Dietary treatment for Crohn's disease

Dietary treatment for Crohn"s disease must start with a solid partnership with your physician. This information is to supplement your knowledge of dietary factors that may influence your disease and can assist you and your physician.

Evidence-based care is something that we in medicine always seek. For medications, it means that the evidence for a benefit is firmly established and strongly outweighs any side effect. For dietary therapy of Crohn"s disease, the evidence is considered soft. This means that there is some research that a certain dietary change is beneficial but that it has not reached the level of near certainty. There are many tantalizing indications that a variety of probiotic bacteria, vitamins, minerals and even fish oil may be helpful. Prebiotics fall into this category as well. 四川省第四人民医院消化内科常玉英
The foods we eat and drink contain hundreds of different substances, natural chemicals if you will. Studying just one food or part of a food is very difficult. The next problem is that the colon contains over 1,000 different bacteria with a total bacteria count of many trillions of bacteria, more bacteria by a factor of 10 than there are cells in the body. So studying how foods mix and interact in this yeasty, wonderful cauldron we call our gut is not easy. But, there is emerging evidence to indicate that diet may be a much more significant factor than we realized.
So, I will present two sections. One will be the Standard Dietary Recommendations that you will find in our gastroenterology textbooks and on the web site of our prestigious organizations like Crohn"s and Colitis Foundation and The Mayo Clinic.
The second section is a learned look at newer things that are emerging in the Crohn"s dietary field. Considerable research has already been done. Much of it is encouraging. I call this second section, Additional Thoughts on Diet for Crohn"s disease.

Standard Dietary Recommendations

The key to good health for all Crohn"s patients is to work with the physician to get the disease under control, usually with medications. Without this basic achievement, getting the full benefit of any dietary program becomes more difficult to achieve. The following are crucial dietary goals:

• Maintain a good weight by ingesting enough calories, minerals and vitamins.
• Protein - The amount of protein you need each day will depend on your weight, age, pregnancy and, especially, on the activity or seriousness of the Crohn"s process. The formula for the healthy person is 0.36 grams of protein per pound of body weight. For the 150 lb person, the number is about 54 grams of protein. If you do serious exercise, if you are a large person or if your Crohn"s is active, you likely need more. So, Crohn"s patients with even moderate activity may need considerably more protein. Much of this protein can and should come from vegetables and fruits. Many nutritionists and physicians think we, as a nation, eat too much animal protein.
• Carbohydrates - In general, you should avoid the low carb craze. The bulk of your calories should come from complex carbohydrates such as whole grain, brown rice, and fresh vegetables and fruits. Plain sugar, high fructose sweeteners, as in soft drinks, and many of the processed foods we buy have very large amounts of these simple sugars that do not have much health benefits.
• Fats - The body needs a certain amount of the right kinds of fat, especially the mono-saturated and unsaturated vegetable oils, such as olive oil. The high saturated fats in meat, creams, and all trans fat products should be used sparingly.

Vitamins

• Multiple vitamin with minerals - Many authorities recommended a daily multiple vitamin for the general population. Patients with Crohn"s disease need to discuss vitamin/mineral use with their physicians, as some patients have been found to be deficient.
• Vitamin B12 - Some Crohn"s patients just don"t absorb enough B12 and they may need monthly injections. The physician may want to check the blood level periodically.
• Vitamin D - Vitamin D is important for bone health. Crohn"s disease patients may be particularly susceptible to the early development of weak bones. Newer information has shown that there are vitamin D receptors or attachment points on the cells of many organs in the body including the small intestine and colon. There is likely a reason for this. Further, vitamin D deficiency has now been found to be far more common than was previously thought. So some experts are now recommending at least 800 IU and even 1200 IU per day, along with at least 1200 mg of calcium in the form of milk and/or supplements such as calcium carbonate. Check with your physician.

Minerals

• Calcium - Most adults need 1200 mg of calcium each day even if you live in the sunbelt and your skin makes lots of vitamin D from sunlight. Calcium can best be obtained from milk, other dairy products, shellfish, and, if needed, calcium supplements. If you take steroids such as prednisone, it is even more important that you get enough vitamin D and calcium, as these steroids are well known to weaken bones.
• Iron - Many Crohn"s patients have low iron levels which can lead to anemia. Your physician may want to check the iron blood level periodically.
• Selenium - Some authorites believe that selenium acts like an antioxidant in the body. Certain medical studies show that selenium may be low in Crohn"s disease patients and that they do better when they take a selenium supplement. 200 mg per day is recommended. Check with your physician.

Fish, Fish Oil and Herbs

• Fish and fish oil - Fish oil has been found in some medical studies to be helpful for inflammatory bowel disease patients. Flax seed oil has the same type of oils as in fish oil. We still do not know the full benefits of fish oil. Fatty fish (blue, mackerel, salmon, and sword), fish oil capsules and flaxseed oil are recommended. They have other benefits and there are no known side effects. In some published studies, patients took up to nine capsules a day of fish oil. This is a lot and could give you a fishy regurgitation smell.
• Herbs - Herbs are dried plants that are ground into powders. Because something is labeled an herb, that does not transform it into a magical medicine. All plants contain hundreds of different chemicals, many of which are still not known to science. We cannot be sure what effect these known and unknown chemicals have on the inflammation process of Crohn"s disease. Until good data is available on the benefits of a specific herb, it is best to avoid them all.

General Advice

Here are the general recommendations that we gastroenterologists generally give to our Crohn"s patients.

• Smaller, more frequent meals - The lower intestine may handle foods better when smaller portions arrive there more frequently. Your body will let you know if four or five smaller meals work better for you.
• Fluids - Adequate fluid intake is a must since diarrhea may be a significant symptom for some patients. For most people, the body tells you when you are thirsty and need fluid. Some authorities recommend eight glasses of fluid per day.
• Caffeine - Caffeine in coffee, tea, soft drinks, and power drinks stimulates the colon to contract and promotes more bowel movements. Caffeine by itself is not known to damage the intestine or colon.
• Alcohol - Alcohol can directly irritate the small intestine if too much is consumed, especially in those Crohn’s patients with extensive involvement of the small bowel.
• Allergies and food intolerance - True food allergies (hives, trouble breathing) are uncommon. Examples are shellfish and peanuts, which are potent allergens for some. Intolerance to certain foods, however, is very common and is not harmful to the body. If a certain food disagrees with you, avoid it.
• Junk food - Most fast food restaurants offer a variety of healthy choices. Dairy products, such as milk, milkshakes and yogurt are available. Pizza provides considerable protein and calcium.
• Lactose and dairy products - Milk and dairy products provide lots of good nutrition and calcium. If you think you are lactose intolerant, you may consider a simple test. Drink 16 oz. of fat free milk on a Saturday or Sunday morning and eat or drink nothing more. If symptoms of bloating, cramps or diarrhea do not occur in 3-4 hours, you likely are not lactose intolerant.

Celiac Disease or sprue - This is a genetic disorder whereby the gluten protein in wheat and certain other grains damages the small intestine. This disorder is much more common than we have thought in the past. The symptoms may be similar to those of Crohn"s disease. A simple blood test can usually screen for this disorder. Ask your physician about celiac disease.

Fiber

Fiber is a special consideration for Crohn"s patients. Food fibers are healthy and should be well-understood so they can be used in an effective and healthy way. All plants rely on fiber for their structure. Each plant food has both insoluble and soluble fiber. Some will be predominantly one type or the other. For instance, wheat is mostly insoluble fiber, oats is about half and half, and psyllium powder is 90% soluble. Our prebiotics powders are 100% soluble.

Insoluble fiber does not dissolve in water; it is not digested by the small bowel and is not fermented by the colon bacteria. It does, however, retain water and therefore produces large, bulky stools. Soluble fiber, on the other hand, does dissolve in water. It is fermented by the colon bacteria and is used as a fuel source to maintain a healthy environment in the colon. However, if too much is taken, soluble fibers may promote harmless colon gas and flatus.
Additional Thoughts on Dietary Therapy for Crohn"s Disease

• There is a genetic link in Crohn"s disease. There is something in the genes that makes the local immune factors in the small intestine and colon less resistant to the normal bacteria that inhabit the colon. There is a lot of research being done in this area, but the facts remain that genes are important to resist the invasion of bacteria into the bowel wall. For now, you can"t change your genes.
• The second factor is the chemistry and make-up of the microbiota of the colon. Microbiota is a fancy word that simply means the whole mix of over 1,000 different bacteria types in the colon, along with its local chemistry, nutrients, acidity and so forth. Needless to say, this is a very complex mixture. Refer to my essay, A Wonderful Colon, for more details. The problem for patients with Crohn"s Disease is that these bacteria adhere to and invade the wall of the distal small bowel and colon. If there are no bacteria, there is no Crohn"s disease.

Well, you can"t nor would you wish to get rid of your good colon bacteria, nor could you ever sterilize your colon. This is neither possible nor smart. But, there may be ways to trick the bacteria that are in the colon and soften the impact on Crohn"s disease.

Probiotics

Probiotics are healthy types of bacteria that are put into yogurt, dairy products and now into various pills. One probiotic uses a healthy form of a yeast. Probiotics have been around for a long time in yogurt, and the field is advanced in Europe. In the U.S., some early studies have been performed on patients with irritable bowel syndrome, certain forms of colitis and, yes, Crohn"s disease. The results suggest there may be some benefit but it is too early to say how much.

There are several problems to consider in the probiotic field. Probiotics are considered a dietary supplement so there is no regulation by the FDA, the federal agency that oversees drugs. You can"t be sure how many live bacteria are in each preparation. Further, the stomach acid is very strong and likely kills many swallowed bacteria. The make-up of existing bacteria in the colon is simply enormous, with over 1,000 different types. Adding one, two or six more may or may not make much difference. The total bacteria count in the colon is many trillions, so adding five to ten billion a day may not make much difference either. A final point. When a probiotic is stopped, the bacteria make-up of the colon resets to its previous stage within two to three weeks. If probiotics help, they would have to be taken indefinitely.
Having said all this, there are suggestive benefits with probiotics and there are few side effects, so stay in contact with your physician.
Prebiotics

I have an essay section on Prebiotics but the short version is that these are relatively newly discovered food fibers that are completely soluble and serve as a fuel source for the good bacteria within the colon. These bacteria churn out certain chemicals, one of which is called butyrate. It is a short chain fatty acid (SCFA), which means it acidifies the local environment and serves as a fuel source for the colon"s own cells. These are the cells that we rely on to keep the immune factors in the colon at a high level. Further, when these SCFA are in a high concentration in this area, there seems to be less adherence to the bowel wall by the bacteria. So, the local immune factors are enhanced and the bacteria seem to be less likely to stick to the colon wall which, we assume, is the first stage in the invasion of the wall by bacteria and likely the first stage in Crohn"s disease.

Well, this sounds rather intriguing, but it should be understood that much of this work has been done in animal models and there have been very few done in patients with Crohn"s disease. Still, the cost-benefit ratio with prebiotics is very favorable. This means that these natural food fibers may produce significant benefits while having virtually no side effects. Excess colon gas is the only one if too much is taken.

As was said at the beginning, all of this information is background and general knowledge. All care, including dietary care, needs to be structured through and with your physician. Our prebiotics are not meant to prevent, treat or mitigate any disease.