Diet and Vitamin Supplementation for IBD, Part 1

Note: Everything in this post and the rest of my series on supplements is synthesized from books and advice gleaned from my reading list.

Health guru’s, nutritionists, doctors, and, yes even my mother, suggest taking vitamin supplements. This is the beginning of a short series on vitamin supplementation. I’ll elaborate on why supplements are needed (even for healthy people) today, and why people with IBD should be especially vigilant in taking supplements.

Healthy Diet

Your body needs around 19 vitamins and minerals for optimum functioning. This is in addition to the appropriate amounts of fiber, fat, protein, and carbohydrate material. Some you need in relatively large quantities (like calcium), and others you only need in trace amounts (like Folic Acid, or Selenium).

The most common argument against supplementing your diet with vitamins is the healthy diet argument. If I just consume a balanced, healthy diet, then I won’t need supplements. Indeed, the argument is simple and generally true. If we consumed, daily, a wide enough variety of foods, and if we consumed those foods in the proper quantity, then we indeed wouldn’t need supplements. Unfortunately, nutritionists agree that the majority of people today (especially in the US and Europe) eat a calorie rich, nutrient poor diet. This means that people can get fat, but they can’t generally get fit (nutritionally) on the average, for example, American diet.

Why?

This is because we consume too many processed foods (the processing of food strips natural nutrients); because conventional farming practices (where most Americans get their food) strip the soil of many essential micro and macro nutrients, essential soil organisms, and natural compost material which in turn lessens the nutritional content of food (nutritional density of food 150 years ago ≠ nutritional density of food today), making it difficult to eat enough variety to get what we need from food alone; and because we just don’t, on average, eat a balanced diet. Americans especially, eat too many processed grains, and not enough whole vegetables, fruits, and legumes. We consume too much red meat, fat, and alcohol. We don’t eat enough fish. We don’t exercise enough. Get the picture?

What’s Unique about People with IBD? Why is it so important for them (us) to Supplement?

People (like me) with IBD are in a unique position where all of the above may be true for us, but at the same time our processing plant is only working at partial capacity. This makes it doubly important for those with IBD to eat as healthy a diet as possible and to supplement, because invariably some portion of what we eat will not be processed and absorbed. Let me elaborate.

For those with Crohn’s, inflammation in the small intestine, where the majority of fat, carbohydrate, and nutrient uptake takes place, can lead to deficiencies in B-vitamins, and the fat-soluble vitamins such as A, D, and E (and much more). Decreased appetite only worsens these deficiencies.

For those with Colitis, inflammation of the large intestine (whose function is to absorb electrolytes and water, produce vitamin K, and retain/store stool) can cause diarrhea and increase transit time in the gut. This diarrhea can lead to folic acid deficiencies (which increases your risk for cancer), vitamin K, calcium, potassium, and other electrolyte deficiencies. Vitamin K is essential for healing and rebuilding tissue. Calcium is essential for bone mineralization and nerve and muscle conduction, and electrolytes are in just about every body process you can think of (and many you can’t). Vitamins are essential for bone health, blood clotting, proper immune functioning, proper neural function, general energy levels, mental well-being (B-vitamins are an accepted treatment for mild depression), etc. Folks with IBD just can’t process or absorb these as well as a gut-normal person.

Medication can complicate your dietary needs. For example, corticosteroids, such as prednisone can increase your need for folate, vitamin B6, and ascorbic acid. They decrease calcium and phosphorus, and increase levels of zinc, potassium, phosphorous, calcium and vitamin C in your urine. Even simple aspirin increases the need for folic acid and vitamin C. Jini Patel Thompson has a short discussion of medications and nutritional needs in Listen to Your Gut. For a more through discussion see the Encyclopedia of Natural Medicine, by Murray and Pizzorno.

Okay, what do I do?

With rapid transit times and decreased absorption, it’s important to increase the quality of food you eat. In the beginning of my last flare-up, I avoided fruits and vegetables at all costs—they sprinted through me like a wild horse. Then I began to read and learn. I started the SCD and followed the diet’s instructions with fanatical flare. But the SCD allows fruits and vegetables, which I couldn’t eat right away, so I read some more (see my growing reading list). After much reading, observing other’s comments, and after experimenting on myself, here’s what I recommend. Ideally, you would do all of this within the parameters of the SCD.

·         Gradually increase your calorie consumption. If you’re having trouble processing food, then you’ll need to take in more than you need, because some portion of that is leaving undigested. I know, eating can make you feel worse, so be gentle on yourself, but not eating…well we all know where that goes.

·         Steam your vegetables. It’s not the veggies themselves your gut can’t take; it’s the complex fiber matrix. Steaming softens the fiber matrix and makes it easier for your damaged gut to process them. This is the method I used for months to get my veggies. Yes you do lose some of the phytonutrients, but you retain most of the vitamins. If you’re really concerned about the nutrient loss from steaming, you can drink the leftover water. Yum!

·         Cook your fruits. Bake or steam fruits high in soluable fiber, like pears or apples. Add a little cinnamon and honey and you have a winner.

·         Peel your fruits, and avoid fruit with lots of insoluable fiber. Again, your system can’t handle the rather rough insoluable fiber skin, so remove it or don’t eat it. Examples of fruit to peel are apples, pears, peaches, plums, etc. Examples of fruits to avoid (or to try cautiously until you can handle them) are, oranges, grapefruit, cherries, grapes, berries, and anything else with a tough outer skin.

·         Avoid seeds. Just do it. You’ll thank me—strawberries, blackberries, raspberries, kiwi, figs, goji berries, etc.

·         Supplement with vitamins. I’ll go over this in more detail in future posts, but for now, a good multi-vitamin (2x/day), a good B-complex (1-2x/d), and a calcium supplement (as calcium citrate) will do for a start.

Onward to Health.

Short-shorts: Imodium (Loperamide) and IBD

Cartoon: www.erstories.net

Imodium (also here) is a popular and (for most) safe drug for relieving symptoms of diarrhea. For people (like me), with IBD, it is not safe. Loperamide slows peristalsis, the natural muscular contractions of the intestine. Peristalsis, this rhythmic movement of the intestine, is what keeps food and waste moving through your gut. Slow down gut motility in people with inflammation, and you can get gas (and fluid, but gas is the biggest problem of the two) build up.

So what? I retain a little gas; at least I’m not running to the bathroom as much. What’s the big deal?

The big deal about the gas (and fluid) build up is that it essentially gets trapped and creates pressure on the already damaged intestinal wall. This increases your risk for toxic megacolon (or here), and resulting sepsis. Toxic megacolon can develop quickly (less than a day), and if it’s not treated immediately (surgery), it will kill you—so don’t mess with it.

When I researched this topic, I found a surprising majority of sites advocating the (responsible?) use of loperamide with IBD. Don't do it. Some people take Imodium under the direction of their doctor. Knowing what I know about the risks, if my doctor told me to take Imodium, I’d have serious questions for him/her.

So, what do I do about all this D, smart guy?

There are natural treatments for diarrhea. See my post on natural diarrheal remedies. Remember, the idea is to get rid of the entire disease, to heal the root problem, not mask the symptoms. Until you take care of the problem, some diarrhea will be a fact of life for those of us with IBD.

Onward to Health.

Natural Anti-diarrheals for IBD

Most natural diarrhea remedies you find on the web do not apply to folks with IBD. They assume your diarrhea is caused by something that 'will pass' with time. i.e., they assume if you can manage the symptoms, kill the infectious agent, and/or stay hydrated for a few days, then you'll be fine--Not so with IBD.

In IBD, your diarrhea is most likely due to one or a combination of the following:

Damaged Intestinal Wall- Damage to the intestinal epithelium impairs, for example, the ability of your large intestine to transport water and salts, causing fluid to accumulate in the colon. Damage caused by inflammation results in poor absorption and digestion of food, which increases transit time in the gut, adding to your diarrhea.

Food Intolerance- Although there are few actual food allergies, there are lots of food intolerances, especially in people with IBD. The only way to know if you have an intolerance to a specific food is to track your diet, and track your symptoms, to see which foods exacerbate your symptoms. (See my posts on diet tracking, and symptom tracking) Of course the first and best diet-related step you can do is to start the Specific Carbohydrate Diet (SCD).

Prescription Drug Use- Some of the drugs that allopathic doctors prescribe have diarrhea as a 'side effect'. Asacol is an example of one such drug. Curious that we take a medicine that gives us diarrhea to get rid of inflammation that causes diarrhea...

Natural Diarrhea Remedies
Most natural remedies just won't work for those of us with IBD. For example, a crushed clove of garlic may work for mild food poisoning in people with a normal gut, but for people with IBD, raw garlic can often cause massive D and exacerbate other symptoms. I've compiled the list below of IBD-friendly natural treatments for diarrhea. Keep in mind that the goal is to heal the root cause, not mask the symptoms, so while these treatments will decrease the severity of your diarrhea, they should be used in conjunction with a comprehensive natural IBD healing program such as the Specific Carbohydrate Diet, natural healing protocols from Listen to Your Gut, or treatments that your naturopathic physician has given you.

Below are a few natural treatments you can try that will help alleviate diarrhea. There are oodles of these out there, but I've only listed the remedies that I have either tried myself, or I've seen from multiple, trusted sources. I've labeled the remedies that are SCD friendly.

L-Glutamine- (SCD Friendly) L-Glutamine, on an empty stomach has a soothing and rebuilding effect on the inner lining of the intestine. Take anywhere from 1-5 grams of free-form L-Glutamine powder (no additives, no mixes, nothing but L-Glutamine) in divided doses throughout the day. This works best if you take the amino acid on an empty stomach. Start slowly (dosages are usu. 1/4 tsp) with one dose/day, and build from there until your diarrhea is under control.

Probiotics- (SCD Friendly) Probiotic therapy has been shown in placebo controlled, double-blind studies to be effective in alleviating the clinical manifestations of Colitis, and thus will decrease your diarrhea. The key with probiotics (and with any natural treatment for IBD, really) is to start slowly. While tracking your symptoms and diet, begin with 1/4 tsp/day, and slowly build to a therapeutic dose of 8-12 Billion CFU (Colony Forming Units). I"ve taken doses as high as 40 billion CFU. Keep increasing the dose until you notice your symptoms are improving.
You should use a probiotic that guarantees potency, is sealed in glass, and comes cold (to ensure that you are ingesting live bacteria). Avoid any product that doesn't list the serving size and CFU per serving on the label. See this post on probiotics, and this one on the probiotic retention enema. Jini Patel Thompson has some of the most detailed work on probiotics for IBD that I've seen. I highly recommend reading her book, Listen to Your Gut, for more information on probiotic (and other) treatments for IBD.

Bentonite Clay- (Not SCD Friendly) Bentonite clay is gray-ish colored and does not taste. It provides a 'filler' for the gut. By absorbing excess water and fluids, it is a good detoxification agent for the gut. The active ingredient is montmorillonite. Do not take Bentonite clay in conjunction with probiotics, as it also removes bacteria from the gut (i.e., the probiotics you just swallowed). Again, start small and note the effects. I'd start with 1/2 tsp/day and work up from there SLOWLY until you reach the desired effect.

Onward to Health.

More from AP and JP: Fatigue, Dehydration, and more.

   Before I start this post, it's important to note that I handle 90% of my symptoms with the Specific Carbohydrate Diet. It took us (both my wife AND me) a long time to accept the lifestyle changes that I needed to make. When you're first diagnosed, or during your first real flare, you're getting a lot thrown at you. I felt like someone was taking away from me everything I enjoyed. I thought, literally, that the rest of my life would be hell.

   Then just as I was getting a handle on things, I started the SCD and it happened again: I felt like the small things I enjoyed, the simple things, dinner with friends, pumpkin pie, good beer, homemade bread were being stolen from me--after more than three decades of enjoying them, it was hard to hear someone suggest that many of those things I enjoyed (like good beer) were the very things that were keeping me sick.

   For a long time, neither of us wanted to hear it. So, when I write, just know it's taken me almost two years to come to terms with my new lifestyle. Every improvement that the SCD, however, has given me has made the transition easier--a light at the end of the tunnel.

   Here's the second in a series of posts from my conversations with AP, about her husband, JP who has recently been diagnosed with Crohn's, but who has been sick for some time. See my first post from AP here.

I've re-arranged the conversation some to make it flow by topic...

My husband and I were just discussing his diet last night. His diet has always been junk. He drinks soda all day long, caffeine, fast food, processed food and junk food. That is it. Aside from the occasional salad he has along with a steak and baked potato meal, he rarely eats any vegetables and he never eats fruit.

   In the beginning of the SCD, my wife and I talked about my diet so much it made us sick. We even had to plan NOT to talk about the diet--especially when we went to see friends. Constant communication with your family, significant other, or housemates (whomever you eat with most often) about the food you're eating and the symptoms you're having (don't be afraid to share with those close to you) is essential.

   JP's diet is horrible, but not all that atypical in the U.S. (though I like to think that's changing...slowly). The chronic inflammation associated with IBD decreases the absorption of essential vitamins and minerals. Decreased transit time in the gut during flare-up further complicates the problem and leaves us in calorie debt too. Even if JP were not sick, his health would suffer from his diet.

In his defense he has always had an aversion to eating. It makes him really tired, and not much ever "sounds good" to him. So he eats whatever seems the most appealing out of the bad. Which is unfortunately never something healthy.

This is not uncommon for people with IBD. We know that eating (especially during a flare-up) increases our symptoms, so we often don't, or don't want to eat--especially when in public or traveling. I also wonder if chronic, widespread inflammation in Crohn's, specifically, could lead to lack of appetite. Certainly chronic illness wears on us mentally which can affect mood, energy levels, and appetite.

He doesn't drink water either. I was secretly hopeful when he got so sick that maybe he would be forced to change some of his habits...

Even if food makes you sick, it is essential to get enough water. This is even more important during flare-ups. A normal person should have about 2L of water per day. A person with diarrhea could need twice that just to break even. Whatever you need to do to get more water, do it. If you don't like water (like JP), then spruce it up! You could do 1 part apple juice (or any juice for that matter) to 9 parts water, or dilute sports drink (not SCD friendly!) with 5 parts water (5:1). I use sparkling water and SCD friendly apple juice, or a dilution of coconut water and tap water (see below).

Unfortunately the doctor seems to basically back him up that he should do nothing to change his diet and rely completely on the medication. The doctor has put him on Asacol and he is beginning to respond. He's having fewer bowel problems but is just as fatigued as always, and I don't think the joint pain has gone yet...

It's interesting to me that conventional GI's advocate that diet has nothing to do with the signs or symptoms of IBD, a gastrointestinal disease. I don't think this is the norm. Most GI's know, for example, that spicy food irritates and exacerbates the symptoms of people with active (read: flaring) IBD. If certain foods can exacerbate symptoms, wouldn't it make sense that certain other foods (or the proper mix thereof) could help to relieve symptoms? Hmmm...

AP later mentioned that JP experiences extreme fatigue. This is common in IBD also. I remember days when I couldn't climb a flight of stairs (I'm a competitive athlete, remember). While there are myriad causes to fatigue in IBD, the most likely (and the ones we have the most control over) are:

         a. Dehydration. Solution, drink water--LOTS of water. You may not want to because either you don't like water (some folks don't) or because water (secretly) makes your symptoms feel worse. You HAVE to drink water. You can use juice to liven it up if you want, but dilute the juice with lots of water. I use an approximate 10:1 dilution with juice, or a 4:1 dilution with coconut water. Coconut water contains four of the 5 major electrolytes and has more potassium per serving than a banana. It is bar none the best natural electrolyte drink out there--and it's far better than conventional sports drinks which are loaded with cheap sugar (which we don't need). One caution: Coconut water in large quantities can act as a laxative in people with IBD, so use it in moderation.

         b. Vitamin and Electrolyte Deficiency. There is a small host of vitamins that either don't get absorbed (like B vitamins in Crohn's), or don't get internally produced (like Vitamin K, in Colitis) when there is so much inflammation. This will be exaggerated with  poor diet. Solution: Take a good multi-vitamin plus Calcium (in the form of Calcium Citrate, it's more absorbable). Freeda makes a good SCD-friendly Multi and B-complex. I take both.

         c. Calorie Debt. When we're sick with that much D, transit time of food is just too fast to be fully absorbed--even in a healthy person. This is a large reason people with flare-ups lose weight so fast.

         d. Anemia. Serious IBD sufferers experience bleeding. This constant leakage can make you anemic. Anemia is a real concern and can cause varying levels of fatigue depending on the severity. See my post on anemia.

Onward to Health

Anemia and IBD

***If you're anemic, then you should see your doctor for treatment. It's serious.***

   Anemia is a common problem in people with IBD. Intestinal inflammation leads to bleeding. If you have active IBD, chances are you're bleeding. For six years I never thought I was bleeding because I couldn't see it. It wasn't until I finally submitted a stool sample that I learned I was indeed bleeding, albeit on a small scale.

   The two main causes of anemia in IBD patients (--that I know of. Your doctor might know more) are iron deficiency caused by bleeding in the intestine (simply, loss of red blood cells through leakage), and anemia caused by vitamin deficiency (poor absorption in the intestine).

There is also a B12 specific, pernicious anemia, caused when the body cannot adequately absorb vitamin B12. (All the more important to take a B-complex supplement, especially those with Crohn's, as B vitamin activity is mostly related to the small intestine.)

   I don't know this for sure, because it varies widely from person to person, but my sense is that anemia in IBD patients with active symptoms is a result of both, leakage and vitamin deficiency. So that's the first question for your Dr.:

      Which is the most likely cause of my anemia, and does the treatment I'm on account for one or the other or both?

Your Dr. may say that as the [IBD treatment] takes hold, and the inflammation decreases, vitamin absorption will increase too. That's true, but you will likely have to wait 6-ish weeks to find out if the [allopathic IBD treatment] will be effective enough to get a hold on the inflammation. Naturopathic IBD treatments take time to, and you'll want to treat anemia concurrently with your other symptoms.

   Regardless of the quality of your diet, you should consider a good multivitamin (there's advice on vitamin supplementation from my reading list-- here and here). When you have active IBD symptoms, the combination of inflammation and increased transit time (not to mention fluid loss from diarrhea) will lead to vitamin deficiency. Freeda makes an SCD friendly multivitamin. I take that and the SCD friendly B complex too.

   There is some evidence that IBD patients could benefit from a calcium supplement. From what I've read it's mostly due to two things. (1) Some of the [allopathic IBD] drugs encourage the leaching of calcium from the bones, or frustrate it's absorption, and (2) chronic inflammation and IBD symptoms deplete the body, leading to nutritional deficiencies, calcium being one of these.

   I found this below that might be helpful. It comes from the National Anemia Action Council FAQ site:

I have been diagnosed with anemia and my doctor has started treatment; how long will it take for my symptoms to improve?

[snip]

Without receiving a blood transfusion, your body must manufacture new red blood cells to reduce the symptoms related to anemia. It takes about 5-7 days for your body to start making red blood cells. This can result in an increase in hemoglobin levels within 2-3 weeks of starting treatments with erythropoiesis-stimulating agents (ESAS), iron supplements, or vitamin supplements.

The NAAC focuses on allopathic medicine. Below are some natural treatments for IBD-related anemia. Remember, you still need to see your doctor.

Natural Anemia Treatments

• Eat dark green vegetables. These are high in iron and B vitamins. If you have active IBD symptoms, lightly steam them to make them more palatable.
• If your system can handle them, beets are an all-around super food. High in lots of things, including iron and B vitamins.
• Iron is better absorbed in the presence of vitamin C, so eating oranges or apples with a high iron meal assists absorption. This argues, again for a good vitamin supplement (Multi with folic acid, and B-complex).
• Salmon and Mackerel are high in B vitamins.
• Take a tablespoonful of blackstrap molasses twice daily. Molasses is a good source of iron and essential B vitamins.
• Eat Liver or take a raw liver extract. Both are high in iron.
• Some recommend 1/2 to 1 tsp. of the Tincture of Yellow Dock Root three times daily (I've not tried this).
• Take an organic form of Iron ( with amino acid chelate [more on chelated minerals]): 100 mg of elemental Iron daily (Iron aspararte, citrate or picolinate), not the poorly absorbed sulphate which may cause constipation and/or stomachache.
• Extra Vitamin C (500 mg), can be be taken with iron for better absorption.

Avoid foods that interfere with the iron absorption. Examples of foods to avoid are: beer, candy bars, dairy products, ice cream, soft drinks, coffee and tea. If you're on the SCD (which I recommend), then the first six won't be a problem for you. Cut the coffee and tea though.

Foods high in oxalic acid interfere with iron absorption (there's argument over the details). Foods such as almonds, cashews, chocolate, kale, rhubarb, sorrel, spinach, swiss chard and most nuts and beans are high in oxalic acid.

Onward to Health.