 Crohn's disease (CD) is an inflammatory disease in the wall of the lower small bowel (ileum) and/or colon. The cause of CD is not known, although a person's genes and the body's immune system are both clearly important.
It is natural to assume that something that is eaten or not eaten is somewhat important in CD. After all, the lower intestine is where the fiber and food residue we eat ends up. Is it not possible that these foods or food additives we eat or don't eat may be part of the problem? Studying this medically is difficult because animal and plant foods contain many different chemicals. When these multiple substances interact in the intestines with the over 1,000 different bacteria in the colon, and with a total bacteria count of many trillions, it is simply very difficult unraveling what foods or food additives are best and even which ones may be a problem.
The bottom line consensus among most physicians is that diet alone rarely reverses a flare of the disease but likely helps to keep the disease under control.
Dietary Recommendations
There are basic nutritional guidelines for good nutrition for Crohn's Disease which have stood the test of time. It is important that the patient work with the physician to get the disease under control, usually with medications. Without this basic achievement, the full benefit of any dietary program becomes difficult to achieve. The following are crucial dietary goals:
- Weight - Maintain a good weight by ingesting enough calories, minerals and vitamins.
- Protein - The amount of required protein each day depends on weight, age, exercise, 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, 54 grams of protein is recommended. This amounts to regular servings of meat, poultry, fish or its equivalent in vegetable protein each day. Regular vigorous exercise, pregnancy or active disease may require more protein.
- Carbohydrates - Complex carbohydrates are those that have not been processed into simple ones. Complex carbohydrates are present in whole grains, brown rice and fresh vegetables and fruits. They contain much more in calories such as minerals, fiber and vitamins. Simple carbohydrates are refined grains, where all these other good nutrients have been removed. "Enriched flour" means that the food manufacturer has then added back vitamins, which were removed along with minerals and fiber. Use complex carbohydrates wherever you can.
- High Fructose Corn Syrup (HFCS) and Sugar - HFCS is manufactured from corn. It is all sugar and fructose, both empty calories. HFCS is cheaper for the manufacturer so it is now widely used throughout the food industries, and especially in soft drinks. There are many physicians who now think that HFCS and excess sugar may worsen the disease of the Crohn's disease patient. The bottom line is to severely restrict HFCS and simple sugar as much as possible.
- Fats - The body needs a certain amount of fat, especially from the mono and unsaturated vegetable oils, such as in olive oil. Highly marbled meats, creams and all trans fat products should be used sparingly. However, they do add calories for that person whose weight needs to be increased.
Vitamins
Patients with Crohn's disease need to discuss vitamin/mineral use with their physicians. There may be specific vitamins that are low in the blood. These can best be detected by blood tests.
- Multiple Vitamin with Minerals - Many physicians feel that a well-balanced diet containing lots of whole grains, fresh vegetables and fruits contain all the vitamins and minerals you need. Others, especially some in academic medical centers, suggest that it is okay to take a multi-vitamin each day. They would agree that there is little medical evidence one way or the other. If you feel better with a multi-vitamin, by all means take one. If you feel better eating fresh foods as mentioned above, then do that.
- Folic Acid - This vitamin is an important one, especially for pregnant females, as its absence during pregnancy may lead to serious developmental problems in the fetus. Furthermore, one medication called mesalamine, used in treating inflammatory bowel disease, may interfere with folic acid absorption. So, this would make the case for using a folic acid supplement or a multi-vitamin with folic acid if you take a mesalamine medication. Check with your physician.
- Vitamin B12 - This is an important vitamin. It is absorbed in the terminal portion of the small intestine, which is exactly where Crohn's Disease may be most severe. The blood level of B12 may therefore be low with resulting symptoms. The physician may check this with a blood test.
- Vitamin D - Vitamin D is important for bone health. Crohn's disease patients may be particularly susceptible to early osteoporosis, especially if they take steroid medicine such as prednisone. There are vitamin D receptors or attachment points on the cells of many organs in the body including the brain, heart and colon. So, it is likely that vitamin D has a role in good colon nutrition. Some authorities are recommending 800-1200 IU per day rather than the previous standard 400 IU per day. Check with the physician. A blood test may be needed.
Minerals
- Calcium - Even if you are Caucasian and live in the subelt where the sun causes the skin to make vitamin D, you still need an adequate amount of calcium by mouth. Milk, dairy products, shellfish, green leafy vegetables, canned fish and, if needed, calcium supplements are the main sources. The goal is at least 1200 mg of calcium per day.
- Iron - Many Crohn's disease patients have low iron levels which may lead to weakness, fatigue and anemia or low blood count. The physician may check the iron blood level periodically.
- Selenium - Selenium is a mineral that is needed in the body in tiny amounts for normal metabolism. This mineral has been found to be low in some patients with Crohn's disease. However, taking a selenium supplement is not recommended, as elevated blood levels are associated with diabetes and cholesterol problems. Brazil nuts are very high in selenium and eating one or two a day likely gives you all the selenium you need. A blood tests by the physician may be indicated.
Fish, Fish Oil and Herbs
- Fish and Flaxseed Oil - Fish oil has been found in medical studies to be helpful for some Crohn's disease patients. Flax seed oil has the same type of oil as in fatty fish. Fatty fish (blue, mackerel, salmon and sword), fish oil capsules and flaxseed oil can all be recommended.
- Herbs - Herbs are dried plans that are ground into powders. Labeling something an herb does not transform it into a magical medicine. All plants contain hundreds of different chemicals, many of which are still not known to science. Until good evidence is obtained on a specific herb's benefit, it is best for CD patients to avoid them all. Get your "herbs" from a rich supply of fresh plant food.
General Advice
The following are good dietary recommendations upon which most physicians agree:
- Smaller, more frequent meals - The lower intestine may handle foods better when smaller portions arrive there more frequently. The body and intestines will generally let you know if 4 or 5 smaller meals work better.
- Fluids - Adequate fluid intake is a must if diarrhea is a significant symptom. For most people, the body tells you when you are thirsty and need fluid. Some authorities recommend eight glasses of water per day.
- Caffeine - Caffeine in coffee, tea, soft drinks, and power drinks stimulates the colon to contract and promotes more bowel movements. So, caffeine limitation may be helpful. 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, which cause hives and trouble breathing, are rather uncommon. Shellfish and peanuts can induce such serious problems in the allergic person. However, intolerance to certain foods is very common. If a certain food causes abdominal symptoms, it should be avoided.
- Fast 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 good nutrition, protein and calcium. However, symptoms from lactose intolerance such as bloating, cramping and diarrhea may mimic Crohn's disease symptoms for the colitis patient. A simple home test can be done. Drink 16 ounces of fat free milk on a Saturday or Sunday morning and do not eat or drink anything else. 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 disorder whereby the gluten protein in wheat and certain other grains damages the small intestine. This disorder is much more common than was 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 disease patients. Food fibers are healthy and should be well-understood so they can be used in a beneficial way.
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 so produces a larger, bulkier stool. Soluble fiber, on the other hand, does dissolve in water. It is fermented by the colon bacteria and is used as a fuel source by the bacteria to maintain a healthy environment in the colon. However, if too much is taken, soluble fibers may promote excess harmless colon gas and flatus.
Eat plant food has both insoluble and soluble fiber. A food generally will be predominantly one type or the other. For instance, wheat is mostly insoluble fiber; oats are about half and half; and psyllium supplement powder is 90% soluble. Prebiotic powders are 100% soluble.
A diet with generous portions of plant foods, up to 25-35 grams per day, is now recommended for most people. However, Crohn's disease patients need to do this carefully, as excess gas may occur with too much soluble fiber, causing harmless cramps and/or diarrhea. Plant fiber does not damage the bowel wall.
The Colon Bacteria
 The colon is home to enormous numbers and types of bacteria. There are significant numbers of bacteria in the terminal small bowel as well, and this is where CD often occurs. This dynamic thriving pool of bacteria is now known to be needed for maximum bowel and body health. When these colon bacteria are fed properly with certain soluble food fibers, a great many benefits normally occur. These include increased calcium absorption and bone density, enhanced bowel and body immunity, decreased asthma and allergies in children, a reduction in certain bowel cancer factors, an increase in the good bacteria and decrease in the bad ones. The small of noxious flatus may even disappear.
Probiotics
Probiotics are bacteria in food such as yogurt, other dairy products and now in pill form. It is still uncertain whether probiotics help in Crohn's disease. The study of bacteria in the colon is difficult. The human colon has the most densely packed collection of bacteria anywhere in the world. There are over 1,000 different types of bacteria and the total number of bacteria in the colon is many trillions. The commercial probiotic preparations use from one, up to six, different bacteria and usually claim to have 5-10 billion organisms per pill. This sounds like a lot. Compared to the trillions that are already there, it is small. It also should be noted that the bacteria makeup of the colon returns to its previous state 2-3 weeks after probiotics are stopped. So, if a probiotic is helpful, it would have to be used long term. However, as of February 2010, there is no probiotic that has been found helpful for CD. People with immune deficiencies such as HIV, AIDS and chemotherapy should probably not take probiotics. Check with your physician on probiotics.
Prebiotics
A prebiotic is a special type of soluble plant fiber that reaches the colon unchanged. There, it is fermented by good colon bacteria. When this happens, positive measurable health benefits occur. Inulin and oligofructose are the most potent of these prebiotics. They are especially rich in foods such as onions, bananas, garlic, yams, asparagus, artichokes, avocados, wheat, chicory root, dandelions, jicaina and agave.
Americans only consume one to two grams of these good fibers per day, a very small amount, and 90% of this comes from white breads and onions. When these soluble prebiotic fibers are fermented by good colon bacteria, a substance called short chain fatty acids is produced. They can be called energy pods. These energy pods do some remarkable things. They:
- nourish the calls that line the colon, the very ones that become infected in CD
- make the colon contents more acidic, which is a good thing
- decrease the ability of the bacteria to move through the mucous layer (biofilm) on the bowel wall and the bowel wall itself
Leaky Gut
A leaky gut means that the cells lining the intestine and colon are not tightly packed one against the other.
A leaky gut has now been found in some medical conditions including diabetes, obesity, metabolic syndrome and, yes, Crohn's disease. When the gut becomes "leaky," the bacteria within the gut can move through the intestinal wall and cause inflammation and infection. This is what happens in Crohn's disease. This is what a leaky gut is.
More specifically, the term does not refer to "leaky gut syndrome," a term which can be found on the web and is often felt by irritable bowel syndrome patients to be part of their problem. At the present time, there is no medical evidence for any such association.
The Gut Mucous Layer or Biofilm
So, the health and tightness of the cells lining the gut are crucial. So is the second part of the gut's defense against bacteria and infection. This part is called the mucous layer or biofilm. This is a clear, thin mucous covering on top of the intestine's cells. It is the first line of defense. Normally, it is free of any bacteria. However, in Crohn's patients, this soft, Jello-like, pristine protective barrier becomes injured in some way. Bacteria invade it and move right up to and then invade the intestinal wall itself.
Food Additives and Emulsifiers
Seventy-five years ago, there were very few packaged or prepared foods. Families and mothers shopped for and ate mostly fresh vegetables, fruits and meats and/or they personally canned vegetables and fruits. Then, the food manufacturers began to package foods for convenience. This is when "food science" entered the picture. In order to put these foods on grocery shelves, food additives had to be created to provide for long shelf life, taste, good mouth feel, and now to claim "low fat, lite, light or no calories". In the end, hundreds of various food additives have been allowed and now are added to our prepared and packaged foods. So, food additives are not part of what are normal fresh vegetables, fruits, meats, poultry or fish. They are now added. All of these are felt to be safe, as determined by federal and state agencies. Yet, there are very large numbers of these additives added to many foods. There is little data that there may not be significant interactions between some of these additives. There is very little information on the long term effects of these substances. Finally, we don't know how some of them may react to patients with Crohn's or other diseases. This is where the food additive emulsifier may be important.
Emulsifiers
Emulsifiers are food additives that have the following properties:
- They blend or homogenize oil and water so that they stay together and don't separate.
- They thicken and increase viscosity of any liquid.
- They increase the shelf life of a food.
- They can improve taste and "mouth feel" to a product.
- They have no calories.
- They are considered safe by the Food and Drug Administration (FDA).
But... they may partially homogenize and disrupt the mucous layer of Crohn's patients. This, in turn, would allow bacteria to move through this protective barrier to reach the intestinal cells themselves. So, what are the names of these emulsifiers and where do they come from?
Emulsifier Names
Many emulsifiers are derived from cellulose, which is present in virtually every plant and tree. It gives structure to the plant. Most of the food cellulose emulsifiers are chemically derived from wood chips. The second emulsifier group comes from gum trees or bushes. The "natural" or "organic" food manufacturers naturally prefer the natural gums. The most common names are:
Celluloses
- Methyl cellulose
- Carboxy methyl cellulose - the most commonly used
- Hydroxy propyl methyl cellulose
Gums
All of these products do the same thing. They emulsify and blend oil and water mixtures; they make the mixture thicker and more viscous; they give a good "feel" in the mouth; they may add taste; they are non-caloric... and they all may disrupt the mucous lining or biofilm in a Crohn's patient.
Food and Drug Administration (FDA) and the Ingredients Label
The FDA regulates food additives, which is what emulsifiers are. The FDA agrees that these emulsifiers are non-caloric, safe and not allergenic. Sounds great. As such, food manufacturers are not required to list these emulsifiers on the ingredient label. It is assumed that there is no upper limit on the amount of an emulsifier that can be ingested. They have been used well before much was known about Crohn's disease and how bacteria move across the protective barriers of the intestine. With the increase in the packaging of prepared foods, their use has increased.
"Fat Free, Lite, Light, Reduced Calories"
The above words are attached to an enormous number of food labels and advertising. How do food companies reduce the calories in a product? One way is to remove the oil or fat from a food and replace it with an emulsifier, which simulates fat. They have, in the right proportions, good "mouth feel," meaning you have a sense of fat in the mouth. The taste can be tailored. Finally, emulsifiers have no calories. With the promotion of foods low in calories, it is no wonder that emulsifiers have increased so dramatically in packaged foods.
The Science
In the medical field, we always want confirmation by science. Of course, we know that emulsifiers blend and change the consistency of almost any liquid or jello-like substance. Simply look at a bottle of salad dressing containing oil and water and see how they stay blended together when an emulsifier like xanthum gum or another emulsifier is added. An animal study confirms that the one such commonly used emulsifier, called carboxy methyl cellulose (CMC), damages the mucous layer or biofilm and allows bacteria to reach the intestinal cells. These animals were bred to develop inflammatory, Crohn's-like disease in the intestine. Other healthy animals that received this CMC emulsifier did not develop such bacteria invasion (reference below).
Where are the emulsifiers? They are everywhere!
The emulsifiers are simply everywhere. If a food is packaged or bottled in any way, it is possible and, in some instances, likely that an emulsifier is used. Here are some examples. Remember - manufacturers do not have to tell you they are using an emulsifier.
- Citrucel - This bulking agent for constipation is pure methyl cellulose, as are all the other generic methyl cellulose agents and pills sitting on the pharmacy shelf next to Citrucel.
- Salad Dressings - If you can't see the different layers of oil and water in the bottle, the dressing will have an emulsifier in it - a cellulose or gum derivative.
- Ice Cream - Emulsifiers are needed to blend the product.
- White Bread - Emulsifiers keep white breads soft and, where desired, low calorie.
- Breakfast Cereals
- Pasta and Tortillas
- Cakes, Icing
- Most Baked Goods (outside your own kitchen)
- Granola, Health or Similar Food Bar - The emulsifier is used as a binder to hold the bar together.
- Veggie Burgers and Meat Substitutes - Emulsifiers bind the product to keep it from falling apart.
- Fish Sticks
- Frozen Dinners
- Omelets and Egg White Substitutes
- Peanut Butter
- Candy Bars and Chocolates
- Ketchup
- Sausage
- Gluten Substitutes - Emulsifiers are used in place of gluten containing grains and wheat.
There are many other foods and food categories where emulsifiers may be used. Codex Alimentarius is a United Nations and World Health Organization entity that sets food standards. Search Google for: Codex Alimentarus ______________. In the empty space, type of the name of the emulsifier - carboxyl methyl cellulose, methyl cellulose, guar gum, xanthum gum, etc. You will come up with a very long list of the categories where this particular emulsifier can be and often is used. It is a bit startling.
Shopping for Emulsion Free Products
Selecting foods that are free of emulsifiers can be a chore. One sure way is to only purchae fresh foods - vegetables, fruits, freshly cut meats, poultry and fish. Once you enter the middle aisles of a food store where processed and packaged foods are on the shelves, it becomes more difficult.
- Read the Labels - Look for the emulsifier words that are listed above. Remember, the manufacturer does not have to include these emulsifiers on the label, as the FDA considers them safe.
- Number of Ingredients - When there are a large number of ingredients on the label, perhaps more than 6 or 8, the likelihood increases that an emulsifier is included.
- E-Mail the Manufacturer - A food manufacturer may respond to your e-mail request on whether a specific food includes an emulsifier.
- Suspect the words "low fat, low or reduced calories, light or lite," or similar words or phrases. The manufacturer may well be substituting emulsifiers for fat or oil in the product.
- Re-educate yourself as to packaged, processed foods. Thirty or forty years ago, there were very few. Times have changed and many food additives have been slipped into our foods in very large quantities with little awareness by the public or government.
For Crohn's patients, the emulsifiers may be an injurious substance to the mucous layer (biofilm) of the lower intestine and colon. There is still much medical research that needs to be done before we can be absolutely certain. In the meantime, simply reducing or stopping emulsifiers in the diet is a no-risk step and may be very helpful. Over the past 10-20 years, the use of emulsifiers has risen dramatically within the food industry. Interestingly, so has the incidence of Crohn's disease. Could this just be a coincidence?
Recommendations for Crohn's Patients
- Follow sound nutritional practice, as outlined in the first section.
- Whenever possible, select fresh vegetables, fruits, meats, fish and poultry. In particular, eat fresh prebiotic-containing foods as often and as much as possible.
- Use an ogliofructose enriched inulin supplement, if such is needed. These stimulate the creation of energy pods in the colon, which increase the health of the mucous layer and the intestinal cells themselves.
- Dramatically reduce or stop eating prepared foods that contain emulsifiers, usually found in the middle aisles of most food stores.
- Maintain a close contact and supervision with your physician. All nutritional recommendations should be followed in conjunction with that person.
References
Intestinal mucus barrier in normal and inflamed colon.
Corazziari ES. J Pediatr Gastroenterol Nutr. 2009 Apr;48 Suppl 2:S54-5. PMID: 19300126
Viscosity gradient within the mucus layer determines the mucosal barrier function and the spatial organization of the intestinal microbiota.
Swidsinski A, Sydora BC, Doerffel Y, Loening-Baucke V, Vaneechoutee M, Lupicki M, Scholze J, Lochs H, Dieleman LA. Inflamm Bowel Dis. 2007 Aug;13(8):963-70.
Comparative study of the intestinal mucus barrier in normal and inflamed colon.
Swidsinski A, Loening-Baucke V, Theissig F, Engelhardt H, Bengmark S, Koch S, Lochs H, Dorffel Y. Gut. 2007 Mar;56(3):343-50. Epub 2006 Aug 14.
Bacterial overgrowth and inflammation of small intestine after carboxymethylcellulose ingestion in genetically susceptible mice.
Swidsinski A, Ung V, Sydora BC, Loening-Baucke V, Doerffel Y, Verstraelen H, Fedorak RN. Inflamm Bowel Dis. 2009 Mar;15(3):359-64.
Bacterial-mucosal interactions in inflammatory bowel disease: an alliance gone bad.
Chichlowski M, Hale LP. Am J Physiol Gastrointest Liver Physiol. 2008 Dec;295(6):G1139-49. Epub 2008 Oct 16. Review.
Enhanced translocation of bacteria across metabolically stressed epithelia is reduced by butyrate.
Lewis K, Lutgendorff F, Phan V, Soderholm JD, Sherman PM< McKay DM. Inflamm Bowel Dis. 2009 Dec 18.
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