Notes from 6/9 Nutrition Group Session: How to Make Smarter Dietary Changes that Help to Manage (and Prevent) a Flare

🎙 Overview

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 worksheet you can use to capture the trend of your symptoms over time, and help devise insight into whether your current intervention is working.

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.

(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.