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What to Eat? is a forum for the IBD community to ask questions of a clinical dietitian who works specifically with people living with Crohn’s and colitis. Andrea Firmin, BASc, RD is a dietitian with six years of experience working with patients with inflammatory bowel diseases and cancer. After five years with Mount Sinai Hospital, she now works in the inpatient medicine program at Southlake Regional Health Centre in Newmarket, and is working in private practice.
What to Eat? is a forum for the IBD community to ask questions of a clinical dietitian who works specifically with people living with Crohn’s and colitis.
Andrea Firmin, BASc, RD is a dietitian with six years of experience working with patients with inflammatory bowel diseases and cancer. After five years with Mount Sinai Hospital, she now works in the inpatient medicine program at Southlake Regional Health Centre in Newmarket, and is working in private practice.
For this edition of What to Eat?, Andrea has shared a selection of the questions she is most commonly asked in her practice.
Q: My nine-year-old son was recently diagnosed with inflammatory bowel disease. I am wondering what kind of diet changes you recommend? We have added fibre (with Metamucil and food stuffs), two active bacterial yogurts per day (due to amount of diarrhea) and are currently using 420 mg of Tylenol five times a day, as he weighs 66 pounds. He is still having a lot of pain. Do you think gluten-free would help? Or eliminating lactose? Please advise, as I would prefer not to use any stronger pain medication if we can avoid it. However he is suffering a lot, and is missing three to four days of school per week right now.
A: When patients are having an IBD flare, we generally suggest following a low-fibre diet (sometimes referred to as a low residue diet). This type of diet reduces the amount of insoluble fibre (roughage), like skins on fruits and vegetables, and seeds and nuts that can create more stool, gas and discomfort. The low-fibre diet does allow some soluble fibre, like that found in oats and bananas, as these foods can help with diarrhea. The goal of the low-fibre diet is to help manage the symptoms of gas, bloating, abdominal pain and bowel frequency that are normally seen during an IBD flare.
We currently do not know of a specific type of diet to cure the disease or prevent a disease recurrence. The role of nutrition in IBD is to help minimize GI symptoms related to food and eating, to manage weight (reduce the risk or severity of weight loss) and to support vitamin, mineral and energy needs.
During a flare, some people may need to eliminate other foods that seem more likely to trigger symptoms (and to clarify, these do not trigger inflammation or the disease, but can trigger the GI side effects of the disease). The most common are: lactose-containing foods like milk, yogurt, cheese; caffeine; high-fat foods; high-fibre foods; spicy foods and acidic foods like tomatoes or citrus fruits. Everyone is different with respect to their tolerance of these foods, so it is important for you to try all foods and see how your body reacts. Keeping track of the foods you eat and your symptoms can help you determine your own tolerance level to different amounts or types of foods.
A gluten-free diet is not generally recommended for those with IBD unless they also have celiac disease (allergy to gluten) or a proven gluten sensitivity. A gluten-free diet can be restrictive and can lead to a further decrease in calorie and nutrient intake and weight loss. If you feel that a gluten-free diet is something you or your family member is interested in trying, I strongly encourage you speak to a registered dietitian to ensure that your diet is balanced and provides adequate energy and nutrition.
Q: I have had ulcerative colitis since 1996. Since 2001 I’ve only had two relapses, but I notice that the latter could have been triggered by dairy products. I drank more milk than ever that Fall and by December, I had a relapse. I cut dairy products (and I was especially careful with Salofalk) and it has gotten better. My question is: do yogurt and kefir that contain bacterial culture are good or bad in this case?
A: Lactose-containing foods can cause gas, bloating and diarrhea in those with lactose intolerance. Some people with IBD are always lactose intolerant, while some people can experience symptoms of lactose intolerance only when they have a flare, but not at other times.
When it comes to lactose intolerance, everyone’s level of tolerance is different. Foods that have higher amounts of lactose and are more likely to cause symptoms of lactose intolerance include milk, buttermilk, evaporated milk and ice cream. Yogurts and kefir also have higher amounts of lactose, however the active bacterial cultures in these foods can break down some of the lactose, making them easier for some people with lactose intolerance to digest. As with all foods, try yogurt and kefir to see how your body tolerates them. If you find that you still experience gas, bloating and diarrhea, look for lactose-free versions of milk, yogurt and cheese, or consider trying a lactase enzyme pill to help digest the lactose sugars. Fortified soy products are another alternative to dairy products to provide good sources of calcium, vitamin D, protein and other nutrients.
Q: I was diagnosed with ulcerative colitis in December 2010, and have been in this flare-up pretty much ever since. I have shown signs of going into remission twice, but this only lasted two days each time and I still had a lot of pain. I can only eat “soft simple” foods at the moment, like pasta, mashed potatoes, cooked carrots, Wheatabix and soups. Eating anything else causes pain, bloating and then I go back into flare-up. I’m finding it really hard to deal with because I’m hungry, but can eat hardly anything without going back two steps in my progress and having to take extra medications to get back on track again.
My doctor only seems interested in when I have blood in my stools, which is quite sporadic. It’s the pains, feeling sick, being unable to sleep, and being unable to eat that effect me the most. Can you recommend anything that addresses the nausea and inability to eat rather than just the intestinal inflammation and bleeding?
A: To minimize the pain, bloating and gas that is food related, try a lower-fibre diet, as described earlier. Foods that tend to be tolerated well are foods like white rice, pasta, potatoes, bread, oatmeal, bananas, applesauce, soups, chicken, fish, eggs, tofu, crackers, smooth nut butters, Jell-o, arrowroot or other plain cookies, liquid nutrition supplements and sometimes cheese and yogurt. Remember, foods do not cause a flare, but they can make some of the symptoms of a flare worse, so lower fibre - and if necessary for you, lactose-free - may help minimize your GI symptoms until the flare is better controlled.
In terms of nausea, try smaller, more frequent meals and snacks. Sometimes nausea can be worse if we let ourselves get really hungry, so eating more often can help with this. Also, eating smaller portions more often may be easier to handle when you don’t have an appetite or are feeling nauseous. If the smell of food bothers you, choose foods you can have at room temperature or cold, like cereal, crackers with peanut butter or cheese, fruit, yogurt, smoothies, Jell-0 or a sandwich. Ginger-flavoured foods and drinks can also help with nausea, so try ginger ale, ginger candies, ginger snap cookies or ginger tea.
Q: Many health professionals have told me a variety of things. But what seems to come up all the time is probiotics. What are your views on colitis and probiotics? Someone also suggested green clay with water to line my colon and help treat the ulcers. Also, I have heard of this product called sea buckthorn that is supposed to help colitis and skin problems. What is your take on those treatments?
A: Up to now, only a few small research studies have found that probiotics MAY be effective in bringing about remission in colitis or reducing the risk of future flares. We still need results from larger, randomized-controlled research studies before we can start making recommendations for probiotics in this area.
That said, colitis patients who have had surgery to create a pelvic pouch can develop an infection called pouchitis. Some smaller studies have found that a probiotics product called VSL # 3 may be effective in reducing the risk of the recurrence of pouchitis. Probiotics have not been found to help induce remission or reduce future flares for those with Crohn’s disease.
Probiotics are generally safe to take and may have some health benefits. But you should be careful if you have a compromised immune system. Choose products that have been reviewed by Health Canada and need to be refrigerated.
There are many health products available on the market these days, and when it comes to supplements, it is important to be careful about products that you choose to take. Be very cautious with products that:
• Make claims that sound too good to be true;
If you choose to take something, look for a Natural Product Number (NPN) or homeopathic number (DIN-HM) on the box or bottle. The presence of this number means that it has been reviewed and licensed by Health Canada. It is also important to speak with your doctor and pharmacist about the supplements you are taking to make sure they do not interact with any medications or treatments you may be receiving. Remember, just because a product is ‘natural’ does not mean that it is safe to take.
Q: Do I need to follow a special diet because of my IBD?
A: For the most part, I recommend “diet as tolerated” for those with IBD. Everyone is different in their ability to tolerate different foods, and sometimes it depends on whether the disease is flaring or in remission. Your body will tell you what diet you can tolerate.
When you are well, we recommend following Canada’s Food Guide to Healthy Eating as much as possible. This helps to promote good health and ensure that you get a good base of vitamins and minerals in case you develop a flare at some point. Some people find that even when they are well, they have certain ‘trigger’ foods that may cause diarrhea, gas or cramping. It is fine to avoid these foods if it makes you feel more comfortable. The most common trigger foods reported by patients include: lactose containing foods (dairy products), caffeine, leafy green vegetables, high-fat foods, very high-fibre foods and spicy foods.
Everyone is different, so it is important to try all foods for yourself and see how your body reacts. The more foods you can include in your diet the better, as it means you are getting more variety in taste, texture, vitamins and minerals on a regular basis.
A low-residue diet (similar to a low-fibre diet, but with restrictions on foods that increase bowel activity) is recommended for those who have strictures to decrease the risk of obstruction and to reduce pain and abdominal cramping. This diet is sometimes suggested for those with fistulas and is generally recommended as a temporary diet (4-8 weeks) after most IBD-related surgeries. For more information on the
Enteral feeding (tube feeding) has been shown to be successful in bringing about remission in Crohn’s disease and is mostly used in paediatric patients to minimize the use of steroids. Enteral feeding uses formulas or liquids that provide all of the carbohydrates, fats, proteins, vitamins and minerals needed for a balanced diet, while allowing the gut to rest and heal during a flare.
Sometimes total parenteral nutrition (TPN) is required, if patients are experiencing significant weight loss, bowel obstruction, fistulas, short bowel or other IBD complications. TPN is intravenous (IV) nutrition that is administered into the blood. It also contains all of the nutrients needed to help maintain weight and nutritional status.
Other diets have been created and suggested by various authors. Be careful of diets that claim they can cure IBD or prevent future flares. If it sounds too good to be true, it likely is. At this point, there is no research to support any specific diet or food that might improve or worsen the disease.
If you are avoiding a number of foods or food groups, you may want to consider speaking to a registered dietitian about how to increase the variety in your diet, or how to ensure you are getting a balance of vitamins and minerals so you can maintain your weight and reduce your risk of developing nutrient deficiencies.
Q: Do I need to take vitamin and mineral supplements for my IBD?
A: The most common nutrient deficiencies in people with IBD include: iron, B12, calcium, vitamin D and folic acid. Less common deficiencies include the fat-soluble vitamins (A,D,E,K), zinc and magnesium.
You may be at risk for nutrient deficiencies if:
If you are concerned, talk to your doctor or dietitian about whether you are at risk for deficiencies. They may order blood
Remember that while vitamins and minerals are natural and healthy, more is not always better. Taking large amounts of supplements unnecessarily can also be dangerous, so it is important to discuss your supplements with a health care professional.
Q: What should I look for when buying supplements?
A: The product you buy should have a drug information number (DIN), a natural product number (NPN) or a homeopathic medicine number (DIN-HM) on the package. This number means the government has reviewed the product to ensure it is licensed, meets safety standards and is labelled appropriately. For more information on NPN numbers, visit the following Health Canada website.