Crohn's Disease Forum » Parents of Kids with IBD » New article - diet Crohns things to avoid


10-10-2018, 02:44 PM   #1
my little penguin
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New article - diet Crohns things to avoid

When you talk to your patients about inflammatory bowel disease (IBD), how many of you also talk about diet? We talk to them about medication compliance, about taking their tumor necrosis factor (TNF)-alpha antagonists, about immunosuppression, but we rarely talk to them extensively about diet. I think it is really important to start doing so, and discuss putting certain things on and taking certain things off the table because of their incredible effect. A review just published in Gut[1] prompted me to bring this up with you.
We know that IBD is an inflammation of the intestinal track. We know that there is an intestinal barrier made up by the mucus layer that is our primary defense, as well as epithelial cells and tight junctions. When it comes to the translocation of bacteria that potentially mediates disease, problems can occur when the intestinal barrier breaks. We do know that there are taxonomic changes that occur in ulcerative colitis and Crohn disease, with patients with these conditions prone to intestinal disruption and translocation.
If you are of an older generation, you will remember that we used to look at using an elemental diet, particularly in patients with IBD, including Crohn disease. However, it was thought that that was not well tolerated enough to be a mainstay of day-to-day treatment.
In the current landscape, diet is thought to potentially play a pathogenic role in gastrointestinal disorders. Past epidemiologic studies have shown that the standard Western diet (eg, high in red meat and fat, fast food) increases the odds ratio of [ulcerative colitis] by nearly five times, whereas a Mediterranean diet that is characterized by largely avoiding those foods leads to a risk reduction of nearly 70%.[2] We have seen that in a number of epidemiologic studies, more so for Crohn disease than for ulcerative colitis.[3]
When you talk to your patients with IBD, why is it important that you start to really scrutinize diet?
Diet plays a key role in maintaining a normal gut microbiome. Data derived primarily from animal studies shows that a high-fat, high-sugar diet impacts the microbial composition, leading to bacterial dysbiosis, which has been shown to affect gut bacteria integrity and also immunity.[4] In rodent models deprived of fiber, there is an alternative use of carbon sources that has a direct mucosal effect.[5] These rodents display a depleted mucus layer and its ability to protect; disruption of the barrier (ie, translocation); and in a reverse of what we would like to see, there is upregulation rather than downregulation of immune response, leading to consequent tissue damage. Rodent model studies show that going from a plant-based diet to an animal-based diet (eg, from the Mediterranean to the traditional Western) results in clear bacterial taxonomic changes that affect metabolism with alterations in bile acids, in particular sulfide metabolism, which plays a pivotal role in the pathogenesis of IBD.[6]
We know that dietary fibers, fruits, and vegetables provide a vital substrate production of butyrate and other short-chain fatty acids that enhance the immune response.[7] Butyrate is clearly important in affecting defensins, which protect against immune response, and cathelicidins, which protect against some of the pathogenic, enteric infections. Butyrate also downregulates transcription cytokines expressed in IBD.[8] You also differentiate the good T-regulatory lymphocytes that decrease immune activation, which is the positive side of immune suppression. Conversely, low-fiber diets increase intestinal permeability (ie, leaky gut), thereby increasing bacterial content and facilitating the problem of translocation.[9]
Specific Diets' Effects

In animal studies, diets high in fat and starch basically have the same effect as low-fiber diets.[4] This has a negative impact on IBD by upregulating TNF-alpha, increasing interferon-gamma and intestinal permeability, and decreasing the levels of the good T-regulatory lymphocytes that downregulate the autoimmune response.
Another thing to be aware of is that the standard Western diet provides an incredible amount of exposure to diet emulsifiers and food additives, which can have harmful effects.
Carboxymethyl cellulose and polysorbate-80 are traditionally used in baked goods and particularly in ice cream. These are the elements that now allow us to make ice cream without the aid of a crank or addition of rock salt, for those of us old enough to remember that process. They make it easier to palletize food products and get a better sense of fullness in the mouth, but they conversely thin the mucus layer and increase gut permeability.[10]
Maltodextrin is another additive used as a thickener and sweetener, and can also thin the mucus layer. These come from plant products, but in their highly refined form they can have the adverse effects of thinning the mucus layer, increasing gut permeability, and impairing intracellular bacteria.[11]
Carrageenan is also used to increase texture, particularly in dairy products and sauces. These are made from seaweeds, which sounds pretty healthy, but they are again highly processed and can induce intestinal permeability.[12]
Advising Our Patients

In the current world of IBD, we really need to have a serious discussion with our patients about these food items. We should restrict animal fat, processed foods, and processed carbohydrates. The data in support of this approach are very strong for Crohn disease. There is a bit of a data gap for ulcerative colitis, but there is no sense in waiting for those studies to appear before making similar recommendations.
There is tremendous emphasis on a translational message now, to take this message to our patients of moving toward plant-based foods, to healthy fats (eg, away from butter to olive or canola oil), to using herbs for flavor instead of salt, and to lean protein. I recommend to my patients to eat red meat rarely, less than once a week. It is basically promoting what we call the Mediterranean diet, which does allow moderate consumption of red wine.
The emphasis here that you want to provide for patients is that we have biologic evidence that this makes a difference. It is time for us to start taking a good diet history and treat patients with IBD appropriately. Start looking at diet; it has a key role in the pathogenesis of IBD and may offer a tremendous opportunity in its treatment. Hopefully this guides you to your next discussion with your patients and optimizes the outcomes.

From

https://www.medscape.com/viewarticle...=1765351&faf=1





Inflammatory Diets: The Foods and Additives That Patients With IBD Need to Avoid

David A. Johnson, MD
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10-10-2018, 06:47 PM   #2
Lady Organic
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I think younger doctors are more aware of and into this new healthy lifestyle trend and its medical evidence. Society as a whole is. I have some young doctors who regularily are interested in talking with me about diet, meditation/relaxation to reduce stress, psychotherapy, etc... From my experience, these subjects find less echos with older doctors.
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''UC-like Crohn's'' (2001)
wrists + ankles arthropathies (2013)
on: 50mg 6-MP (Purinethol)+ B12 shots


Diet: ''IBD-AID'' : http://www.nutritionj.com/content/13/1/5+ organic food only
suppl Curcuminoid extract, Inulin,psyllium, apple pectin, Vitamin D

past meds:
pred 50mg, 5-ASA (pill, rectal), cortifoam, Imuran, Purinethol, methotrexate.
10-12-2018, 02:36 PM   #3
Maya142
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In the current world of IBD, we really need to have a serious discussion with our patients about these food items. We should restrict animal fat, processed foods, and processed carbohydrates. The data in support of this approach are very strong for Crohn disease. There is a bit of a data gap for ulcerative colitis, but there is no sense in waiting for those studies to appear before making similar recommendations.
There is tremendous emphasis on a translational message now, to take this message to our patients of moving toward plant-based foods, to healthy fats (eg, away from butter to olive or canola oil), to using herbs for flavor instead of salt, and to lean protein. I recommend to my patients to eat red meat rarely, less than once a week. It is basically promoting what we call the Mediterranean diet, which does allow moderate consumption of red wine.

This is great info - thanks MLP!!

My question is this - what if you have a child who does not seem to tolerate fiber, for whatever reason (in our case, Gastroparesis, but the same could happen with Crohn's or even IBS). In addition to the severe nausea, she also has bad cramping and diarrhea with fiber.

So then what do you do??

I'll tag several parents in case anyone has advice:
pdx, crohnsinct, my little penguin, Tesscorm, Clash, Jmrogers4, Pilgrim
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Mom of M (20)
diagnosed with Crohn's Disease at 16
Juvenile Idiopathic Arthritis at 12
Juvenile Ankylosing Spondylitis at 16

Mom of S (23)
dx with JIA at 14
Ankylosing Spondylitis at 18
10-12-2018, 10:34 PM   #4
my little penguin
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Ds has gastroparesis
So we trialed various veggies to see what was tolerable
First those recommendations from the Crohns exclusive diet
Extremely similar to the what is stated above
Eggplant
Squash - summer /spaghetti/butternut/zucchini /pumpkin
Tomatoes
Onions -various types
Carrots cooked
Some other veggies cooked in soups
Whole grain organic bread without emulsifiers or any additives
Fruit is tricker (oral allergy syndrome) so cooked apples , cantaloupe/honey dew /watermelon /blueberries
And bake in muffins as needed for other berries
Sweeten with maple syrup or fruit
Add oats as pulverized flour when possible in small amounts
So not a lot
Still avoid things that are rough like broccoli/cauliflower etc...

Keep things as un processed as possible and if earring process chose as one with as few ingredients as possible avoiding emulsifiers as well


And DS still drinks a lot of elemental formula a day
But he is a growing teenage boy (added 50 lbs and close to. 7 inches in the last year )
10-12-2018, 10:53 PM   #5
Maya142
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Eggplant
Squash - summer /spaghetti/butternut/zucchini /pumpkin
Tomatoes
Onions -various types
Carrots cooked
Some other veggies cooked in soups
Whole grain organic bread without emulsifiers or any additives
Fruit is tricker (oral allergy syndrome) so cooked apples , cantaloupe/honey dew /watermelon /blueberries
She can't manage any veggies currently (unless in a soup/pureed), without getting severely nauseous or even throwing up . And somehow, even soup sits in her stomach for 6-8 hours...it's really amazing .

We have had to add formula back in. Guess we will see what her GI says.
10-16-2018, 10:39 AM   #6
Tesscorm
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Thanks for posting MLP. After reading this, I feel like I should've done more in controlling S's diet when he was a child. S had a diet of exactly what he shouldn't have eaten! He was such a picky eater and, in particular, fruits and vegs were 'off limits' for him! (And, trust me, I did try... but should've tried harder. )

Unfortunately, don't have much advice to offer. I'v e only done the 'basics' that are pretty much mentioned above - pureed soups, mashed potato made with cauliflower, pasta sauce with tomato 'base' but with other vegs pureed into it, etc. While it doesn't add fibre, he does have Boost shakes on a regular basis.


Just wanted to add... when my kids were young, I did use a cookbook that was pretty handy - Deceptively Delicious by Jessica (Jennifer?) Seinfeld. I think she then published Deceptively Delicious 2... all the recipes had pureed veggies mixed in, ie brownies with spinach, macaroni & cheese with squash, etc. At the time, I made a few dishes from the cookbook. The cookbooks might have some new ideas for those with limited choices in their diets and/or for picky eaters where the veg need to be hidden.
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Tess, mom to S
Diagnosed May 2011

Treatment:
May-July 2011 - 6 wks Exclusive EN via NG tube - 2000 ml/night, 1 wk IV Flagyl
July 2011-July 2013 - Supplemental EN via NG, 1000 ml/night, 5 nites/wk, Nexium, 40 mg
Feb. 2013-present - Remicade, 5 mg/kg every 6 wks
Supplements: 1-2 Boost shakes, D3 - 2000 IUs, Krill Oil

Last edited by Tesscorm; 10-16-2018 at 01:39 PM.
10-16-2018, 03:08 PM   #7
pdx
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Thanks for posting MLP. After reading this, I feel like I should've done more in controlling S's diet when he was a child. S had a diet of exactly what he shouldn't have eaten! He was such a picky eater and, in particular, fruits and vegs were 'off limits' for him! (And, trust me, I did try... but should've tried harder. )
While I'm always happy to see diet research, I do think that parents shouldn't use the not-yet-very-definitive results to beat themselves up! My kids grew up vegetarian, actually almost vegan, with lots of homegrown fruits and veggies, lots of whole grains, and not much sugar. That didn't stop E from getting Crohn's, and most kids who do eat the standard American diet don't get IBD. (E did probably get a lot of artificial thickeners like guar gum and carrageenan, though, because those things are in SO MANY products now, even the "natural, organic" ones. It's crazy how most organic ice creams are full of emulsifiers like "organic guar gum." Drives me crazy!)

We aren't vegan any more, and I don't feel any less healthy, but I do agree it's probably good to try to eat a diet of mostly unprocessed foods, and to avoid weird ingredients when eating processed foods from the store. I still have a huge garden, so we're eating lots of fresh vegetables.

E has a short stricture, so she does have to be careful not to eat too many raw fruits or vegetables at once. She does OK with cooked vegetables and peeled fruits, so we're lucky with that.

I don't have any suggestions for you, Maya, since it seems like in your daughter's case, fiber causes more harm than good. Maybe adding probiotics would be another way to encourage good gut bacteria--I think she may already use those?
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Daughter E (16) dx with Crohn's 12/18/14 at age 12

Current treatment:

Remicade started 12/24/14 (9 mg/kg every 6 weeks)
Oral methotrexate restarted 12/2/16 (20 mg weekly)
vitamin D, folic acid, iron, multivitamin, Prozac

Past Treatment
90% EN via NG tube 2/9/15 - 4/2/15
50% EN via NG tube 4/3/15 - 4/18/15
Supplemental EN via NG tube 5/7/15-6/19/15
Budesonide 3/3/15-6/30/15, 3/24/18-5/18/18
Oral methotrexate 3/13/15 - 5/14/16 (15 mg weekly)
Clobetasol for Remicade-induced psoriasis
10-16-2018, 06:39 PM   #8
Maya142
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While I'm always happy to see diet research, I do think that parents shouldn't use the not-yet-very-definitive results to beat themselves up! My kids grew up vegetarian, actually almost vegan, with lots of homegrown fruits and veggies, lots of whole grains, and not much sugar. That didn't stop E from getting Crohn's, and most kids who do eat the standard American diet don't get IBD.
I hadn't ever thought of it from this perspective - that most kids on a standard American diet never develop IBD. That makes me feel better about what we fed my kids - we somehow managed to feed them an American diet even while living abroad .

We do probiotics - tried VSL#3 but it didn't agree with her. She's on Culturelle now.
10-17-2018, 09:10 AM   #9
Tesscorm
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I agree that a non-processed diet which includes all types of fresh food (even a bit of junk, in moderation) is best. And, I do agree that most people, even those not at all following clean, non-processed, etc. diets do not develop crohns. I think our kids had something trigger a dormant gene (or something) to kick off crohns. I do not believe S's diet, over YEARS, helped but, in his case, we do believe it was the overuse of nsaids which set it off. I do wonder if his diet had left him vulnerable or perhaps that gene (or whatever) was simply ready to be set off??? (Does that make sense?? )

An allergist once had a different perspective that may also explain S's diet preferences... my daughter was/is a very healthy eater, adventurous and open to trying all new foods and likes 99% of all foods. The two things she did not like were corn or melons (including watermelon!) - this surprised me because, really, who doesn't like corn or watermelon?!? At around 7-9 years old, she was having allergy symptoms so we had testing done. She had intolerances to corn and melon (among other things) and allergist told us to avoid the foods. When I mentioned that, funny enough, those were two foods she did not like, he suggested that they may have made her feel 'off/bad' from the time she was a younger child and had instinctively learned to avoid them. Made sense to me... and, in S's case, as a child he strongly gravitated to low fibre/residue foods such as breads, pasta, rice, dairy, proteins... I've wondered if it was due to pickiness or instinct that he avoided high fibre??

But, Maya and others who have problems with fibre in a 'solid' form, do have a look for that recipe book. All the recipes were made with pureed veggies and included recipes for breakfast/baked goods, main courses, desserts. It's a bit of prep to have the pureed veg ready. Best was to have the vegs cooked, pureed and frozen so that it was easy to pick a recipe and have the veg ready to go.
10-17-2018, 07:17 PM   #10
Maya142
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But, Maya and others who have problems with fibre in a 'solid' form, do have a look for that recipe book. All the recipes were made with pureed veggies and included recipes for breakfast/baked goods, main courses, desserts. It's a bit of prep to have the pureed veg ready. Best was to have the vegs cooked, pureed and frozen so that it was easy to pick a recipe and have the veg ready to go.
Thanks Tess, but even pureed vegetables sit in her stomach. Many people with delayed gastric emptying for solids are able to empty liquids at a normal rate, so they do not feel sick with them. Unfortunately, M's stomach is not like that. She threw up NG tube feeds. I gave her pureed spinach the other day and then used broth to make it more like soup, so it would go down easily. Well, 8 hours later, she was horribly nauseous so we drained the contents of her stomach out of her G tube, hoping to give her some relief.

I expected to see what she had eaten for dinner, not lunch and most definitely not a liquid she'd had for lunch. That means it had just been sitting there for 8 hours. No wonder she was nauseous!
10-18-2018, 08:12 AM   #11
Tesscorm
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Poor M! Must be so hard on her. And hard on you in trying to find the right foods.
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