Perianal Crohn's Disease
Treatment, causes, symptoms, diagnosis
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Crohn's disease diet
There seems to be as many purported diets for Crohn’s disease as there are health websites and, like opinions, everybody’s got their own Crohn's disease diet to tell you about or sell to you.
There are at least three major reasons for such numerous and varied diets for Crohn’s disease:
As physicians are quiet on the issue of a suitable Crohn's disease diet and because any patient with Crohn’s disease can tell you that it is quite sensitive to diet, various health and wellness sites make claims to have the best Crohn’s diet, one that is “proven effective” or “guaranteed to work.”
If a Crohn’s disease diet was proven effective, gastroenterologists would be clamoring to offer it to their patients.
Unfortunately, despite several small and medium studies that have been done, there is still no consensus.
Possible reasons that physicians are a bit hesitant about giving a Crohn's disease diet
From about the time Crohn’s disease had a name and a description until the 1980s, the standard Crohn's disease dietary advice to patients with this serious disease was to maintain a low fiber diet.
This approach was based on the notion that fiber would worsen the main symptom of Crohn’s disease, namely diarrhea.
While this was standard of care for some time, many fought against it or refused to adopt the practice for their patients.
In fact, not only is a diet with liberal use of fiber safe5, but a high fiber diet is likely useful for Crohn’s disease that is in remission.
Thus within the last forty years, medicine has made a complete reversal about this single dietary component.
Likewise, there have been a number of recommendations which have later been ignored or downplayed. In many ways, medicine has been burned by a lack of reliable evidence when it comes to Crohn’s disease and perianal Crohn's disease treatment using diet. Unfortunately, this has meant an enormous amount of suffering for patients with the disease.
While there is no single Crohn's disease diet that has been shown to be universally effective in Crohn’s disease, nor has there been enough randomized, controlled trials to make definitive conclusions, several different Crohn's disease diets have shown some promise.
Crohn's disease diet: The Elemental diet
An elemental Crohn's disease diet is one in which all vitamins and nutrients are already in their smallest functional units. For example, proteins are in the form of individual amino acids.
Theoretically, no digestion is required for elemental diets and individual amino acids cannot function as antigens to exacerbate the disease.
This diet is one of the better known Crohn’s disease diets and has been shown to induce and maintain remissions3.
Unfortunately it is not palatable and patients often reject it over time.
For patients that have adapted to an elemental Crohn's disease diet and then stopped it, sudden and severe relapse has occurred.
Also, because of its high osmolarity, an elemental diet can lead to a particular form of diarrhea (different than Crohn’s diarrhea), which complicates the picture.
For those that can commit to it and can consume enough vitamins and calories, an elemental diet is a safe and effective Crohn’s disease diet.
Crohn's disease diet: The Polymeric diets
In contrast to elemental diets, polymeric Crohn's disease diets are diets in which whole proteins such as albumin in eggs or casein in milk are eaten.
Most (but not all) studies using a polymeric diet show the same benefit as seen with an elemental diet, but is more palatable.2,7
It is important to note that these diets are given in conjunction with steroids in order to induce a Crohn’s disease remission. Neither the polymeric Crohn's disease diet, nor the elemental Crohn's disease diet, has been shown to induce a remission alone.
Crohn's disease diet: Specific Carbohydrate diet
One grassroots diet that has achieved a bit of notoriety is Elaine Gottschall's Specific Carbohydrate diet.
The reasoning behind this approach is similar to that of the elemental diet in that foods that are easier to digest are better for the gut.
The approach is similar to the idea of gluten-free diets for patients with celiac disease.
The rationale is that the guts of people with Crohn’s disease lack certain enzymes capable of digesting polysaccharides.
While there are many testimonials to support this claim, the science has not been performed to support this concept.
Crohn's disease diet: Microparticles
Microparticles are small inorganic molecules like titanium dioxide that are postulated to be linked to the cause of Crohn’s disease.
Since Crohn’s disease occurs more often in Western, urban areas, substance that are more common in these areas (microparticles) are thought to be explain this increased incidence.
While it may be difficult to consume a microparticle-free diet, studies that have accomplished that very thing have shown to be of some benefit in the disease.6
Crohn's disease diet: Fiber
While a reasonably high fiber content in a Crohn’s disease diet is a good thing, it matters what kind of fiber it is.
Fiber that is prone to a lot of gas formation such as the kind found in legumes can increase the sensation of bloating and discomfort.
Dietary fiber can decrease some mediators of inflammation and promote repair of damaged cells in the wall of the colon.
When used judiciously, dietary fiber can help support gastrointestinal regularity also.
Crohn's disease diet: Probiotics
One of the main precipitating factors in Crohn’s disease is an abnormal or disrupted intestinal bacterial flora.
In other words, our GI tracts (with the exception of the stomach) are covered with bacteria, just as our skin is covered with them. Under most conditions, the bacteria that colonize the gut are helpful—not only do they prevent harmful bacteria from staking claim to a region of bowel, but they can also help digest certain foods.
Several studies have shown the benefit of some types of bacteria and the detriment that other types can cause.
In terms of a Crohn’s disease diet in which the intestinal bacterial flora are in a higher state of flux than in most people, the consumption of useful bacteria or probiotics can be of benefit.
One of the better sources of GI-friendly probiotic bacteria is yogurt with active Lactobacillus cultures (for people that can digest lactose).
Certain probiotic supplements that do not require dairy consumption are available as well.
Since some bacteria are specifically harmful to the gut of patients with Crohn’s disease it is important to choose a probiotic microorganism that is safe and effective.
Crohn's disease diet: Aloe Vera
As strange as it may sound, aloe vera actually shows some beneficial effect in inflammatory bowel disease.
While this finding was specifically in patients with ulcerative colitis (the other inflammatory bowel disease besides Crohn’s),4 it was from a randomized, double-blind, placebo-controlled trial.
Caution should be used when applying this herbal preparation to Crohn’s disease, however.
Crohn's disease diet: Glutamine
Glutamine is an amino acid that some have advocated as a treatment/dietary supplement for Crohn’s disease.
The clinical and laboratory results are mixed, however.
In one respect, glutamine may help maintain the mucosa of the GI tract, but it may also be pro-inflammatory, which is not helpful in inflammatory bowel disease.
As it stands right now, glutamine is one of those things that should be considered with skepticism.
It may turn out that all little glutamine goes a long way but that too much is actually harmful in Crohn’s disease.
Since no one knows what dose or even dose range is, it is probably best not to supplement.
Crohn's disease diet: Potato alkaloids
While there are few foods that are always forbidden in all people, deep fried potatoes may be one of them.
Not enough evidence exists to demonize French fries completely, but certain lines of evidence suggest that they may exacerbate Crohn’s disease.
In addition to their high fat content (not good) they contain substances called potato alkaloid. Potato alkaloids concentrate when the potato is subjected to frying.
These alkaloids work to reduce the mucosal barrier of the gut—the very thing that patients with Crohn’s disease want to preserve at all costs.
Crohn's disease diet: Bromelain and Boswellia Serrata
Bromelain, the herbal supplement that is extracted from pineapple stems shows some beneficial effect in Crohn’s disease.
While there is some laboratory data to support this, the effect in humans is limited to case reports.
Boswellia serrata, also known as Indian frankincense, has been studied in a randomized, controlled trial. Even though it showed no statistical difference from mesalamine treatment, it means that the extract is as good as that treatment.1
More work needs to be done, of course, but Boswellia serrata may actually be one of the hundreds of herbal remedies that belongs in a Crohn’s disease diet.
Crohn's disease diet in Conclusion
While medical science is not ready to endorse a single diet for inducing or maintaining remission in Crohn’s disease, several different Crohn's disease diets have potential to be useful in some patients.
Any change in a Crohn's disease diet should be discussed at length with a physician before it is undertaken.
Any diet must be safe in general and safe for Crohn’s disease.
Remember that patients suffering from this debilitating disease can easily acquire severe protein and overall calorie malnutrition along with vitamin deficiencies through an improper Crohn's disease diet. Because of these deficiencies, through poor absorption and/or decreased appetite/feeding, it is important to make sure that any Crohn's disease diet includes enough nutrients and vitamins for your body.
Regular surveillance for nutritional deficits should be done by a doctor.
Once you have selected a safe and nutritious Crohn's disease diet, be watchful for how your body reacts. Are you noticing a longer period between remissions? Were you able to induce a remission earlier than normal? Have you noticed that your need for corticosteroids (steroids like prednisone, methylprednisolone, and Solu-Medrol, for example) has decreased on this diet?
Unfortunately finding the right Crohn’s disease diet will take a bit of trial and error. Find one that is palatable and one to which you can adhere for the long term. The elemental diet might work great, but can you eat that way every day knowing that a flare usually follows soon after this Crohn's disease diet is broken?
Part of this trial and error approach to Crohn’s disease diet involves identifying and eliminating foods that can trigger a flare.
Highly fatty foods are notorious trigger foods.
While dietary fiber is good for most, fibers that result in a lot of intestinal gas formation (like beans and cabbage) might not be.
Also, people with obstructive symptoms (severe constipation and pain) should limit fiber intake until that situation is resolved.
For some reason, people with Crohn’s disease are often lactose intolerant also. Sometimes the diagnosis is obscured by the Crohn’s disease symptoms and goes undiagnosed for some time. It is prudent to try a period of dairy product avoidance to see if this relieves or reduces gastrointestinal symptoms. Otherwise, a physician can make the diagnosis of lactose intolerance.
Living with Crohn’s disease is a life-long process. Finding the healthiest path will take commitment, research, and effort but achieving freedom from symptoms (or infrequent flares) leads to a greatly improved quality of life.
Only attempt Crohn's disease diets that are safe, healthy, and palatable plus listen to your body and be mindful of how it reacts. Good luck!
Crohn's disease diet Reference List
1 H. Gerhardt, et al., "[Therapy of active Crohn disease with Boswellia serrata extract H 15]," Z. Gastroenterol. 39(1), 11 (2001).
2 F. Gonzalez-Huix, et al., "Polymeric enteral diets as primary treatment of active Crohn's disease: a prospective steroid controlled trial," Gut 34(6), 778 (1993).
3 A. L. Hart, A. J. Stagg, and M. A. Kamm, "Use of probiotics in the treatment of inflammatory bowel disease," J. Clin. Gastroenterol. 36(2), 111 (2003).
4 L. Langmead, et al., "Randomized, double-blind, placebo-controlled trial of oral aloe vera gel for active ulcerative colitis," Aliment. Pharmacol. Ther. 19(7), 739 (2004).
5 S. Levenstein, et al., "Low residue or normal diet in Crohn's disease: a prospective controlled study in Italian patients," Gut 26(10), 989 (1985).
6 M. C. Lomer, et al., "Efficacy and tolerability of a low microparticle diet in a double blind, randomized, pilot study in Crohn's disease," Eur. J. Gastroenterol. Hepatol. 13(2), 101 (2001).
7 A. H. Raouf, et al., "Enteral feeding as sole treatment for Crohn's disease: controlled trial of whole protein v amino acid based feed and a case study of dietary challenge," Gut 32(6), 702 (1991).
Written by Michael T. Sapko, M.D., and edited by Donald Urquhart, psychologist.
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