🎙 Overview
In this session, we invited Dr. Ali Arjomand to talk about how one can expand their diet as an Inflammatory Bowel Disease(IBD) patient.
If you are an IBD patient, food and diet are where you feel IBD mostly on a day-to-day basis. It's also probably where your standard GI clinics don't have the time or resources to support you. In this session, Dr. Arjomand talked about important nutrients for IBD patients, and how you can expand your foods step-by-step to get to a more diverse diet and healthier gut ecology.
At the end of this page, you can find the materials Dr. Arjomand shared with the session participants in Shared Materials.
This page captures the key ideas and highlights from the session. You can also watch the full session recording here: Full Session Recording
👤 Who is the host?
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Dr. Ali Arjomand is a certified nutritionist and a Crohn’s disease patient for 20 years. He is the founder of Modulla Health, an IBD-focused nutrition clinic where he delivers personalized nutrition interventions to IBD patients. Dr. Ali’s science-based nutritional interventions have transformed the disease course for many IBD and IBS patients.
🍏 What are the important nutrients missing and how do I get them as an IBD patient?
The US Dietary Guidelines are the official guidelines from the US government and health authorities However, the guidelines aren't highly adhered to by the average population. In the average population, there is a general lack of intake of vegetables and fruits, while foods such as refined grains are being overly consumed.
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As a way to sneak much-needed nutrients into an average diet, the standard food supply is enriched with fortified nutrients. In the case of enriched flour, it contains nutrients such as thiamine, niacin, folic acid, riboflavin, and iron. Because of various food restrictions, IBD patients are not only missing out on the natural foods that provide these nutrients, but also missing out on the nutrients that would come from foods like enriched flour.
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There are 5 major macro-nutrients that the human body needs to function properly. Dr. Arjomand introduced them and talked about how IBD patients can work to acquire these nutrients:
Water: IBD patients may eliminate consumption of non-nutritive beverages such as soda, sports drinks, beer, and fruit juice. Instead, one should rely on consuming pure water and beverages like tea or coffee if they can tolerate these foods. It is important to remember that food is also a substantial source of water.
Protein: One cannot store protein in their body. If too much protein is consumed, the excess protein will come out of the body via urine. If one consumes too little protein, they will end up sacrificing other parts of their body to meet their needs. It is important to ensure a sufficient intake of protein each day. Otherwise, it leads to weakness, sarcopenia, and other dysfunctions. For IBD patients, protein is the most important macro-nutrient to focus on because the disease increases the protein requirement. Normally, people need about 0.8 grams of protein per kilogram of body weight to keep from getting sick. Dr. Arjomand suggests that IBD patients should aim for 1.2 ~ 1.4 grams per kilogram of body weight to suffice their daily protein intake (For example, if your weight is 120 lbs or 55 kg, you will need to consume 65 ~ 76 g protein per day). Most patients struggle to find sources of protein to be included in their diet. Here are some foods that are high in protein, listed from high to low:
Fat: Fat is essential for the healthy functioning of the human body as long as it comes from healthy sources. Fat is a great source of calories for problems like weight loss or growth faltering from IBD. However, one should take caution if they have gallbladder surgery (where ability to absorb fat is limited) or they have rapid diarrhea. Here are some example sources of fat.
Carbohydrates: People’s ability to store carbohydrates is very limited and anything in excess is converted to fat. Technically, there is no dietary requirement for carbohydrate. Most people consume 100 to 400 grams of carbohydrates per day. Carbohydrates induce insulin release, which is important for anabolic growth(the process where your body uses nutrition and energy to build muscles). It may be hard to gain weight on low carbon due to low insulin induction. It is also important to select the right set of foods where IBD patients get carbohydrates. Refined carbs like bread, rice, potatoes, pasta, and sugar are a pretty large portion of people’s diet. However, these refined carbs can aggravate IBD symptoms. In some cases eliminating them altogether is super beneficial. Instead of depending on refined carbs for calories, one can instead add more whole grains to their diet. Calories are important to maintain your current weight. You can scan the following QR code for a calorie calculator to get a rough estimate of daily calories needed:
Fiber: Fiber doesn’t get absorbed into the bloodstream but it feeds the gut microbes. Most people don’t get the vegetables they need, meaning they don’t get the fiber they need in their body. Fiber is a key missing part of IBD patient intake. From Dr. Arjomand’s experience, he was told by every IBD doctor that he had to go on a low residue and low fiber diet. After 15 years, it took a heavy toll on his health. In his opinion, IBD patients should instead get as much fiber as they safely and quickly can. As IBD patients, depending on your disease, you may differ in how fast you can increase your fiber intake. You may be able to consume more fibers faster if you have ulcerative colitis and slower if you have Crohn’s Disease. It is also important to expand the diversity of fiber. To increase the diversity of fiber intake, you can try to increase the kinds of plants in your diet. You can start by eating five different kinds of plants in your diet and then gradually move on and increase this number to ten. When it comes to fiber, even spices count – you can sprinkle a little bit of cinnamon on your yogurt and that counts as one kind of fiber source.
🥗 How do I gradually expand my food diversity?
After understanding each essential nutrient, the next step is to learn about how to incorporate these nutrients into one’s daily diet. One of the best ways is to expand the diversity of food. As IBD patients, it is important for you to take gradual steps, starting from the foods that are friendlier and easier to tolerate, to foods that are more advanced. Dr. Arjomand shared a worksheet and strategy on how to gradually expand the diversity of your food.
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The table lists foods by stages, from stage 1 to stage 4. Stage 1 contains the easiest and most basic foods many patients feel comfortable with. As the stage number goes up, the foods become more advanced, and might be harder to tolerate if you are in flare or your disease is in a bad place. But as you gradually advance to the next stages, you will be exposed to a much diverse diet and in turn, your gut ecology becomes more diverse and resilient. Once you are comfortable with foods in your current stage, introduce some foods from the next stage and make sure to prepare them in a way that is more tolerable to your gut. When you notice that a newly introduced food is triggering symptoms, you can dial back to foods from your last stage so that you know that your basic nutritional needs are always covered. Once your symptoms subside and you are comfortable with expanding your foods again, try to reintroduce them. Gradually you will have a large set of ingredients available to you that supports your gut health.
For more information, listen to Dr. Ali Arjomand as he explains how to use the table to gradually expand your food diversity: https://vimeo.com/733016166/cf1a1febc5
🙋♀️🙋♂️ Q & A
During the session, Dr. Ali Arjomand answered questions from participants live. The following are the transcripts of the questions and answers.
Q: Do you have any Insights on turmeric or ginger?
A: Turmeric is a spice from the root of the turmeric plant and has been proven to have real benefits. It’s an anti-inflammatory ingredient, which is important for IBD. Dr. Arjomand advises against taking curcumin capsules (curcumin is the active compound in turmeric) instead of turmeric the spice. Because a lot of these spices, including turmeric or ginger, contain fiber. By consuming things like curcumin capsules, you are missing an opportunity to introduce them as fiber sources into your diet.
Q: Do you have any insights on almond milk?
A: Almond milk is a great nutrient source for IBD patients. However, you need to be careful as store-bought almond milk or coconut milk typically contain emulsifiers. Emulsifiers are used to help blend the fatty and watery components so that they do not separate in the store. You should avoid emulsifiers in your almond milk since there are evidences that emulsifiers promote intestinal inflammation. There are a couple of brands that are out there without emulsifiers such as “Malk“. They sell pure almond milk. Another option is to make almond milk yourself. This is an even better option because you are in charge of what goes into it.
Q: How important are probiotics in my diet?
A: It is important to add probiotics in your diet. Your gut ecology may have been stripped over the years because you have had antibiotics or eliminated fiber for a long time. The intake of probiotics will help you re-establish your gut ecology. Probiotics are living organisms in food. Anything fermented (for example - cheese, yogurt, kimchi, sauerkraut and etc.) has probiotics in them. To consume probiotics, you don’t necessarily need to buy their capsule form. A better way is to expand and introduce fermented foods into your diet. If you are not tolerating any of those foods, you can then choose to take probiotic capsules. This will help you get through the tough spot where your gut environment is fragile and re-establish gut ecology. It is important to ensure the diversity of your gut ecology. So, if you are taking probiotic capsules, don’t stick with one brand for too long. You can buy two probiotics and every week switch between one and the other. You can also add more diverse sources of fiber into your diet to feed different strains of probiotics to add to the diversity in your gut ecology.
Q: If I am on a Specific Carbohydrate Diet(SCD) and I want to expand my food, should I introduce new food that is considered illegal in the diet?
A: SCD is likely the most studied and implemented diet for IBD. An important thing to note is that SCD should not be thought of as a life-long endeavor. You should think of it as an intervention that has a start, a middle, and an end. It is up to you to define where to end. One way of defining the end is when you are fully in remission for two years and off all medications. At that time you should move off of SCD gradually. When you introduce some non-SCD ingredients, you may start seeing some symptoms come back. In that case, you can always dial back and go back to full SCD and try again. SCD is a restrictive diet that may negatively impact your weight and nutrient intake, so it is perfectly acceptable, or even recommended for you to venture out from SCD when your disease is in a good shape.
Q: Do you recommend cooking vegetables to make them easier to digest? Are there some vegetables that are easier for IBD patients to digest?
A: In Dr. Arjomand’s opinion, vegetables are your exit out of IBD. If there was an off-ramp to IBD, it’s the combination of probiotic fermented foods and vegetables. There are some vegetables that are more friendly and easier to tolerate. And there are some that are more advanced and you may not want to try them now. To make vegetables generally friendlier, cooking them is the way to go. You may want to try over-cooking your vegetables - cooking to the point where it’s so soft that you can give it to a baby who has no teeth.
Q: How to expand food with the help of food journaling?
A: There are a lot of things to track in your head. So having a food journal is really important. It helps healthcare providers watch over the patients to see where the gaps are. It also helps the patients themselves to better understand their foods and the correlation with their symptoms. When you are journaling, you don’t have to find the actual ingredients item by item, but a rough journal is much better than nothing. When you start to keep a journal, you will be able to pair your journal with your symptoms and notice patterns over time. With a journal, when you are symptomatic, you can even retrospectively go back and remember what you had a month ago when your symptoms were under control and structure your diet so that you can get your symptoms back down. Without a journal, it would be incredibly hard to remember. Furthermore, a journal helps you to have your shopping list already in place so that you can reorder the same ingredients, making it easy for you to keep your pantry and fridge stocked with foods that are compliant with your disease.
Q: How can expanding foods potentially reduce my fatigue?
A: Unfortunately, feeling fatigued is typical with IBD as your body is fighting this condition. But as your disease is managed, your symptoms will be as well. Therefore you will have more energy and will naturally feel better.
The fatigue can also come when your symptoms are bad enough that your sleep is disrupted and you are not getting a full rest. Finding methods to enhance your sleep will lessen your fatigue.
The other reason could be that if you are short of energy because your body does not have enough calories or the nutrients to function. Lack of iron, or anemia, is commonly related to fatigue. Anemia is very common in IBD patients. Without iron, you cannot deliver oxygen and other nutrients that your body needs to function. In that case, you may want to think about taking multi-vitamin supplements.
Q: My sensitive food seems to change all the time, how do I know if what is tolerable today is also tolerable next month?
A: The landscape is always changing on you, what used to be very tolerable one day may not be tolerable in the future, so you always have to keep an eye on things. Knowing what you are eating is the first step. If you are eating different things on different days at a different place it is hard to look back and remember everything you ate. That is one of the reasons keeping a journal is good for you. When you don’t feel well you can always backtrack the last 48 hours and remember new food or new changes in your diet. Once you identify them, you can avoid them until the symptoms settle. You can also keep a list of foods that you are confident are safe to eat (for example, you can refer to foods in stage 1 in Expanding Foods by Stage form). You can always keep these foods in your pantry or refrigerator so that at a moment’s notice, you can dial back to an easier set of foods instead of needing to go to the grocery store in a pinch.
Shared Materials
Dr. Arjomand suggested some easy-to-read research papers to the session participants. You can read these papers to understand more about nutrition and dietary intervention for IBD:
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The slides Dr. Arjomand used in the session:
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Flare is a very generic term. When Doctors ask “do you feel like you’re in a flare“ or “how many flares have you had?”. People are usually confused about what they meant.
Flares are usually very distinct. You know when it comes and you know it when it is gone. Sometimes the reason you can not distinguish the flares might be that you have always been in a flare.
In this session, Ali dug into how to distinguish signs and symptoms of a flare that are tied to IBD from intestinal symptoms that are unrelated to IBD directly, and explored how to identify triggers and make smart changes based on the findings.
✨ Capturing snapshots of symptoms to identify trends and device interventions to get better
Symptoms are important reflection of how well you are doing with IBD and whether you are making progress. However, It is important to distinguish symptoms closely tied to IBD vs generic intestinal symptoms. Some of the symptoms people usually experience are generic intestinal symptoms maybe more closely tied to some food you had, or some reaction you are having to your food, which can be remediated through some alterations of your diet. These symptoms maybe present themselves the same way, but it is really important to separate them out. Because each has its own solution. Dr. Arjomand shared a worksheetyou can use to capture the trend of your symptoms over time, and help devise insight into whether your current intervention is working.
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On the worksheet, Dr. Arjomand groups symptoms into 3 sets:
The first set of symptoms are generic symptoms that don’t necessarily correlate with IBD. They are symptoms like acid reflux, bloating, diarrhea. Symptoms that could happen to any person. Dr. Arjomand suggested that these symptoms are tied to incoming food. They might be triggered by whatever you ate, the way you ate it, the time you ate it. We can address these symptoms by adjusting eating behavior such as adjusting some of the foods, chewing better and not rushing your meal, etc.
The second set of symptoms are more likely to be related to IBD. They are uncommon symptoms like abdominal cramping, bleeding, mucus in the stool and shiny oil drops in the stool, etc. Ali suggested that if these symptoms present, it’s an indication that you are in a flare. It could be an indication that your medications might not be working or there is a significant dietary intervention that needs to be put into place to remedy.
The third set of symptoms are secondary manifestations of IBD. These are symptoms like joint pain, back pain and fatigue etc. They are caused by persistent IBD symptoms, like persistent loss of blood or the ability to retain iron, being in constant battle mode and never getting a good sleep. Dr. Arjomand suggested that the best way to mitigate these issues is, instead of tackling them directly, work on the source of the problem and get the inflammation under control.
By taking notes of your symptoms and the interventions, you will be able to clear see what intervention worked, what did not. And you will be able to make necessary changes based on this insight.
✨ Finding and avoiding triggers by keeping a correlation journal
With all the different symptoms it is really hard to identify what caused those symptoms. A lot of times it's good to just document in real time, take a snapshot of what’s going on. Over time you can create an archive and a record of what’s been going on with your symptoms. With this collection of data, you can find correlation between your symptoms and some of the recurring things that you did that correlate with those symptoms. For example, the symptoms usually happen when you are getting ready for a big exam or a stressful event, they could happen when it’s spring and there’s pollen in the air, they could also happen in the middle of the event you don’t even know could be triggering but if you document it and we look at the timing and the pattern, you will see that they might be correlated. It is important to recognize that we are all different, there is not going to be a straight up guidebook. However, It is important to build awareness on how your body reacts to certain things to be able to predict and prevent a flare.
To help you stop the guesswork and find possible triggers, Dr. Arjomand shared a worksheet that you can use to document your symptoms, and the possible culprits that may have caused the symptoms.
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(1) Use this form each time you notice appearance of unusual symptoms.
(2) Enter the date, symptoms and come up with three possible triggers, no matter the likelihood of them being the actual trigger.
(3) Explore all areas of your life, triggers can be:
Dietary (individual meals, ingredients, mode of preparation, serving size)
Lifestyle (stress, event, exercise, etc)
Environmental (weather, pollen, location)
New medications
(4) Review your entries over time and look for patterns or a particular trigger that keeps showing up.
(5) Once you find a potential trigger, try eliminating it from your routine and see how well you respond.
✨ Q&A with Dr. Ali Arjomand
Q: What if I can never seem to identify correlation between my food and my symptoms? How do I know if my diet needs to be changed?
A: Journaling can help identify triggers. They might or might not be food related, it will take some tries to find out. Maybe you went to birthday party and ate something you don’t realize is the trigger, or you cook something and it was four days old in the refrigerator. Or it could be stress related and not related to food. It is like an exposure experiment. Remember that when thinking about the possible triggers, it doesn't have to be remotely plausible. What is important is that you can find the correlation between this and a flare. It is possible that something people thought was completely safe, safe even on Specific Carbohydrate Diet (SCD) match to events trigger. It is a dynamic and experimental process learned over time. And it is important that once you find your trigger, don’t stop there. What you should do next is to find an option to replace the trigger. For example, if you found yogurt to be your trigger, your options could be sheep’s milk instead of dairy milk, or you can use coconut milk instead of any kind of dairy. In the end, you will be able to re-route your journey and find a lifestyle that is better and more compatible with your IBD.
Q: Could you cover changes in diet following a small bowel resection - vitamins, what to avoid while still getting complete nutrition, adjusting to complications with abdominal adhesion?
A: Small bowel resection is when they remove certain portion of your intestine. There's a couple of important parameters that can help us understand the nature of the resection. There is how much they remove. Is it 10 centimeters or know 100 centimeter? And then there is whether they leave the ileocecal valve intact. The ileocecal valve is the gateway between your small intestine and your large intestine. When the valve is removed or not working you have reverse flow possibilities and that could cause SIBO, or fermentation in your small intestine. Because these microbes that should be in your colon have crept upstream and are causing troubles in your small intestine. Regardless of how much they remove and whether ileocecal valve is intact, vitamin B12 is key. Whether you have resection or not, if your Crohn's is in the small bowel in the terminal part of the ileum. That's the only place that absorbs vitamin B12. And if you have active inflammation or a resection vitamin B12 doesn't get absorbed as well almost not absorbed at all. You need B12 for red blood cell production, so anemia risk goes up. You need vitamin B12 for nerve function. Your nerves lose the protective layer and you may get damage to your nerves. It shows up as pain usually in your feet. So you stand on the ground and you feel like it's burning. Tt's pretty dangerous and it's irreversible. Unless you catch it early. You should be on sublingual vitamin B12. This is the drops that you put underneath your tongue you don't swallow. Let it just sit there for 30 seconds to a minute, right, and then through your gums and your tongue area there are capillary's and it's kind of a backdoor into your bloodstream. You can also get B12 intramuscular injections as well once a month from your doctor. Besides that, when we talk about a whole slew of micro-nutrients that are poorly absorbed, you should double up, triple up on your intake because you're not absorbing.
Q: What are the processed foods that we should stay away from vs ones that is OK?
A: The definition of processed foods is vague, so let’s focus on highly processed foods. They are essentially foods that have been deconstructed, and fortified with artificial additives. Because they have been deconstructed, your gut has an easier time to deconstruct the foods itself. So it may seem you are having an easier time initially. But in the long run, these foods lack sufficient nutrient to support your body. And Dr. Arjomand suggested that over exposure to these processed foods might contribute to IBD flare ups. Whole foods (foods that are less processed or not processed) are generally much more enjoyable, much safer, and it puts you on longer term well-being. To overcome transitory symptoms, you can go with a gentler set of foods, such as a mashed banana, couple of scrambled eggs, some chicken broth and other simple foods that are low residue.