Sunday, November 25, 2012

Meal Size

Smaller or Larger Meals With IBD?

Because diet is integrally linked to symptoms in IBD, a lot of focus is put on what to eat.  Less focus is put on when to eat, though several diet strategies have different recommendations.  Three squares a day is the old standby, while some diets recommend as many as seven micro-meals.  Alternatively, one big meal makes planning easier.  Looking at mealtimes objectively requires a bit of history of how we got to the current norm.
Back in the old times – before David Hasselhoff made wearing shirtless jackets cool.  Before Farah Fawcett’s swimsuit showed how cold the water was.  Before Jimmy Hendrix faded in a Purple Haze.  Back in those times we had the food icons known as Ward and June Cleaver.  I know – what do they have to do with food?  The 1950’s as portrayed on Leave it to Beaver presented what we still think of as the “typical” meal schedule.  A hearty breakfast, maybe some bacon and eggs with a piece of toast and some coffee.  For lunch, a sandwich and an apple, and can of soda.  For dinner, a salad then a roast turkey and gravy, stuffing, mashed potatoes, and some carrots.  Finally, a slice of apple pie for dessert.  Many of us grew up with the idea that this is the “traditional” way meals are structured.  But history tells us a different story.

In hunter-gatherer times, eating was feast or famine.  With no effective way to preserve many types of food, it was consumed when available, and weight (largely fat) was put on to get folks through lean times.   Once folks settled down, consumption became somewhat more regular.  In Roman times, the wealthy ate a single large meal at lunchtime, with an occasional smaller meal later in the day.  During the middle ages, breakfast became a popular addition.  Dinner as we know it didn't come about until the availability of cheap lighting – bedtime came about with sundown prior to that.  The regularized three meals we know today largely evolved during the industrial revolution.  Shift work required breakfast be eaten early, that lunch be portable and taken mid-shift, and dinner come beyond the late afternoon. (1)

Today, we have the flexibility to eat on whatever schedule we desire, so what is best for symptom abatement?  Most of the advice from competent sources centers around frequent, smaller meals.  For example:

  • The Mayo Clinic notes you may “feel better eating five or six small meals” a day. (2)
  • The NY Times recommends “Eat small amounts of food throughout the day.” (3)
  • UNC’s Medical School provides the guidance that smaller,  frequent  meals may avoid some of the  “backed  up” type feelings associated with near blockages (pain, bloating, gas) (4)

Though these are recommended, there isn’t any direct evidence of a specific meal size conferring global benefit to the underlying disease.  That said, what about the quality of life issues noted above by UNC’s guidelines?

In terms of meal effect, the largest concern of most IBD patients is the post-meal urgency to use the bathroom.  Urgency is caused by stimulation of the lower part of the large intestine, the rectal ampulla, distending.  Both chemical and nervous triggers contribute to this.  In general, the large intestine produces 3-4 movements a day, and they can result in the need to defecate if they result in fecal matter being deposited in the rectal ampulla.  Otherwise, the intestinal movements just move the future feces further toward the rectum. 

One of the primary triggers for intestinal motility is the consumption of food (which kicks off the whole digestive process).   This can result in urgency after eating a meal (or during the meal for an extended meal).  The urgency is generally not proportional to the amount eaten, as that food has many hours of transit time left to reach the end of its journey - there is no evidence that the smaller meal movements contribute to urgency more or less than larger meal movements.   * Meal size also impacts the rate the stomach empties.  Smaller, lighter meals empty quicker.  Larger meals take longer to empty.  (5)

 Because the stomach emptying is a trigger for the whole intestinal system to kick-in, eating smaller meals can result in more movements.  On the other hand, eating smaller meals may mean less bloating in the intestines 3-4 hours post-mealtime, resulting in a more “comfortable” gut.  Smaller meals also allow oral drugs to flow to the small intestine more evenly (and not “wait” for the full digestion to occur), showing a benefit for those on oral steroids.  Plus, if you need to take medication frequently during the day, having a small meal coincide with that may be necessary if it is a “take with food” drug. (6,7)

In general, intestinal motility slows down approximately four hours after eating.  If you are travelling and need to increase your chances of not having a bowel movement in-transit (while stuck in rush hour traffic, for instance), eating fewer meals timed appropriately can be a lifesaver.  The same goes for events where a bathroom may not be accessible. (5)

There have been no extensive objective studies showing any evidence of a positive effect on symptoms based on frequent small meals, or on fewer larger meals.  The clinical evidence is not present to support a recommendation either way.   Because of this, allow your lifestyle and what you can individually tolerate to dictate meal size and frequency.

Bottom Line

  • Eating frequent, small meals complementing the consumption of medicine is a good idea.
  • One or two larger meals if tolerated are just as good if oral medicines aren’t a factor.
  • When travelling or attending an event where facilities are limited, meal planning may require you to not eat 4 hours before the event to avoid triggering increased intestinal motility. 

* Note:  Diarrhea is not associated with increased intestinal motility, but reduced intestinal motility. For IBD sufferers, there can still be loose stool movements with increased motility, but in the water rush with traditional diarrhea the intestines are generally not in motion.

(6)    S.S. Davis, J.G. Hardy, M.J. Taylor, D.R. Whalley, C.G. Wilson.  The effect of food on the gastrointestinal transit of pellets and an osmotic device (Osmet).  International Journal of Pharmaceutics.  1984.
(7)    S S Davis, J G Hardy, J W Fara. Transit of pharmaceutical dosage forms through the small intestine.  Gut, 1986.

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