🎙 Overview
In this session, we invited Dr. Ali Arjomand to talk about how you can expand your diet as an IBD (Inflammatory Bowel Disease) patient. Food and diet is where you feel our IBD mostly on a day-to-day basis. it's also probably where your standard GI clinics don't really have the time or resources to support you. In this session Dr. Arjomand talked about the important nutrients for IBD patients, and how you can expand your foods gradually step by step to get to a more diverse diet and a 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?
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 of many IBD and IBS patients.
🍏 What are the important nutrients missing and how to get them as IBD patients?
The US government and health authorities have guidelines for food intake - the US Dietary Guidelines. However, the guidelines aren't really adhered to in 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.
As a way to sneak much needed nutrients into an average diet, the standard food supply is enriched with fortified nutrients. In case of enriched flour, it contains nutrients such as thiamine, niacin, folic acid, riboflavin and iron. As IBD patients, because of your food restrictions, you are not only missing out the natural foods that provide these nutrients, you are also missing out these nutrients that would come from foods like enriched flour.
As IBD patients, you are trying to work with that landscape and even do better - you do not just use food to manage our condition, but even go further and use food to help move forward and hopefully put yourselves into remission. Therefore, it is important to understand the relationship between nutrients and what you eat in your diet.
In Dr. Arjomand’s definition, nutrient is a substance or ingredient that promotes growth, provides energy and maintains life. Essential nutrients are nutrients that cannot be produced by the body (or cannot be produced in sufficient amounts) and must be obtained through other means. Diet is where you obtain your essential nutrients.
There are 6 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:
Oxygen: Many people probably don’t think of oxygen as a macro-nutrient. Technically it’s not. You don’t get it from diet, but it’s an essential element for survival, and you cannot store it.
Water: You can’t store it just like you can’t store oxygen, but this is part of your diet.
IBD patients may eliminate consumption of non-nutritive beverages such as soda, sports drinks, beer and fruit juice. Instead, you should rely on consuming pure water, and beverages like tea or coffee if you can tolerate them. It is important to remember that food is also a substantial source of water.Protein: You also cannot store it in the body. If you eat too much protein, you end up peeing it out and if you eat too little you end up sacrificing other parts of your body to meet your needs. You need to ensure sufficient intake of protein each day. Otherwise, it leads to weakness, sarcopenia and other dysfunctions. For IBD patients, it is the most important to focus on because the disease increases the protein requirement, and most of the patients struggle finding the sources of protein to be included in their diet. 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 your 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). Here are some foods that are high in protein, listed from high to low:
Fat: You can store fat, and that is not necessarily a bad thing. Fat is essential for healthy functioning of human body as long as you find it from healthy sources. If you are working on weight loss or growth faltering from your IBD, fat is a great source of calorie for those problems. However, you should take caution if you have gallbladder surgery(where your ability to absorb fat is limited) or you have rapid diarrhea. Here are some example sources of fat:
Carbohydrates: You can store only a little bit of carbohydrate, but not much and anything in excess gets converted to fat. Technically, there is no requirement from the diet. In practice, you likely consume 100 to 400 grams per day. Carbohydrates induce insulin release, which is important for anabolic growth. It may be hard to gain weight on low carbon due to low insulin induction. Refined carbs like bread, rice, potatoes, pasta and sugar are pretty large portion of people’s diet. In some cases eliminating them all together is super beneficial. 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 your bloodstream. Either it comes out of you or, more importantly, it feeds the gut microbes and this is the one that you want to focus on. Most people don’t get the vegetables they need, and it means 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. He did it for 15 years and it took a heavy toll on his health. In his opinion, what IBD patients should do is to instead get to as much fiber as you can safely and as fast as you can. Depends 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. A challenge that you can try is to increase the kinds of plants in your diet. You can start with getting five different kinds of plants in your diet. Or if that’s already happening, get to 10 kinds of fiber sources, even spices count – you can sprinkle a little bit of cinnamon on your yogurt and that counts as one kind of fiber source.
🥗 How to gradually expand your food diversity?
For IBD patients, some foods are easier. As you are expanding the diversity of your foods, it is important 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 table and strategy of how you can use this table to gradually expand the diversity of your food.
The table lists foods by stages, from stage 1 to stage 4. Stage 1 contains the easiest and most basic foods most patients feel comfortable with. As the stage number goes up, the food becomes more advanced, and might be harder for you 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 more resilient. Once you are comfortable with foods in your current stage, to advance to the next stage, the best way is to introduce some of the foods from the next stage and make sure to prepare and cook 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 subsidized and you are comfortable with expanding your food again, you can try introduce those food again. Gradually you will have a large set of ingredients available to you that supports your gut health.
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
Q: Do you have any Insights on turmeric or ginger?
A: Turmeric is a spice. It’s ground up from the root of the turmeric plant and has been shown to have real benefits. It’s an anti-inflammatory ingredient, which is exactly what you want for IBD. Most of the supplements you see at supplement shops try and get the turmeric in a pure form - curcumin capsules. Dr. Arjomand advised against that. Because besides the active compound, a lot of these spices, turmeric or ginger, contain a lot of fiber. By consuming things like curcumin capsules, you are missing out 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. You need to just be careful that store bought almond milk or coconut milk typically has what’s called an emulsifier. It is used to help blend the fatty and watery component so that it doesn’t separate out in the store. You should avoid emulsifiers in your almond milk. There are a couple of brands that are out there without emulsifier. One of them is “Malk“. They sell pure almond milk. If you are making almond milk yourself, that is even better because you are in charge of what goes into it.
Q: How important are probiotics to add to my diet?
A: It is important to add probiotics in your diet. Your gut ecology may have been stripped over the years because you’ve had antibiotics or you have eliminated fiber for a long time. Intake of probiotics will help you re-establish the gut ecology. Probiotics are living organisms in the food. Anything fermented(for example: cheese, yogurt, kimchi, sauerkraut and etc.) have probiotics in them. To consume probiotics, you don’t necessarily need to buy probiotics in capsule form. The better way is to expand and introduce fermented foods in your diet. If you are not tolerating any of those foods, the next best thing is to take probiotics in capsule form and that will help you get through a tough spot and re-establish the gut ecology. It is also 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 2 probiotics and every week switch between one and the other. You can also add more diverse source 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 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 probably 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, has a middle and an end. It is up to you to define where to end. Some people want to be fully in remission for two years and off all medications, then it is time for them to move on from SCD gradually. When you introduce some non-SCD ingredients, you may also start seeing some symptoms come back. In that case, you can always dial back and go back full SCD and try again. SCD is a restrictive diet and that it may negatively impact your weight and your nutrient intake, so it is perfectly acceptable, or even recommended for you to venture out the 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, easier to tolerate. And there are some that are more advanced and you may not want to try them now. To make vegetable generally friendlier, cooking them is definitely the way to go. Even over cooking your vegetables - cooking to the point where it’s super 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 to 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 ingredient 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 really hard to remember that. Furthermore, a journal helps you to have your shopping list already in place so that you can reorder the same things over and over again, making it easy for you to keep your pantry and fridge stocked with food that are compliant with your disease.
Q: How can expanding food potentially reduce my fatigue?
A: Feeling fatigue is pretty typical with IBD and some of it is just by virtue of having a disease and your body is fighting this condition. You don’t have too feel too bad about your fatigue. When your disease is managed better and your body isn’t so tied up fighting IBD and actually has more energy, you will naturally feel better.
The fatigue can also come when your symptoms are bad enough that you wake up at night or your sleep is disrupted that you are not getting full rest. The next day you are going to be tired. You should see if you can enhance your sleep and get more restful sleep.
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. Iron is a big one of such nutrients. Being short of iron, also anemia, is very common in IBD patients which makes you exhausted. 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 what I can tolerate today I can tolerate 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 randomly eating different things on different days, at different places, it is hard to look back for the last five days and remember everything you ate. That is one of the reason 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 food that you are confident that they are safe to eat (For example, you can refer to foods in stage 1 in Expanding Foods by Stage form.). You can always keep those foods in your pantry or refrigerator so that on a moment’s notice, you dial back to a set of easier food to ride out the next couple of days instead of needing to go to the grocery store in a pinch.
Shared Materials
Dr. Arjomand suggested some easy-to-read research paper to the session participants. You can read these paper to understand more about nutrition and dietary intervention for IBD:
The slides Dr. Arjomand used in the session: