A guide for Crohn’s and Colitis patients

Nutrition for Crohn’s and Colitis patients

You are what you eat!

When I was fifteen years old and I was diagnosed with Crohn’s disease they explained to me that it was an inflammation of the bowel which is part of the digestive system, and that as a result of this I would have to adapt myself to various eating habits. “No problem”, I said, “just tell me what’s permitted and what’s not, and I’ll keep to a correct diet and everything will be alright.”

After a conversation with the doctor who diagnosed me with the disease, a medical insurance dietician and a range of clerks and other officials at the health institutions, I managed to make the following summarized list of problematic foods:
·         Spicy is forbidden – “because it burns you bowel”.
·         Everything that includes fiber is forbidden – “because it scratches the bowel wall”. That meant vegetables and fruit were not allowed (especially citrus fruits) as well as whole-wheat bread and other foods that contain fibers. Tomatoes, eggplants and peppers were forbidden also, as foods that contain fiber, and more than that, because “they are too acidic”.  Naturally ketchup was out of the question, and if you thought about it – the same went for all other herb products as well.
·         Meat is not recommended because “it is hard to digest”.
·         White sugar – “not recommended because it encourages inflammation, and is anyway generally not healthy”. It’s true of all foods of course, that they contain sugar, especially all the sweetened drinks. White bread was also not recommended because of the white flour it contains.
·         Everything that contains preservatives is forbidden – because “with them the food remains in the intestine and can encourage inflammation”.
·         Everything that contains food coloring is forbidden – “because it is simply not healthy”.
·         Every fizzy drink is forbidden – “because as it stands we already have enough gas in the bowel”. Cola, from which it was very hard for me to part, of course contains both sugar and food coloring. The prohibitions on fiber and sugar left me with a glassful of water.
·         It’s not recommended to eat out – “because it’s not clean”.
·         Fried foods – “not healthy”.
·         Dairy products – “not recommended because they are not digested well and can encourage diarrhea”.
·         Pulses such as chick-peas and broad beans – they cause gas and are therefore not worth it.




After all the conversations, consultations and the lists, I was left, as you can see, with rice and water. The doctors of course added that it was important to eat a lot because I was very thin and needed lots of vitamins so that my body could cope with the disease.

After a week of a strict and depressing diet, I celebrated its sooner than expected end at McDonalds.

Setting aside the cynicism, I admit that the advice that I got was not wrong. It is all correct in principle, but of course one needs to follow it in moderation. First and foremost, you need to understand that Crohn’s is not a disease for lazy people (in the end it will turn out that excess diligence will be the real reason for the disease…). Also and mainly, from a nutritional point of view, there is no alternative to hard work. Every patient has to make an investment and learn by himself which types of food are good for him, and which are not. After long years of treatment, and ups and downs, it seems that the best advice I got from any doctor ever was “eat everything you want, and if something gives you a sore stomach, don’t eat it again.” In the end, you are for yourself and your health, and as the wise man used to say: “Listen to everyone’s advice, but take your own decisions.”

The great problem with the subject of nutrition stems from the gap between what is forbidden and the many constraints, and the body’s need for essential nutritional elements (vitamins, minerals and so on). What is even more serious for patients is that their disease is active in the small intestine, something that causes absorption problems. Thus, even if your nutrition is appropriate, balanced and contains all the required nutritional components, you will still encounter deficiencies. Many Crohn’s patients therefore suffer from a deficiency of iron, vitamin B12, folic acid, zinc and calcium. Similarly, not a few suffer from malnutrition and weight-loss. This gap obliges every patient whose health is important to him to thoroughly know the state of his health so that he can consume most of the nutrients his body needs while making the least possible mistakes.

Despite the fact that every patient responds differently to various types of foods, it’s possible to define a number of common guidelines for correct nutrition:

No eating out
Long before the question “What should I eat?” comes the question “Where should I eat?” I’ll try to be as clear as possible on this matter because people sometimes have a tendency to distort things. Repeat aloud after me, and practice with me the most important rule of nutrition: “I will never be tempted to eat out!” Repeat this mantra three times a day – there’s a chance that you’ll start to feel better.  I know at first-hand that this is a harsh sentence, and not just from the point of view of entertainment and indulgence. It’s also from a practical point of view that it seems impossible. Most people are not at home for most of the hours in a day, and they can’t return home every time they want to snack on something. I’m definitely aware of the problematic nature of this. I live it. However, as I indicated earlier – this is not a disease for lazy people, and the solutions require investment.

Eating out endangers your health for the simple reason that you can never control the quality of every ingredient that appears before you on the plate. An unsuccessful dish that would cause an ordinary member of the community no more than a little gas, could send us to the emergency room within half an hour. I must emphasize that it makes no difference how clean the place is, and how nice the people there are. It could be any restaurant, any cafeteria, any fast food stand or any kiosk that sells popcorn for the movies. It can happen even if the owner cleans the kitchen three times a day (something he doesn’t do), and even if he verifies that the person making the snack remembered to wash his hands after going to the bathroom (and who knows if he did so). It’s enough that one single tiny pickled cucumber has had enough of its miserable life in the jar. Such a cucumber, already not fresh, becomes a large dwelling for germs. All on its own, as part of the wonderful and sterile “health helping” that you ordered, it can get you into deep trouble.  Our angry bowels are just looking for a reason to get irritated, and the quality of the food is an excellent reason. Even if you don’t feel the results immediately, an angry bowel has the memory of an elephant. It will not forget, and will definitely not forgive, the unnecessary bite you gave to a dying cucumber.

You will say, and rightly so, that home food is also not sterile. Having said that, because we know exactly what the level of sterility is and what the best ingredients are (and we can ensure a high level that suits our needs) we can minimize the danger significantly. Likewise, when the person preparing the food does it in the knowledge that the customer is the owner of a sensitive digestive system, it’s clear that the ingredients and the herbs will be suitable.

And when you do go out? It’s very simple: we take food and drink with us – sandwiches that will keep you going at your studies until the afternoon, or a container of food to heat up in the microwave at work. True – it’s not always the tastiest, and it’s definitely less simple and pleasant. “Not for lazy people,” did I say? I promise that you’ll thank yourselves in the evenings, when your stomach remains calm.

The ban, my friends, is in place when you’re enjoying yourself at a restaurant. Do your best to make do with a light dish and a drink. Remember that even if someone else is paying the bill, you will pay the price for every mistake – with your health. For those of you who can’t help yourselves, or when there is simply no alternative, do yourselves a favor: reduce the amount, and avoid experimenting with new dishes and with adventures at the expense of your intestines. Even in cases where you have to eat out, keep fast foods out of the picture, and choose from among the better quality restaurants.

Learn to cook
Just as a diabetes patient learns to use syringes and needles to inject himself with insulin; just as a celiac patient learns to look for the gluten in every food he consumes – in the same way Crohn’s and Colitis patients need to become proficient in everything connected with food, and yes – learn to cook. We have to know exactly what’s in every single thing that we put into our mouths, and to adapt ourselves to habits of checking the ingredients and expiration date of every product.  It is only in this way that we’ll be able to discover which ingredients are problematic for us, and it’s only in this way that we’ll know to guard against them in the future.

Despite the negative viewpoint, you must never forget that food is one of the greatest joys of life. You have to discover what you can eat, and to vary your menu as much as possible. If the menu is not varied and tasty enough, you will lose your appetite and you won’t eat enough, and worse than that, you will be tempted to find easy and harmful solutions.

As I mentioned in the chapter in which I discussed lifestyle, cooking can also benefit you psychologically – both as occupational therapy and out of a sense that you are taking responsibility for your health – being proactive for the sake of your health as opposed to the passivity of taking medication and following the instructions of the doctors blindly.



Small meals with high frequency
The digestive system of bowel patients is very sensitive, and therefore should not be overburdened, even if it’s with healthy, quality food. Give the system small amounts that it can deal with. Eat a little, but with high frequency. Eating large meals is an unhealthy custom for any person, and most certainly for bowel patients. In addition, it’s desirable to stop eating a moment before the stomach is completely full – when the feeling of satiety is just beginning to appear.

Nutritional Agenda
It’s important to ensure daily nutritional planning. When you go out of the house for an extended period, it’s important to take sandwiches or food in a container to avoid as far as possible arriving at a state of hunger. That kind of situation is dangerous for a number of reasons. (1) When you are hungry, your judgment concerning what you should eat becomes blurred. A situation like this increases the chances of giving in to the temptation of food not prepared at home, or food of lesser quality. (2) Most bowel patients are not overweight, which means that their reserves are relatively diluted. Hunger is just one step before bodily collapse. (3) Hunger tends to lead to a large meal the next time you do eat. And large meals are not recommended for owners of a sensitive bowel.

The daily struggle over the amount of food that we consume is extremely important. There is a tendency to eat less when there is pain and diarrhea, something that can cause fatigue in our bodies. In accordance with what I said in the last paragraph, I recommend that you spread the amount of food you eat over the whole day, and not concentrate it, especially not towards the end of the day. I recommend that you reduce your eating before sleep, and in this way allow your system to rest and the body to enjoy a calm sleep without pain and stress. Eat only food prepared at home, but if you have to eat out it’s important to know exactly where it will be so that you can avoid disastrous spontaneity. Yes, it’s boring, but the disease loves routine, and we love life.

We pay for every mistake
You cannot play with nutrition. You will pay with your health for every wrong decision, even if it’s in ways that are not immediately apparent. The accumulated damage that is caused to the system as a result of poor nutrition will also cause you to regret every time that you gave up when it came to food. Be honest with yourself – know which food is not good for you and don’t eat it again. There is no dish in the world that is worth the deterioration of your health.

Let the system rest
The digestive system (yours in particular) needs rest, especially in light of the fact that it is active for most of the day. Do your best to calm the system a good few hours before you go to sleep. About three hours before going to bed it’s desirable to consume mainly liquids and food that is easy to digest and to prepare the system for complete rest during sleep. Just as you need rest in front of the television or with a good book at the end of a hard day, so should you also give your digestive system a chance to recover from the hardships of the day.

Try on your own
The directive regarding spicy food, preserved food, or low-quality food is simple – it’s out of the question. The decision concerning most other types of food is not so clear-cut. All might go smoothly with a particular food for a particular patient, yet wreak havoc in the stomach of another. The reason is the complexity of the intestine and the location of the inflammation which differs from patient to patient, with time, and even within the bowel of each patient himself. Every patient therefore must learn which foods are good for him and which are likely to make the state of the disease worse.

The only way to do this is via trial and error, but try to ensure that the ‘error” part will be as small as possible. Introduce an item of any given food gradually and in an isolated manner into your menu, and check the response of your system in the hours following the meal. It’s important to take note of every sound and feeling in your stomach, not to mention of course any diarrhea and pain. In my experience the real problem of this check is actually psychological. It’s very difficult for people to admit that a particular food that they love is not good for them. However, we need to remember that the obligation to discover and research lies with you, and in order to succeed you have to be honest. It is only through honesty and awareness of the fact that you have to take that wonderful dish that you love off your menu, that you will succeed in avoiding a colossal catastrophe in the toilet after each meal. It is important not to give up on adding new items to your menu, otherwise it will be difficult to maintain nutritional discipline.

It’s not just the disease, but the studies too that are dynamic. It’s very possible that your correct diet will change over the years. With time and experience you will become your own best dieticians, and you will know by yourself which foods are good for you and which you should not eat, and you will even be able to quickly adapt to changes.


The senses as sensors
Our bodies contain many senses and we need to learn how to use them. When it comes to food, this is extremely important, especially for those of us who are the owners of sensitive digestive systems.

Smell – You need to use your sense of smell without any sense of shame or guilt. Smell the dishes that are presented to you, from milk to fish. Using it is important for example in identifying the early stages of decay in meat, chicken and fish. Even if it only smells a little bad, don’t eat it, and it doesn’t matter how prestigious it is. There is only one reason why the food smells bad, and it’s not such a good one. Your stomach will also be quite resolute on this issue, believe me.

Taste – You can immediately feel on the tongue whether a dish is too spicy, too sour or too hot. The burning sensation in the oral cavity is a warning sign to us that the food that we are about to swallow in another few seconds is not good for our bodies.

Sight – A dish that doesn’t look good testifies to its quality. It’s especially true when you eat out. Pay attention to the general state of hygiene in the place (which is usually a reflection of the state of the kitchen), as well as to the look of the dish that you are getting, of course.  Just about every food product can reveal its condition by its look – freshness, rottenness, level of sterility and so on. Open your eyes and in time your senses will get sharper.

Start your day gently
After you get up in the morning it’s desirable to also allow your digestive system to wake up calmly. Begin the day with a hot drink, preferably tea or an infusion, and move to something light like a slice of bread or toast. After a few minutes you can continue with heavier things (but still with care!).

Hot is preferable to cold
On the recommendation of a number of alternative therapists, I adopted the rule according to which hot food and drink is preferable to cold. The digestive system responds better to these kinds of dishes, especially in cases of inflammation and narrowing of the bowel. It’s possible that this is connected with the fact that heat expands the blood vessels, and cold shrinks them. I must emphasize that I’m not saying that you should take cold foods off your menu, only that you should reduce the amount you consume, especially in cases of active inflammation.

Know the ingredients of every product
Create a habit for yourself: read the label on every product that you buy, and check what it’s made up of. You should avoid substances that are not natural like food coloring and preservatives. Remember that when there is doubt there is no doubt: if you come across strange names of ingredients that you don’t know, you can safely assume that they are not natural ingredients, and therefore also not particularly healthy. The order in which the ingredients appear on the label is also very important. The ingredient that appears first is the one of which the product contains the greatest amount; the second is found in a lesser quantity and so on.

Preservatives
There are substances that are known not to be particularly healthy, and even less so for patients suffering digestive system problems. Preservatives are among the most prominent of these substances, and as their name implies, they preserve the food so that it won’t decay and rot. The problem is that the preserving does not end at the moment of swallowing, but continues also inside the body causing the food not to be digested properly. The result is an increase in food residues in the digestive system. It is therefore recommended to avoid, as far as possible, products that contain preservatives (pastrami, sausage and yellow cheese, among others).

Beef
This is a sensitive subject for every lover of beef who suffers from a disease of the digestive system. In meat there are many essential substances such as iron, protein, B12, and fats that are lacking in the bodies of many Crohn’s patients. But before these substances there is an even more difficult problem – meat is simply tasty, and someone who is used to consuming it on a daily basis will find it hard to part from it. The problem for Crohn’s patients is that meat is hard to digest, and its passage through the digestive system requires a lot of time and resources. Moreover, meat, as it is sold today in all its different forms is very likely to contain organisms that cause a deterioration in the inflammation. Therefore, and with a heavy heart, I have to admit that meat is indeed a problematic item on the menu, and it is desirable to reduce its consumption to a minimum. If you can’t resist it, at least insist on quality and on small amounts, in particular to make it easy on the system.

Chicken
People need to eat, and for someone who has to give up meat on the menu, chicken is not a bad substitute. Chicken can provide the energy that is lacking for us as patients, while at the same time being easier to digest than beef. More than that, chicken can be very tasty – even more so than meat – if you put some effort into it. However, before you pounce on the nearest chicken run, it’s advisable even with chicken, not to overdo it. It’s preferable to eat fish, but for those who insist it’s better to make do with three portions a week, in small amounts (free-range chicken is preferable, not fried and without side dishes).

Fish
After we have finished with the negative side of the ten commandments of diet, we can happily move to the positive side – what is allowed, and even worth eating: fish should be the main item on your menu. We’re talking about every kind of fish (sea-fish are preferable), as long as they are fresh and perfectly cooked. Fish is easy to digest and rich in proteins essential for the body. For the sake of comparison, the digestion time for fish is on average twice as fast as for chicken, and five times as fast as for meat. While these figures are true for a healthy person, the relative ratios remain more or less the same also for ourselves, the patients. More than that, fish dishes are rich in fish oil that contains omega 3 (yes, exactly the same supplement from the advertisements, only better because it comes in its natural form). The omega 3 acids have a hugely positive effect on the immune system in preventing inflammation in the body and even cancerous growths. Similarly these acids are responsible for the production of many balancing substances and processes in our bodies – blood pressure, temperature, inflammations, welling, pain and so on. Thus, for Crohn’s patients, there are great benefits in consuming fish, both dietary and medical.

Eggs
I have yet to meet a patient who claimed that eating eggs caused him digestive problems. As opposed to other protein-rich foods such as chicken or meat, eggs are usually digested properly and supplement the missing energy that results from the eating of less chicken and meat. Even when I have had an acute attack with pain, when every other food only encouraged the inflammation, the eating of soft-boiled eggs never caused problems for me. The opposite is true – eggs helped return energy to the body, and even produced a feeling of fullness. Eggs cooked in different forms are recommended for your weekly menu.

Milk
For various reasons many people are sensitive to products produced from cow’s milk. Officially, Crohn’s and Colitis patients are not described as among these, but in my experience milk is difficult to digest, and even promotes diarrhea. In Dr Arieh Avni’s book Fools of Milk [i] he describes how an organism that is found in cow’s milk causes many diseases, among them Crohn’s.  “I have determined that Crohn’s disease is caused by the infection in people by the organism MAP, that is found in cow’s milk and its products.” Also: “Today with sophisticated methods the organism can be identified in between fifty to eighty percent of all patients… milk is contaminated by what generates the disease. If you do not touch milk products – you will not see Crohn’s disease…”

It must be pointed out that no proven connection has been found in research between Crohn’s disease and the consumption of dairy products. It is important to know that there is a high frequency of a lack of lactose [1] among Crohn’s patients, and therefore, in cases where milk is avoided, it is necessary to supplement the diet with vitamin D and calcium.

I recommend approaching cow’s milk and its products with suspicion and trying them with caution. Milk is also forbidden in the Specific Carbohydrate Diet (see below). For those who are sensitive there are substitutes in the form of goat’s milk and soya milk (see also camel milk in the sub-section that deals with alternative medicine). Today there is a wide range of products that make a good substitute for cow’s milk in cheeses, delicatessen products, and milk in cartons. It’s easy to find them on the shelves, and after you try them, you’ll find that most are even more tasty.

Rice
Rice is healthy and nutritious and helps in stopping diarrhea. It’s recommended not to eat large amounts in one go and not to eat Brown rice that contains fiber. There are many kinds of rice and dishes that can be made with it (please note – not to spicy!). Even cooking doesn’t need to deter you – there is a special Chinese pot that makes it particularly easy. You can put the rice together with chicken or fish and thereby enrich the taste. This dish is forbidden for those who choose the Specific Carbohydrate Diet (see below).

Millet and quinoa
Millet and quinoa are grains that have a high nutritional value. Millet is particularly rich in iron, while quinoa is rich in carbohydrates and proteins. Both are very rich in vitamins. They are very easy to digest and can form a good basis for a menu for anyone who suffers from a sensitive digestive system. Millet and quinoa are also easy to cook (simple cooking with water, similar to rice, only without the need to be exact with amounts and time). They are now available not only in health shops. This dish is forbidden for those who choose the Specific Carbohydrate Diet (see below).

Organic or not organic – that is the question
The organic food faithful can skip this paragraph. For those who don’t know about it, and before taking any decision as to whether to consume it or not, it’s recommended that you at least learn about the advantages of organic food. The price of organic food is higher than for regular food, but the advantages are proportionately greater.  Here are a number of points that as patients you should know:

Vegetables and fruit – No sprays harmful to health are used in the growing of organic vegetables and fruit, as opposed to that of regular crop growing. While it’s frustrating, it’s still important to know that when we consume regular vegetables and fruit, and pat ourselves on the back, aside from vitamins we are also putting harmful substances into our bodies. In our case, these substances are likely to promote inflammation. Apart from the risk, it’s important to know that the nutritional value of organic fruit and vegetables is higher, and mostly, their taste is richer too.

Meat and chicken – The conventional raising of cattle and chickens also suffers from methods that serve up to our tables products filled with harmful substances such as various drugs, antibiotics and other matters. These are intended to fatten the animals and grow them to dimensions beyond their natural size. If the danger of these substances reaching your table doesn’t convince you, perhaps the moral argument will (even if you aren’t vegetarian) – during the process of raising the animals, the conventional chicken and meat industry causes dreadful suffering to the them, from force-feeding to slaughter. The organic industry, in its more natural approach, causes a lot less suffering in terms of this.

Fish – There are two kinds of fish: marine fish, and farmed fish. As I have mentioned, marine fish are preferable, in both taste and quality, for one simple reason – the non-interference in the raising process. (In the farm ponds they use various substances to feed the fish.)

Milk – There are those who claim that cow’s milk is less healthy because of the antibiotics and drugs with which the cows are injected. Goat’s milk, which contains fewer harmful substances, is therefore recommended.

I am not a fanatic about organic food, but I definitely do my best to consume it as much as I can. For those who don’t consume organic food, either for economic reasons or because they don’t know about its advantages, I recommend at least broadening your information on the issue, and to try out and include organic products out on your weekly menu.

Vegetables in forms you did not know
Vegetables can cause problems because of the fibers which make them up. Foods which contain fibers may scratch the interior of the bowel and cause pain and feelings of discomfort. Having said that, integrating vegetables into your daily menu is very important, mainly because of the vitamins they contain. Here are some ways to consume vegetables in a manner that makes it easier for patients who suffer from inflammation of the digestive system.

Eat little – Few people who have a sensitive bowel are able to eat a large salad and not feel that they are going to explode immediately afterwards. Therefore, if you are not prepared to give up fresh vegetables add a different vegetable each time to your meal. When it comes to dressings, incidentally, it’s worth giving them up completely. It’s possible to make do with a little olive oil.

Preferably cooked or steamed – Cooked or steamed vegetables are very easy to digest, and they still maintain a nutritional value similar to that of fresh vegetables. The taste may not suit everyone, but whoever can adapt and persist with it will reap great benefits for their health. It’s desirable to try different forms of cooking and steaming – the investment will pay off. If you can’t eat cooked vegetables, it’s desirable that from time to time you have a soup that is rich in vegetables (without soup powder and with some chicken to improve the taste).

Spraying – Most vegetables are sprayed with substances that kill not only harmful organisms, but us as well. It’s very important to wash vegetables thoroughly. Getting rid of the peel can help to a degree, as well as ease the digestive process. For those who are willing to make the effort, it’s recommended to move to organic vegetables.

Vegetable juices – This is a fantastic way of supplying the body with the vitamins that go to make up vegetables. There are quality appliances that are made especially to separate the juice from the fiber and enable you to gulp down juice that is pure health. It’s important to drink the juice soon after preparing it to take advantage of its full nutritional value. Chef’s recommendation: carrot juice with a little beetroot that provides lots of iron.

Not recommended – certain vegetables that are considered acidic such as tomatoes, eggplants and peppers.

Fruit
As with vegetables, eating fruit is important mainly because of the vitamins, but is dangerous because of the fiber. Citrus fruit, for example, is completely out of the question in this regard. Here too an appropriate solution is to drink home-made juices that do not contain fiber and maintain the nutritional value of the fruit (for example those that have been squeezed in machines that filter out the fiber). If you’re having fruit, do your best to eat those that are less acidic and that contain less fiber.

Dietary fiber [2]
Dietary fiber is that part of the plant that the body does not digest. It arrives at the large intestine where it is fermented by bacteria. Dietary fiber has no nutritional value and lacks calories, and therefore provides no energy at all. It’s possible to distinguish between two main groups of fiber: the insoluble and the soluble.

Insoluble fiber has an outstanding capacity to absorb water, and thus increase the volume of the feces and facilitate their exit. It also limits the mobility of the intestine, shortens the time taken for the passage of food through it and exerts pressure on its walls. It’s therefore clear that patients who suffer from Crohn’s disease or patients who suffer from narrowing with a background of intestinal scarring must exclude this fiber from their menu.



Foods rich in insoluble fiber:
·         Vegetables: cabbage, cauliflower, broccoli , celery, kohlrabi, peels of fruit and vegetables
·         Whole grains: brown rice, whole wheat, bran, corn
·         Seeds: walnuts, almonds and peanuts

Soluble fiber, as opposed to these, inhibit decomposition and the passage of food through the digestive system, and extend the feeling of fullness. They are able to absorb toxins, excess bile, cholesterol, carcinogenic substances, and even remove them from the body. They also slow down the absorption of sugar in the blood.

Foods rich in soluble fiber:
·         Fruit: apples, bananas, pears
·         Vegetables: zucchini, carrots, pumpkin
·         Pulses: chick peas, lentils, dried beans, dried peas, broad beans and soya beans.
·         Oats

Dishes rich in fiber such as fruit and vegetables, contain soluble and insoluble fiber in varying proportions. It is therefore advisable to avoid all fiber-rich foods when there is active inflammation, and to try to include them in your daily menu later on if the inflammation allows it.

Pre- and Probiotics [3]
In the digestive system there are friendly bacteria that inhibit the action of undesirable microorganisms, and that improve the breakdown of food and its digestion. These are called probiotic bacteria. There are several types of probiotic bacteria, and each part of the digestive system has its own different types that are capable of existing in it. During antibiotic treatment, and even after it, these positive bacteria can be harmed. They are also likely to be harmed in cases of preparation for a colonoscopy, operations on the digestive system, and frequent diarrhea and vomiting among other things. Today there are two main approaches in maintaining a balance in positive bacteria:
The first is the probiotic approach – the consumption of a food supplement or food that contains live microorganisms (usually bacteria) that have a positive action and ability to break down food. Yoghurt is an example of a food that is rich in positive bacteria. It is important to match the food or the supplement to the area of the digestive system that we want to strengthen – that they contain the same type of probiotic bacteria. The problem with this approach is that most of these bacteria do not survive the acidity of the stomach. Therefore, in order that a certain amount will reach the areas (such as the bowel) that need them, you need a large amount of bacteria.
The second approach is the prebiotic approach – the consumption of food or supplements that contain ingredients that are not digested, such as dietary fiber, that encourage the growth and thriving of friendly bacteria in the bowel.

There is research that points to probiotic bacteria aiding in maintaining remission in Colitis. There is no evidence that these bacteria directly help in suppressing Crohn’s disease, but it is important to maintain them at proper levels. This is because their positive action is essential to the proper functioning of the digestive system. Because dietary fiber is not desirable for those with a sensitive bowel, you should adopt the first approach and consume food that is rich in bacteria such as yoghurt (preferably made from goat’s milk) on a daily basis to maintain normal numbers of the bacteria.


Snacks and munches
This is a subject that hurts. One of the most difficult things is giving up snacks and munches when you’re watching a game on TV, or giving up popcorn at a movie. Experience shows that there is no option. None of these snacks contributes to your general condition and can even mean the beginning of the next attack. The reason apparently lies in the fact that most of them are saturated with oil or that they are not made with nutritious ingredients (particularly in the case of snacks). If you cannot manage, and sometimes slide into sin, it’s preferable to deal with baked snacks like pretzels, with as little oil and spices as possible.

Dried fruit
I have often been urged to eat dates and figs with the claim that they have a high nutritional value and that they have energy-giving natural sugars. Even one of the Chinese therapists that I had recommended dates, that according to him could suppress the inflammation. After I chose to begin the Specific Carbohydrate Diet I discovered dates as a source of energy and as a good substitute for sweet foods that contain sugar.

Sweets
The sweeter and more complex a food is, the more problems it causes. This is particularly true with heavy cakes that contain cow’s milk, white sugar and other ingredients that can stimulate the inflammation. As one who doesn’t like sweet tastes it was not especially difficult for me to give these things up. I’m sure it’s not at all that easy for many others. Despite the difficulties, however, it’s desirable to reduce your consumption of sweet foods as much as you can and to check out a graduated system of smaller and smaller helpings of those that are digested properly as well as those that are not. Remember that your health comes first.
Bread and pasta
Most bowel patients who take all forbidden items off the menu are usually left with bread as the main component. There are many kinds of bread. The simplest is white bread. Every alternative therapist will tell you just how bad it is, and just how much it promotes inflammation. I’m not at all sure that many patients will agree with this statement, but in any event it worth checking it yourself. The main alternative to white bread is whole meal bread. This bread is problematic for us, of course, because of the large amount of fiber that it contains. You should therefore try any other type of bread that doesn’t contain a large amount of fiber on the one hand, but is not white on the other, such as spelt bread (you can find spelt in health food stores – baking bread is an experience that even people who are not ill appreciate). With every bread purchase it’s advisable to pay attention to the ingredients: Sometimes what seems like whole meal bread or spelt bread can in fact contain white flour mixed with buckwheat. I’d like to add that for sensitive people it’s advisable to eat the bread as toast to make it easier on the digestive system. By the same token, pasta that is not made from white flour is also recommended. Pasta can indeed be a good source of energy, but the quality of the pasta is also important to ensure easy digestion. For those who choose the Specific Carbohydrate Diet (see below), this food is not permitted.

Sugar
The claim is that white sugar is not healthy because it is processed. Various nutritionists even claim that it promotes inflammation, although this has not been proven in research. In any event it won’t hurt to move to brown sugar (real, and not the “colored” kind that is offered in most coffee shops). In addition, there are natural candies that make use of sugar substitutes such as stevia (which doesn’t sweeten enough to my taste), or molasses, an extract of sugar cane, and with the value of pure gold. The substitute that I prefer is honey.

Tea or coffee
Generally it’s preferable to drink hot drinks rather than cold. Herbal tea is preferable to coffee, which contains caffeine, and for most, also milk – especially if it’s a caffeine-free infusion which helps to calm the stomach. Anyone who is prepared to go beyond the sachets, can buy the loose herbs for infusing, or can grow them themselves in pots. A recommended infusion is from the chamomile plant, which in high concentrations is a great help in calming the digestive system.

Cola
In the past I used to drink nothing less than a liter and a half of cola a day. It was difficult for me to admit the distressing fact that I was addicted. I wouldn’t be telling you anything new if I detailed here the harm that is likely to be caused to any person by the acidity, the caffeine, the sugar and the rest of ingredients that are to be found in this wonderful and cursed drink. Even from my addicted perspective cola has the most problematic characteristics. Patients with a sensitive digestive system who constantly drink cola find it particularly difficult to be rehabilitated because cola is an available source of energy, tasty, and comfortable mainly during periods of diarrhea. Heavy diarrhea causes exhaustion, and patients will seek easy sources to supplement the energy they lose. In cases like this, cola is a very bad solution. Only after you’ve stopped for some while do you understand just how much your stomach has not been calm, and how easy it is to develop a dependency on the amount of sugar that there is in cola. The perfect solution would of course be to move to water, although for people who are addicted (there is no easier word) as I was, the change can likely to be too sudden. Begin perhaps with raspberry juice – it also contains sugar but it is not acidic and does not contain caffeine. In any event, during times of diarrhea it’s important to increase the amount you drink so that you do not become dehydrated.

Alcohol
Alcohol is not recommended for patients with inflammatory bowel disease. For those who nevertheless choose to drink, it’s preferable not to drink cheap drinks, or those that are too harsh. High percentages of alcohol are likely to stimulate anyone’s digestive system. It’s desirable, therefore, to be careful.

Powders and ready meals
As I’ve mentioned, our disease is not for lazy people. In order to get quality products that don’t come already prepared in packages needs time and effort. You should just stay away from the different powders of soups and meals, and from every food that comes ready from the supermarket (all the various frozen schnitzels). Apart from the fact that fresh food is both healthier and tastier, you can’t exactly know what a ready meal contains. Don’t be lazy – it will pay off in the future. Every minute you save with the help of ready meals will cost you an hour in the bathroom.

Pomegranate juice
Pomegranates are rich in iron, and without the seeds they are also relatively easy to digest (if a little acidic). I warmly recommend organic pomegranate juice that is a hundred percent pomegranate. It’s an excellent daily nutritional supplement, especially for patients who suffer from a lack of iron. You can find the juice at organic stores throughout the year. Those who are sensitive to the acidity can dilute the juice with a little water. In the last few years pomegranate juice has been found to have anti-inflammatory properties, and hence has the capacity to help those who suffer from chronic inflammation to cope with their disease.



Supplements and additives
In cases where the food is not absorbed as it should be the attending doctor might recommend food supplements. Food supplements are important in restoring to the body what it lacks in vitamins and minerals, even those that don’t appear in blood tests. Only if we balance the body nutritionally can we help it to better fight the inflammation. It’s important to consume only those products that the doctor has recommended, and not to be tempted by the various supplements that are not suited to the intestines of Crohn’s patients. It’s important to note that the supplements that we don’t consume don’t cause stomach pains or deterioration of the inflammation. And be sure to check that they are indeed absorbed properly. It is important to match the supplement you’re getting with the current state of the inflammation. A supplement suited to a state of calm, can cause problems with a state of active inflammation. In severe cases in which the patient does not manage to achieve nutritional balance, it’s possible to give nutritional support with an enteral feeding regimen. An enteral feeding regimen means balancing by means of broken-down food constituents.

Enteral feeding formulas are divided into protein and fat constituents. Research has shown that enteral feeding is efficient in inducing remission in Crohn’s in fifty to seventy percent of active flare-up cases [4]. In cases where the patient’s bowel does not function, the digestive system is bypassed by means of an intravenous infusion that supplies the nutritional constituents that the patient needs. As you might expect, this method brings with it serious side-effects, and is recommended only in extreme cases.



Guidelines for the chef
Forbidden ingredients:
·         Hot foods or foods that have too many spices
·         Reduce fiber-rich food such as vegetables and fruit. You can use them in combination in low doses
·         Brown rice and bread that contains fiber
·         Beef that is difficult to digest
·         Any low-quality food such as preservatives, food colorants, powders  and ready foods
·         Fried foods rich in oils
·         Reduce cow’s milk products
·         Reduce foods rich in pulses such as chick-peas and beans. You can use them in combination in low doses
·         Reduce eggplants and peppers
·         Reduce  the use of hard cheeses in order to ease digestion
·         Reduce sweet foods and sugar

Permitted ingredients:
·         Baked or cooked foods
·         Cooked vegetables
·         Eggs – organic is preferable
·         Chicken – not in large amounts
·         Fish – not in large amounts
·         Goat’s milk, goat’s milk yoghurt and soft cheeses
·         Honey



The following ingredients are allowed but are not part of the Specific Carbohydrate Diet:
·         Fruit and vegetables that are low in fiber such as sweet potato, garlic, pumpkin, zucchini, artichokes, carrots, potato and more
·         Bread and pasta – recommended, but only if made with flour that is not white such as spelt
·         White rice
·         Root vegetables
·         Soya

In addition to your current diet it’s important keep up a constant monitoring according to various parameters to ensure that there is no suspicion of malnutrition. With children it is especially important to monitor height and weight. You need to do blood tests in order to identify nutritional deficiencies, especially of iron and vitamin B12, and to bring their levels up with food supplements, injections or transfusions when necessary. Balancing the diet for a Crohn’s or Colitis patient is not a simple matter. Even with mentoring (which doesn’t exist for most people) it is difficult to balance the digestive system, especially in the case of active inflammation. However, it is important to remember that the hard work pays off. A patient in the right nutritional state will deal better with the inflammation, experience fewer difficulties in daily activities, and will maintain a normal bodily condition. You should take your diet as seriously as a prescription medication – a correct diet is your real medication.




The Specific Carbohydrate Diet – SCD
The Specific Carbohydrate Diet or SCD is aimed at patients with inflammatory bowel diseases, those diseases affects the intestinal wall, and as a result of which the bowel has difficulties in breaking down disaccharides and multi-saccharides that remain in the bowel and comprise a substrate in which bacteria grow and cause additional harm to the intestine.
The diet was developed by Elaine Gottschall, a clinical dietician and bio-chemist whose daughter was diagnosed as a Colitis patient. Despite intensive drug treatment her condition deteriorated until Elaine moved her to the Specific Carbohydrate Diet. Within two years the symptoms from which the girl had suffered disappeared. After a few years she returned to a normal diet and her health continued to be excellent. Following that, Elaine researched the diet and published her results in a book Breaking the Vicious Cycle.
Many patients have said that the diet has helped them, although the research results are not definitive for all patients. The diet is not an easy one, but patients who have achieved a state of calmness have returned to a normal diet after a few years.
With this method you need to avoid foods that contain disaccharides and multi-saccharides, which means that you can’t eat foods that contain the flour of any grain whatsoever – corn, potato, sugar, rice, chick-peas, pulses, soya and more. You are allowed to eat the following: honey, eggs, fruit and vegetables, meat, chicken and fish and types of nuts (you can for example prepare cakes with almond or walnut flour).

You can find the full list of what products are allowed and what are not on the internet. The name of the book is Breaking the Vicious Cycle. The Specific Carbohydrate Diet, by Elaine Gottschall. The site is www.breakingtheviciouscycle.info .





[1] Lactose – the sugar that is found in milk – www.answers.com/lactose
[3] Probiotics: www.webmd.com/digestive-disorders/tc/probiotics-topic-overview
[4]  “Ten years” experience with an elemental diet in the management of Crohn's disease. K Teahon, I Bjarnason, M Pearson, and A J Levi –   www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1378738




[i] Dr Arieh Avini - Fools of Milk, On the damage caused by milk to health (2006) 114-128

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