Crohn's Disease

The Facts

Crohn’s Disease is a chronic, recurrent inflammatory disease of the intestinal tract. The intestinal tract has four major parts: the esophagus, or food tube; the stomach, where food is churned and broken down; the long small bowel, where nutrients, calories, minerals, and vitamins are absorbed; and the colon, where water is absorbed, stool is stored and a good many health benefits occur. The two primary sites for Crohn’s disease are the last portion of the small bowel (the ileum) and the colon (Crohn’s colitis). The condition appears to start when the colon’s normal bacteria stick to the colon’s lining more readily. Normally, the colon easily fights this off as its immune defenses are so robust and strong. In Crohn’s Disease, however, this does not occur. Small nests of inflammation occur, persist and smolder. The inflammation becomes worse and spreads. The lining of the bowel can then become ulcerated and the bowel wall thickened. Eventually, the bowel may become narrowed or obstructed, at which time surgery would be needed.

What Causes Crohn’s Disease?

For the most part, Crohn’s Disease is a disorder of young people, even children. There is now evidence of a genetic link as Crohn’s frequently shows up in families and certain ethnic groups. For instance, the disease is more common in Jewish people and less so in African Americans. As noted, there is evidence that the normal healthy bacteria that grow in the lower gut may, in some manner, act to promote inflammation. The body’s immune system, which protects it against many different infections, is a factor.

So, a number of clear factors are necessary for Crohn’s Disease to occur.

• There is a genetic link that predisposes some people.
• The colon’s normal bacteria are necessary.
• The colon’s own immune system fails to control the local infection.

There are still a number of unknowns about the cause of the disease; however, research is rapidly increasing our knowledge. Fortunately, a great deal is known and there are now a variety of effective treatments available.

Crohn’s Disease Symptoms

The symptoms of Crohn’s disease depend on where in the intestinal tract the disorder appears. When the ileum (ileitis) is involved, recurrent pain may be experienced in the right lower abdomen. At times, the pain mimics acute appendicitis. When the colon is the site, diarrhea (sometimes bloody) may occur, along with fever and weight loss. Crohn’s disease often affects the anal area where there may be a draining sinus tract called a fistula. When the disease is active, fatigue and lethargy appear. In children and adolescents, there may be difficulty gaining or maintaining weight. Nutrition and vitamin deficiencies often occur. So, the main symptoms of Crohn’s Disease may be:

• Recurrent, lower abdominal discomfort
• Failure to gain weight normally, especially in the young
• Chronic fatigue and lethargy
• Bowel urgency and/or diarrhea, sometimes bloody
• Sores or drainage in the anal area

Diagnosis

The diagnosis often begins with a physician’s suspicion that Crohn’s Disease may be present. The patient’s medical history and physical exam are always helpful. Certain blood and stool tests are necessary. X-rays of the small intestine and colon are usually required. In addition, a colonoscopy exam of the entire colon is often the best way of diagnosing the problem. A colonoscopy exam is where the colon is cleaned out and then visually inspected with a lighted endoscope. Biopsy specimens can be obtained. Colonoscopy is usually the definitive exam in making a diagnosis.

Course and Complications

The disorder often remains quiet and easily controlled for long periods of time. Most people with Crohn’s disease continue to pursue their goals in life, go to school, marry, raise a family, exercise and work with few limitations or inconveniences.

Some problems, outside the bowel, can occur. Arthritis, eye disorders, skin problems, and in rare instances, chronic liver conditions may develop. If the disease occurs around the anal canal, open painful sores called fissures can develop.  A fistula can also form. A fistula is a tiny channel that burrows from the rectum to the skin around the anus. Infrequently, fistulas can track into the urinary bladder, the vagina or even another part of the intestine. In addition, when inflammation persists in the ileum or colon, narrowing and partial obstruction may occur. Surgery is usually required to treat this problem. When Crohn’s disease has been present for many years, there is an increased risk of cancer.

A major problem that may occur very early in the disease is the loss of calcium in the bones. This occurs without any symptoms.  At this stage, it is called osteopenia. Later, when it progresses, it is called osteoporosis. Since Crohn’s Disease, for the most part, is a disease of young people, this bone loss can occur at a very early age. This is why most Crohn’s patients need to take extra calcium and vitamin D in their diet and with supplements. In addition, they should get a bone scan (densitometry) to detect early loss of bone. A simple x-ray will not detect early bone loss.

Treatment

Effective medical and surgical treatment is available for Crohn’s disease. It is particularly important to maintain good nutrition with a balanced diet, get adequate exercise, consume adequate vitamins and minerals, especially calcium and vitamin D, and keep a positive, upbeat attitude. See Crohn’s Dietary Therapy for details. Five types of medications are available to treat this disease.

• Cortisone or steroids (prednisone) – These powerful drugs can provide highly effective results. A large dose is often used initially to bring severe disease under quick control. The drug is then tapered to a low maintenance dose, perhaps taken just every other day. Hopefully, the drug may eventually be stopped altogether. Unfortunately, steroids promote calcium loss from bone. This is a major problem for Crohn’s patients. So, early detection and preventative therapy is imperative.
• Anti-inflammation drugs – Sulfasalazine, (Azulfidine, Dipentum, Asacol, Rowasa, Pentasa and Lialda) belong to a group of drugs called the 5-aminosalicylates. These drugs are most useful in maintaining a remission, once the disease is brought under control. They are most effective when the disease is present in the colon and less so for Crohn’s in the small bowel.
• Immune System Suppressors – These medications suppress the body’s immune system, which appears to be overly active and somehow aggravates the disease. The names of two of these commonly used medications are azathioprine (trade name: Imuran) and 6MP (trade name: Purinethol). These drugs are particularly useful for long-term maintenance. There are other potent immune-suppressing drugs that may be used in difficult cases.
• Biologics – These are newer and highly effective compounds that block certain stages of the inflammation. Infliximab (trade name: Remicade) and adalimumab (trade name: Humira) are two such medications.
• Antibiotics – Since there is frequently a bacterial infection along with Crohn’s disease, antibiotics are often used to treat this problem. Two that are commonly used are ciprofloxacin (trade name: Cipro) and metronidazole (trade name: Flagyl).

Dietary Therapy

Dietary therapy for Crohn’s patients is being increasingly recognized as a vital part of overall care. In a real sense, the patient must become an active partner in her or his care. Dietary therapy means that the patient or the caregiver of a patient understands the importance of the following in Crohn’s patients.

• Protein – how much and what type
• Carbohydrates – again, how much and what type
• Fat
• Vitamins – especially the importance of C, D and some of the B vitamins
• Minerals – calcium, selenium, zinc
• Fish oil
• Herbs

A full outline of this information can be accessed in the Diet block below.

Fiber, Prebiotics, and Probiotics

Fiber in plant food is now known to be especially healthy for everyone’s general health. For Crohn’s Disease patients, fiber can be recommended when the disease is inactive, and especially when there is no narrowing of the bowel, where plant fiber could induce blockage.

Soluble prebiotic fibers are a more recently discovered type of fiber, which has some real bowel benefits. Their use in Crohn’s patients is still not certain but since they are simply plant food, there are few side effects. The prebiotic fibers, inulin, and oligofructose are the names of the best-studied ones. They promote the growth of good colon bacteria which, in turn, make short chain fatty acids. These fatty acids may be a real benefit to Crohn’s patients as they seem to make bacteria less adherent to the bowel wall and are actually the fuel source for the bowels own cells.

Learn more about probiotics here.

A probiotic is a good bacteria or yeast taken by mouth that, hopefully, grows in the colon and produces good results. There is some scientific evidence that probiotics may help some Crohn’s patients. In particular, the use of probiotics and prebiotics together may be appropriate for some. Again, check with your physician.

Learn more about prebiotics here.

Stress and Surgery Surgery is commonly needed at some time during the course of Crohn’s disease. It may involve removing a portion of diseased bowel, or simply the draining of an abscess or fistula. In all cases, the guiding principle is to perform the least amount of surgery necessary to correct the problem. Surgery does not cure Crohn’s disease.

Summary

Most people with Crohn’s disease lead active lives with few restrictions. Although there is no known cure for the disorder, it can be managed with present treatments. There is increased emphasis on patients helping themselves by good dietary management, meaning adequate calories, vitamins, minerals and even prebiotic food fibers and probiotic bacteria. For a few patients, the course of the disease can be complicated, requiring extensive testing and therapy. Surgery sometimes is required. By working closely with your physician and managing your own emotional and dietary behavior, most patients will have a good long-term outcome.

Medical References

Inulin and oligofructose in chronic inflammatory bowel disease.

Visit the Crohn's and Colitis Foundation for supporting information.

Scientific Research

There is now very clear evidence that Crohns Disease always has a dysbiosis of the colonic bacteria. This means that there are more bad than good bacteria within the colon. What is not known as yet is whether this is helping to cause the Crohns problem or whether it is a result of the disease. However, what is now apparent is that making a major effort to change this bacterial makeup is a logical potential therapeutic goal. The following articles from major academic centers speak directly to this issue, mentioning prebiotics as a possible agent.

You can read more about new therapeutic options for inflammatory bowel disease by following these links to "Future directions in inflammatory bowel disease management" and/or "Role of nutrition and microbiota in susceptibility to inflammatory bowel diseases".

Another article that addresses this issue of modulation of the gut microbiome as a therapeutic measure in inflammatory bowel disease.

Changing the gut flora in inflammatory bowel disease

Crohn’s Disease Dietary Therapy

Introduction

Crohn’s Disease (CD) is a disorder of the small intestine and often the right side of the colon or large bowel. It is an inflammatory disorder in that the bacteria that normally reside in the gut are able to invade the bowel wall and cause the disease.

In the past, we physicians did not think there was anything specific about the diet that needed to be avoided. We prescribed a good nutritious diet with enough protein, calories, and vitamins and that was about it. However, there has been an explosion of information and research not just about the very cause of Crohn’s Disease, but also about the diet itself – and how the foods we eat could favorably (and unfavorably) influence the disorder.

The Lower Gut and the Importance of Insoluble Fiber

People with a healthy bacterial mix tend to weigh less, demonstrate better immunity to disease, absorb vitamins and minerals easier (resulting in stronger bones), feel less stress and more.

Up until the past 15 years, the importance of the lower gut has been downplayed in medical literature and in education in general. Training physicians relegated the gut to a minor health role and largely ignored the pounds of bacteria living in and on the human body. Only recently has medical science began carefully examining these bacteria, the roles they play in overall health and wellness, and how a nutritious diet comprised of fiber-rich foods can positively affect Crohn’s disease and other conditions.

It turns out that the microbiota in the lower gut plays an enormous role in health. People with a healthy bacterial mix tend to weigh less, demonstrate better immunity to disease, absorb vitamins and minerals easier (resulting in stronger bones), feel less stress and more. Although a healthy body can result from good genes to some extent — as demonstrated below — you can positively affect your overall health and the symptoms of Crohn’s by manipulating your lower gut’s microbiota yourself. You can do this by modifying your food intake to a diet designed for Crohn’s disease.

The effective Crohn’s disease diet contains a diet rich in the insoluble fibers found in foods such as chicory root, bananas, onions, garlic, Jerusalem artichoke, whole grains and more. For optimal health, eating between 25 and 35 grams of soluble and insoluble fiber every day is recommended; unfortunately, most people simply do not eat enough fiber to make a difference in their overall wellness. Why is fiber important? Fiber fertilizes the lower gut’s healthy bacteria, reduces the permeability of the bowel wall and can help with the uncomfortable symptoms of Crohn’s disease, among other things.

Supplementing the Ideal Crohn’s Diet

Getting enough fiber to satisfy your diet for Crohn’s doesn’t have to mean eating garlic and bananas on whole wheat bread several times per day. These foods contain the plant fibers inulin and oligofructose, which are prebiotics that has been proven to fertilize healthy lower gut bacteria. Although these fibers won’t fix Crohn’s disease completely, they can improve the strength of your bowel wall and fight the other factors that worsen disease symptoms. Adding a prebiotic fiber supplement to your diet that contains both inulin and oligofructose is an easy way to favorably adjust this bacterial mix and boost your overall wellness.

Treating CD With a Specialized Crohn’s Diet

The dietary treatment of CD, based on known recent and startling science and research, is now one of the most exciting new discoveries in gastroenterology. It promises to have enormous benefits to almost everyone with this disorder. Although diet modification is an exciting new frontier in the treatment of this condition, before embarking further into the diet, it is useful to know briefly about 3 important areas. Here are 3 new proven key facts about Crohn’s Disease.

What Does Research Tell Us?

We, physicians, take pride in using evidence collected from research to guide us in treatment. Everyone wants proven facts whenever it comes to their treatment. We are slowly getting a handle on the very basic causes of Crohn’s. We know that a genetic makeup is required. We also know that something in what we eat and/or drink is really important. The answers are not all in yet, but we now know enough that we can give some pretty good answers to the dietary questions everyone with this disorder has.

A large medical study was published in the American Journal of Gastroenterology in 2011. The authors reviewed over 1000 published medical articles on this subject and found 19 that provided good enough information to reach important conclusions. Here is what they found.

There was an increased risk of getting the Crohn’s Disease if a person ate:

• A high protein and/or meat diet
• A high saturated fat diet, including trans fats
• A high vegetable polyunsaturated fat and especially omega 6 and oil diet
• A low fiber diet

a) Protein

Some of the reports looked at all animal protein that was consumed-meaning meat, poultry, fish and dairy products. Others evaluated just meat, meaning mostly beef and pork products. The consensus was that Crohn’s patients should not go overboard on animal protein, especially meat. The average daily amount of animal protein in an American diet is 75-100 grams. 50 grams is almost certainly enough. This is about the size of a deck of cards.

b) Fats

Saturated fat is found in well-marbled meat, bacon, all processed meat including sausage, but also in whole and even 1-2% fat-reduced milk. Butter, lard, chicken skin, coconut and palm oil are other sources of saturated fats. But the information on poly-unsaturated fats was what was most disturbing. These are the fats found in fish, most vegetable oils, and nuts. They are the ones that have been shown to be so good for you in reducing cholesterol and perhaps heart disease. Nevertheless, in the Crohn’s-prone individual, they seem to act differently. This was particularly true of the omega 6 vegetable oils. They make it more likely you will get CD. The bottom line seems to be that a reduction in most fats, including the omega 6 vegetable oils, may be a smart move.

c) Fiber

Here is where the payoff might be for the Crohn’s patient. It is the soluble plant fibers that are the major fertilizers and foods for the very best colon bacteria. It is these bacteria species that are so healthy for the gut wall. They produce lots of nutrients for the health of the colon cells. They acidify the inside of the colon, a very beneficial outcome. When they are exuberantly growing, these good bacteria prevent bad bacteria that none of us want in our lower bowel. Eating a wide variety of vegetable, fruit and whole grain foods every day does the trick.

Genes

There is clearly a genetic makeup for those people who get CD. Up to 100 genes have been identified that may be involved and there are likely many more. Some of them are also present in those people who have or will get ulcerative colitis. They are also present in other non-gastrointestinal disorders such as certain immune-related diseases like rheumatoid arthritis and multiple sclerosis. Research is moving very fast but as of this time, we know that genes are important. The gene is the 1st fact to remember.

Environment

By this, I want to cover a very broad area, but mostly it involves the diet. When people have active CD, we know it gets better when the bowel is put at complete rest. This means hardly anything except water by mouth. There is something in foods or liquids that we take by mouth that aggravates the Crohn’s inflammatory process. When you remove these injurious factors, you get better. But we haven’t known for sure what it is that is causing the problem. Could it be a non-food item such as some environmental factor or chemical that is added to food? We don’t or, before now, didn’t know, but now we are beginning to get some pretty good ideas. The important point is that someone or multiple things that we take by mouth, most likely in the very foods we eat, are the problem. So, the 2nd fact to remember is environment or diet.

Gut Bacteria

Bacteria have a bad reputation because of advertising and the occasional bad bacteria that gets into the news. However, almost all bacteria are either benign or actually good for us. We simply have bacteria everywhere both inside and outside our body. For the most part, they protect us and usually provide very real health benefits.

The lower part of the small intestine and particularly the colon contains an immense number of bacteria. These are the key factors for the CD patient. As noted, the bacteria within our gut are usually our friends and give us many benefits such as making vitamins and a robust immune system. In the Crohn’s person, a few of them can and, indeed, do behave differently. For reasons that are only now becoming clear, these bacteria are able to move through the protective defenses of the gut and then invade the bowel wall. If there are no bacteria within the gut, there is no Crohn’s Disease. So, the 3rd key fact to remember is bacteria.

Your Gut Bacteria Factory

To understand Crohn’s Disease as we physicians now do, it is important to know the basics of what is happening within our own gut bacteria factory. The gut, especially the colon, is packed with over 1000 species of bacteria and the total number of these little bugs are trillions upon trillions. For every cell in our body, there are at least 10 bacteria cells in the colon and the total number of genes of these bacteria outnumber our own gene count by over 100 times. These beneficial bacteria have been part of us for as long as living things have been on earth.

As noted, we simply could not live without the benefits that these bacteria provide us. The most remarkable is that they give us a robust immune system that protects us our entire life. But here is where it gets troublesome for those with Crohn’s Disease. If the bacteria factory is so beneficial, then why is it such a problem for those with the genetic makeup for CD? The answers to that question are slowly becoming known. Along with this knowledge is the fact that our treatments for CD have improved dramatically. But, just as important, so has our understanding of what happens within our gut with certain foods. We now know that some foods can and, indeed, do make a difference in the intestinal inflammation that is the hallmark of CD.

The Mucous Layer

The word mucous brings up a vision of a runny nose when you have a common cold. Not very pleasant. However, mucous is a very valuable and healthy substance to have in the body. Every membrane within our body has a mucous layer overlying it, including the inside of our nose. The excess mucous that comes from a nasal cold is simply the body’s method of protecting us and helping us get rid of the cold. A better term and one that we physicians and researchers use is biofilm. The mucous layer or biofilm is a dense layer of protein-like material that adheres to the inside lining of our intestinal tract. It is the first line of defense in the gut and prevents bacteria from moving through and attacking the wall of the gut itself. In addition, we have a vigorous and robust immune system in the wall of the colon itself. The mucous layer and these immune cells together are a strong defense mechanism except for people who get Crohn’s Disease. Something happens to this mucous layer or biofilm. Under these conditions, bacteria are able to migrate through the mucous layer and cause inflammation to the underlying tissue. This is how Crohn’s begins. In no other intestinal condition that we know is the mucous layer breached like what happens in Crohn’s Disease. One final comment. Emulsifiers are a large group of additives that manufacturers put in many foods. Detergents are another group of chemicals that are extremely prevalent around the house and kitchen. Remember these 2 words-emulsifiers and detergents. I will have more to say about them and how they may disrupt the intestinal mucous layer or biofilm.

Dietary Information

There is simply an enormous amount of good information available on a low saturated fat and high fiber diet. These can be accessed at usda.gov, eatright.org, amazon.com and every bookstore. Searching Google for high-fiber and a low-fat diet can be useful. In particular look for non-commercial sources. The low saturated fat, high fiber diet recommended for coronary heart disease patients is exactly what seems to be beneficial for inflammatory bowel disease patients. The American Heart Association has cookbooks and recipes that can be ordered on their website, heart.org.

Inflammation

Inflammation is what Crohn’s Disease is all about. The key fact is that bacteria within the gut, for reasons we now understand rather well, penetrate the protective mucous layer covering the inside of the gut. From there they invade the bowel wall and so cause Crohn’s Disease. Science now knows a lot about inflammation in the body. For the Crohn’s patient, they are worth knowing.

a) Colon wall

The typical Western-style, high saturated fat, high meat diet does 2 things that we know. First, it stimulates the production of excessive bile from the liver. In animals, this excess bile promotes the growth of certain bacteria in the colon which can cause a Crohn’s like inflammation in susceptible animals. This is bad enough. But the 2nd major thing that these saturated fats do is to induce a change in the makeup of the bacteria in the gut itself. Again, this leads to mild but definite inflammation in the colon wall. Just as important, the cells that line the colon weaken and allow bacterial materials to leak between the cells and accumulate in the blood. This is known as a leaky gut. People on a Western style, high-fat diet have a leaky gut. This is not desirable.

b) Immune strength

The major part of your immune system comes from the colon wall. This starts on the day we are born when bacteria first start to grow in the infant’s intestine. Following a diet, as outlined above enhances the strength of your immune system through your entire life. This, in turn, likely makes a positive difference in how your body responds to inflammation.

c) LPS (lipo-poly-saccharide)

This terrible sounding word refers to break down materials from the wall of the bacteria within the gut. When these substances slide through a leaky gut wall, as is present in CD, they then enter the blood stream. There they are called endotoxins or simply toxins. They induce inflammation throughout the body, in fat cells, in the lining of arteries (atherosclerosis), the liver and elsewhere. Nobody wants the toxins in their body, especially a Crohn’s patient.

d) Omega 3 and Omega 6 oils

Understanding these oils can be plain confusing. Omega 3 oils are the really desirable ones. They are protective of the heart, are present in fish, especially fatty fish and in some nuts and vegetable oils such as canola oil. Omega 3 oils decrease inflammation in the body. Omega 6 oils, on the other hand, may be bad and not so desirable, even though they are of the polyunsaturated fat type. It is the ratio or the proportion of the omega 6 to the omega 3 oils in the product that appears to be important. For instance, olive oil has a ratio of 10:1, which is borderline desirable. However, olive oil has a great deal of the very desirable mono-unsaturated fats. Canola oil, on the other hand, has a ration of omega 6 to omega 3 of about 2:1, which is very good. Canola and olive oils are likely the healthiest cooking and vegetable oils for our bodies.

The bottom line for inflammation is to follow a Crohn’s diet as outlined above. This diet:

• Reduces the inflammation in the bowel wall
• Enhances the immune factors within it
• Reduces the inflammation that can occur within the body through a leaky gut and endotoxins

Animal Protein

Our bodies need amino acids in order to build the proteins we need to stay healthy. These amino acids come from proteins that we eat, either in animal meats or in plants such as fruits, whole grains, and vegetables. In either case, these proteins are broken down by our digestive system into amino acids, which are absorbed and then used to build our own proteins. Animal protein provides all the essential amino acids we need, whereas it is necessary to eat a variety of plant material to get the full complement of required amino acids. This is rather easily done. The bottom line is that our body doesn’t much care where the amino acids come from. They are all the same whether they come from animal or plant. However, there are other things in meat, especially the saturated fats that make a difference in what happens in the colon. Here a high animal meat diet leads to a bad balance of bacteria. This, in turn, induces inflammation and a leaky gut, which are not good for the Crohn’s patient. Reducing the meat portion of a meal to about 50 grams provides the protein we need and also shifts the bacterial balance in a favorable way. 50 grams of meat is about the size of a deck of playing cards.

Fiber

Every vegetable, grain or fruit has fiber in it. It is what gives the plant its specific shape. Although there are many types of fiber, there are just 2 that are important for health, insoluble fiber and soluble fiber. Insoluble fiber means that the fiber does not dissolve in water and is not fermented by the colon’s bacteria. Rather, it retains water and, in so doing, helps to promote stool softness and regularity. Wheat in all its forms is mostly insoluble fiber. Soluble fiber, on the other hand, does dissolve in water. More important than this is the fact that the bacteria within the colon ferment it. It is a fuel for their own growth. The very best of the soluble fibers are called prebiotic fibers. A prebiotic fiber is used by the very best bacteria for their own nutrition and in so doing produce measurable health benefits for the body. Our Prebiotin Prebiotic Fiber is the most researched type of prebiotic fiber.

National authorities recommend the following daily intake of fiber.

• Men: 30 grams
• Women: 25 grams

These numbers will vary depending on sex, weight and body size. A varied mix of fruits, whole grains and vegetables will usually provide an adequate amount of both insoluble and soluble fibers.

A person with Crohn’s Disease needs to increase fiber intake gradually so as to allow the gut to become tolerant to it. If this gradual process is followed, harmless excessive gas and bloating should not be a problem. Caffeinated beverages may overly stimulate the bowel.

Prebiotics

Prebiotic soluble plant fibers are the very best. They are present in many vegetables and fruits. These plant fibers promote the growth of the best beneficial colon bacteria. When these bacteria thrive, many positive health outcomes occur, including better immunity, increased calcium and magnesium absorption, a healthier bowel wall (no leaky gut), less inflammation, reduced toxins in the blood and many others. Oligofructose and inulin are the names of the 2 best-known prebiotics with the most research behind them. These prebiotic fibers are particularly rich in wheat, rye, leeks, asparagus, chicory, Jerusalem artichokes and many other root vegetables like yams, bananas, garlic, agave, and others. Our Prebiotin supplement, taken daily, can provide the assurance that you are getting enough prebiotic.

Fruit

It has long been known that fruits are an exceptionally healthy food for just about everyone. What has been recently found in Crohn’s patients is that fruits are specifically protective for them. Fruits have so many vitamins, minerals, antioxidants and so much fiber that there is virtually no limit to how much can be eaten. Fruit juice, on the other hand, may cause some problems. These are often high in plain glucose and fructose which may be troublesome for some. They usually have had all the beneficial fiber removed. Some Crohn’s patients will note that their GI tract tends to act up with fruit juices. You simply have to test yourself.

Vegetables

Vegetables are the dietary backbone for the Crohn’s person. These are the foods that have so many of the beneficial fibers, including the very best prebiotics, inulin, and oligofructose. They provide bulk for bowel regularity and are the source of fuel for the beneficial bowel bacteria. It is these good bacteria that we want to see predominate within the gut. A high fat, high meat diet will always shift the bacterial balance in the opposite way, weakening the bowel wall, allowing a leaky gut to develop and ensuring that endotoxins or toxins are absorbed into the bloodstream. A wide selection of vegetables should be eaten and prepared with condiments as desired. If oils are to be used in preparation, note that canola oil and olive oil are likely the healthiest and best, as they provide a very good ratio of the good omega 3 oil to the not-so-good omega 6 oils.

Vitamins

It is important to discuss vitamins with the physician. For the Crohn’s patient, the following points on vitamins are worth considering.

• Multiple vitaminMany physicians feel that inflammatory bowel disease persons should take basic multiple vitamin preparations each day.
• Folic acid – This vitamin prevents birth defects so it is particularly important for the female who may become or actually is pregnant.
• Vitamin B12 – Some Crohn’s patients do not absorb enough B12 from the intestinal tract. The physician will want to check this level in the blood and, if low, give B12 injections.
• Vitamin D – This vitamin is important for bone health. Crohn’s people may be particularly susceptible to vitamin D deficiency which has been found to be much more common than previously thought. Some experts are recommending up to 800 IU each day. Check with your physician regarding vitamin D and calcium supplements as well.

Minerals

Eating a well-balanced diet with adequate whole grains and vegetables will usually provide all the minerals that the body needs. Additionally, most one-a-day vitamin preparations will contain the minimum recommended doses of all minerals. However, there are 3 minerals that may warrant special attention for Crohn’s patients.

• Calcium – In order to absorb and use calcium you need adequate Vitamin D which you get from sunlight and foods such as milk or supplements. If you take a steroid medication such as prednisone, it is even more important as this drug can deplete the bones of calcium over the long term. A dietary supplement may be needed.
• Iron – Since iron is absorbed from the small intestine where Crohn’s disease may be most active, there may be a deficiency in iron with the result that iron deficiency anemia can develop. Regular blood tests are usually needed to check for iron deficiency.
• Selenium – This mineral appears to act like an antioxidant which has beneficial health benefits in the body. Some medical studies have shown that Crohn’s patients may be low in this mineral and may need a supplement. Check with your physician.

Prepared, Packaged and Bottled Foods

We know that there is a rising incidence of inflammatory bowel disease, especially Crohn’s Disease, in the Western world and America. These increasing numbers parallel the change in our diet that has occurred over the past 100 years. There has been an increase in the saturated fats in the diet that is likely a significant factor. In addition, we now have a very wide variety of prepackaged, prepared and bottled foods that were not present in the past. These are truly manufactured foods. Food manufacturers add a wide range of chemical and other additives to their foods to enhance taste, smell and appearance, to improve mouthfeel and, especially, to increase shelf life. Each of these substances has long ago been approved by the federal Food and Drug Administration (FDA) as GRAS (Generally Accepted As Safe). However, most of them were accepted long before much was known about how they might act in the gut of a Crohn’s patient. Furthermore, we know virtually nothing about how they may interact one with the other. The best choice is to avoid these foods whenever possible. Most of them are present in the packaged foods in the central areas of large food stores. Shop the periphery of the store where fresh foods are sold. You also need to read labels. Be suspicious of foods that have dozens of ingredients and substances listed. In particular, if you don’t recognize the ingredient or word, simply do not buy the food. Look it up in a dictionary or the web. You need to be your own detective. Be suspicious of additives. They may be hurting you.

Emulsifiers

An emulsifier is a chemical that is added to prepared, packaged and bottled foods that we eat. It acts as an emulsion, for instance, emulsifying water and oil in a salad dressing so it is blended and does not need to be shaken. In addition to salad dressings, they are added to a great many of the common foods we all buy and eat, such as ice cream and sauces. They are used to give foods a better taste. They have no calories and so are substituted for many fats and are used in “low calorie” or “no calorie” foods, since many of them have the taste of a fat.

Here is a possible problem for the Crohn’s patient. In an earlier section, you will find information on the mucous layer in the intestine. It is also called the biofilm. It is a major defense barrier for the body as it keeps bacteria away from the bowel wall. In fact, it is the invasion of the mucous layer or biofilm by bacteria that is the hallmark of Crohn’s disease. Anything that potentially can damage this valuable layer should be avoided. Here are just some of the emulsifiers found in many of the prepared foods we eat.

• Xanthum gum
• Gum Arabic
• Guar gum
• Polysorbates, such as 40 and 80
• Lecithins from eggs
• Hydroxypropyl methyl cellulose (HPMC), also call hypromellose
• Carboxymethyl cellulose (CMC) -very commonly used in many products, even toothpaste.
• Many other celluloses such as methyl cellulose which is stool bulking agent Citrucel

Polysorbate 80 and HPMC above have had published research where each of these 2 chemicals badly damaged the mucous layer in the animal’s colon and allowed a Crohn’s like illness to occur. It simply makes sense for a Crohn’s patient to avoid these chemicals wherever possible. Read labels. Do not buy products where you do not know what all the ingredient are. Assume one can be an emulsifier. You need to become educated on labels and food additives so you can protect yourself. Remember that the FDA has approved these ingredients long before we had any idea of how they might react in the intestine in a Crohn’s patient. One final comment. Bread and other food manufacturers are now substituting emulsifiers for gluten, so if you see a food labeled gluten-free, suspect that an emulsifier has been added in its place.

Detergents

Detergents, of course, are cleaning agents that dissolve fats and oils. They may do the same to the wonderful mucous membrane that lines the inside of our intestine. Once dissolved, the underlying cells of the intestine would be exposed to harmful bacteria. No one intentionally ingests detergents. However, they are everywhere around the house, especially the kitchen. They are used to clean dishes and glasses from which we eat food and drink liquids. Some very small dried amounts may remain on dishes that would be particularly harmful to a person who was genetically susceptible to Crohn’s the next time the utensil is used? It is possible. It makes sense to use plenty of clean water to rinse the kitchen utensils thoroughly.

Probiotics

Probiotics are beneficial live bacteria taken by mouth that we hope will take up residence in the gut and thereby provide a benefit for the gut and the body. They are now being tested in many different medical disorders. There is some early evidence that certain specific probiotics may be helpful in certain patients with ulcerative colitis. However, in mid-2012 there is still no evidence that any probiotics are helpful in Crohn’s Disease. New research on probiotics is ongoing so this may change. In any event, the use of probiotics for any medical condition should be undertaken only with a physician that is knowledgeable in their use.

A Gastroenterologist’s Advice

I have seen and treated many patients with Crohn’s disease for many years. Way back then, even before the colonoscopy was invented, we had a pretty good idea of what we were dealing with. It was basically an infection of the wall of the small bowel and colon by the bacteria that normally live within the bowel and usually cause no problem. For some reason, these bacteria became the enemies for CD patients. We knew even then that there was a vague genetic link but really did not know very much beyond that. Now we know down to very specific genes that genetics is critical as to who gets Crohn’s. But, we cannot change the genetic makeup of anyone, at least not yet. But, there have been 2 really huge findings in the last 20 years that have changed.

The first research success has been the discovery of the “biologics” as treatment. These biologic drugs are a whole new area of therapy for those people who have severe immunity-related disorders like Crohn’s, rheumatoid arthritis and psoriasis. Remicade is the trade name of the one that has changed the lives for the better for some people with CD. Our researchers, drug companies, and our very physicians deserve a lot of credit for making this happen.

The second major change in our understanding of CD is just cresting right now. It is 2 pronged. The first is the spectacular discoveries of how the bacteria within our very gut are of such a vital importance to our very health and well-being. Incredible new research tools have driven these findings. For the Crohn’s patient, this new research has become critical because we now know that most CD patients have an abnormal and unwanted mix of bacteria in their gut. There are simply many more bad ones than good bacteria. This results in some bad things happening within the gut wall, none of which are desirable.

Along with this new research and understanding of these lifelong companions within our gut, has come new information that Crohn’s patients themselves can change this bacterial mix in a positive way. Yes, what we now know is that CD is a complex disorder where you need a genetic background to get the disease, but the bacterial load in your gut must change in a bad way to allow the Crohn’s inflammation to occur. We have discovered some risk factors for Crohn’s such as tobacco smoking and a low vitamin D blood level. These seem to increase the risk of getting Crohn’s. But by far the most important finding is in the diet. We used to think that a high protein, meaning a high meat and saturated fat diet, was needed to assure the Crohn’s patient of good nutrition. Now we know that was wrong. It is the fat in the diet, especially the saturated fat, and perhaps excessive meat as well that makes and allows the bacteria makeup to change in a deleterious way. It may be that simple. Reduce the daily saturated fat in the diet from 40% of the calories ingested to 20-25%. More difficult may be the finding that even vegetable fats, especially the omega 6 oils, in excessive doses may increase the risk of getting Crohn’s. Finally, increasing the daily fiber in the diet is likely just as important. It is these fibers that fertilize the very best bacteria and that can push out the bad ones. Using daily prebiotic supplements such as Prebiotin can provide the assurance that enough is being ingested.

This diet could be a tough one to follow for many patients. It is different from the standard Western-style diet where meats of all sorts are the central part, along with the saturated fats and low fiber that always accompany this diet. Nevertheless, it would be important for CD persons to know just how much they can contribute to their own well-being by adjusting what goes in their gut. A 2-3 month strict trial on this diet will likely tell you. You perhaps will need a nutritionist to guide you. Do it. It is a lifelong deal. We cannot cure Crohn’s Disease yet, but you, the patient, may have so much more that you can do to help yourself.

Medical References

1. High fat and low fiber diet increases risk of Crohn’s disease
   Hou JK, Abraham B, El-Serag H. Dietary intake and risk of developing inflammatory bowel disease: a systematic review of the literature. Am J Gastroenterol, 2011 Apr;106(4):563-73.
2. How food interacts with the gut bacteria in Crohn’s Disease
   Albenberg LG, Lewis JD, Wu GD. Food and the gut microbiota in inflammatory bowel diseases: a critical connection. Curr Opin Gastroenterol, 2012 Jul;28(4):314-20.
3. High animal protein intake increases the chance of inflammatory bowel disease
   Jantchou P, Morois S, Clavel-Chapelon F et al. Animal protein intake and risk of inflammatory bowel disease: The E3N prospective study. Am J gastroenterol, 2010 Oct;105(10):2195-201, Epub 2010 May 11.
4. Prebiotic fiber provides health benefits for Crohn’s Disease patients
   Gauarner F. Inulin and oligofructose: impact on intestinal diseases and disorders. Br J Nutr, 2005 Apr;93 Suppl 1:S61-5.