’re bigger inside than anything you can comprehend. If you’re on the religious side, know that you’re a spiritual being forever with a human body but fleetingly.

Feel welcome to post any tweaks you’ve found beneficial.

Over.

Terri

 

Explaining That Diet Does Help Severe “Stomach” Problems

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baadsgaard-alfrida-ludovica-vi-opstilling-med-ananas-druer-ogImagine having diarrhea 15 times a day, every day. Add some blood to that. While you try to walk across a university campus. Or coach basketball.  Or serve on a Navy ship in the middle of the vast ocean. Or learn to add, subtract, and multiply.

This is life with Crohn’s disease or ulcerative colitis, collectively called inflammatory bowel disease (IBD). And when I was a medical student on general surgery, I swear it seems like we were digging around every day in some poor patient’s intestines due to his or her inflammatory bowel disease. Many emerged from surgery with bags to collect their liquid bowel movements.

I feel like I’ve heard it a thousand times. “My doctor says it doesn’t matter what I eat for my Crohn’s disease.” Have you heard that? Do you believe that? That’s 100% false. Research since the 1970s shows that patients can go into remission with special “nutritional shakes.” 

Patients are often convinced that food impacts their disease, but they can’t always pinpoint how or which foods. Medical studies weren’t very helpful in the past; they looked at things like fats, amino acids, and vitamin D, finding some correlations, but nothing to hang their hats on. So hard-working doctors just shrugged their shoulders and said, “It doesn’t really matter, dear patient. Just eat.” [Scram. I’ve got 8 patients waiting to see me. I don’t have time to listen to you speculate about whether or not milk gives you diarrhea.]

But fascinatingly, studies have shown for forty years now, plus or minus, that IBD can be controlled with nutrition! Well, more accurately put, researchers and patients controlled IBD with exclusive enteral nutrition. Exclusive enteral nutrition, EEN for short, is basically just a “nutrition” shake kind of like Ensure or PediaSure, only it tastes much worse. The ingredients in the shake have been pre-digested so they can be absorbed completely in the small intestine.

Studies have repeatedly and reproducibly shown great results for IBD patients and EEN, particularly Crohn’s disease. How great? Well how does upward of 100% sound to you for a remission rate? Would you even settle for a 70% rate? Yeah. That good. I’m cherry picking a little; some studies didn’t have such high success rates, but most did. And some studies that didn’t look all that good to begin with looked better after the study results were adjusted for patients who just couldn’t tolerate the special liquids (often quite a few). Also, results were consistently better for pediatric patients [who often heal more quickly and have to be compliant whether they like it or not—and sometimes choose to be compliant because they feel so much better!]. (Kansal, 2013)

But patients and doctors, I guess, weren’t having that. Too yucky. Too restrictive. (Just for interest, I notice that Nestle seems to make many of these nutritional EENs.)

What’s in that shake?

Great minds pontificated about what it was in the EEN drink which could cause these patients to do so well. They played around with the liquid formulas with good success, trying to make them less repulsive and less expensive. Then they pondered, “Well, can we let our patients eat [cake] and take some of this EEN stuff?”

So researchers let patients drink the liquid EEN formula and have free access to table food at the same time. Yum! With free access to table food, despite the nutritional “shake,” the remission rates weren’t as good as when a patient ate only EEN liquid—but they were better than the patients who received no EEN at all. Aha! So it’s starting to look like something in table food perpetuates increased inflammation in inflammatory bowel disease patients. (Triantafillidis, 2015)

Okay. All Mama’s good table food really threw a wrench in the great effects of the EEN shakes. What next?

Well, allowing table food was a step backward, and researchers thought, “We need another twist. What can we do? This is fun.”

So researchers gave patients nutritional “shakes” and they let them eat only certain allowed foods. (NO CAKE this time. Sorry.) Bingo. Success rates held at about 70% of patients showing improvement and or sustained remission. (I know a lot of doctors who made just 70% in class and are successfully practicing. Pass equals MD, baby. Seventy percent is pretty good.) That’s awesome. How happy would you be to be symptom-free and able to eat some real food?  (Sigall-Boneh, 2014)

It’s 2017. Can we ditch the EEN altogether and just eat real food?

Now, we have to cap it off. Could patients get off of the disgusting “shakes” altogether? (Good-bye, Nestle…) Well, the Journal of Clinical Gastroenterology is about to publish a study done by a Dr. Suskind (and his team, of course!) from Seattle Children’s Hospital. Ten pediatric patients followed a diet called the Specific Carbohydrate Diet for three months, and 80% of them had symptoms improve significantly and even resolve and lab markers normalize. Eighty-stinking-percent! Let me repeat: eighty percent success. WITH FOOD.

Way to go Dr. Suskind and team. Way to take medicine back to truly patient-centered, do-no-harm care! And most importantly: WAY TO GO PATIENTS AND PARENTS WHO PARTICIPATED IN THIS STUDY! Changing how you eat is hard work, and most people balk, standing in the corner cowering with too much fear to leave their pizza and bread behind. Not you. Not you. (Suskind, 2017)

[Click here for a readable summary of Suskind’s report and here for an abstract of it.]

Meh. Study needs to be bigger.

Now, I showed someone Suskind’s research summary, and she replied, “But there’s only ten patients. I wish it was bigger.”

Sigh. So do I. But it’s what we’ve got. And it’s so promising. I’m ebullient. Diet alone! Eighty percent remission! With real food. No diarrhea! No bleeding! No stomach cramps! Virtually 100% safe. No injections! No risk of white blood cell counts crashing. Why won’t people try this?

Reminds me of a verse I learned from a big book, although I’ve adapted it. “The fiddle plays and you won’t dance. The singer wails a mournful tune, and you will not cry.” We are hard to please. Impossible nearly. What do we want? A magic bullet pill with no side effects?

I must close now. But you will not want to miss my next post about the amazing stay-at-home mom who made it her life mission to show the world that inflammatory bowel disease can be controlled most of the times with real, whole food. And I’ll explain a little about the diet that saved her 8-year-old daughter’s life and which she spent her life studying and evangelizing.

Terri

Citations:

Kansal, S., et al. “Enteral nutrition in Crohn’s disease: an underused therapy.” Gastroenterology research and practice 2013 (2013).  https://www.hindawi.com/journals/grp/2013/482108/

Triantafillidis, John K., Costas Vagianos, and Apostolos E. Papalois. “The role of enteral nutrition in patients with inflammatory bowel disease: current aspects.” BioMed research international 2015 (2015). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4352452/

Sigall-Boneh, Rotem, et al. “Partial enteral nutrition with a Crohn’s disease exclusion diet is effective for induction of remission in children and young adults with Crohn’s disease.” Inflammatory bowel diseases 20.8 (2014): 1353-1360. https://www.researchgate.net/publication/263548102_Partial_Enteral_Nutrition_with_a_Crohn’s_Disease_Exclusion_Diet_Is_Effective_for_Induction_of_Remission_in_Children_and_Young_Adults_with_Crohn’s_Disease

Suskind, D. L., Cohen, S. A., Brittnacher, M. J., Wahbeh, G., Lee, D., Shaffer, M. L., … & Giefer, M. (2017). Clinical and Fecal Microbial Changes With Diet Therapy in Active Inflammatory Bowel Disease. Journal of Clinical Gastroenterology. Abstract only: http://journals.lww.com/jcge/Abstract/publishahead/Clinical_and_Fecal_Microbial_Changes_With_Diet.98120.aspx