Sunday, April 28, 2013

Food Journals and Elimination Diets


Food Journals


Keeping a food journal can help keep track of what foods irritate you and take some of the guesswork out of the diet planning process for IBD.  One of the biggest mistakes that those with Crohns and Ulcerative Colitis can make is to unnecessarily limit the diversity of their diets based on unfounded diet claims or by singular experiences under poorly isolated conditions.

It’s human nature to react negatively when your body has an adverse reaction following a meal.  Evolution developed the instinct to avoid foods that make us sick – eating berries that make you throw up may indicate they were poisonous to the system.  As such, we developed visceral reactions to food that made us ill.  Just think back to a food you absolutely won’t eat – there may be a negative association with a single incident.  For me, there are two that come to mind – Moo Goo Gai Pan (resulted in a case of food poisoning) and blue Gatorade (I used to mix it with my colonoscopy prep drinks – now it has that as a permanent association for me).  For individuals with inflammatory bowel disease, those single incidents occur a lot, and may or may not be related to what has recently been consumed.

The second factor that skews our rational thought with food reactions is proximity.  If we get sick 10 minutes after eating a particular food for dinner, we tend to blame that food and not the early afternoon snack.  Even worse, the incident may not be food related at all – it may just be an idiosyncratic response to medications the previous day, or to an environmental allergy.  Eliminating a particular food from our diet because of a single incident just doesn’t make sense.  How do we figure out what foods cause distress, then?
The first step is creating a food journal or diary.  It can be a small notepad you carry with you, an Excel spreadsheet on your computer, or an app on your smartphone (http://www.foodallergydetective.com/ is an iPhone app that was originally created for tracking allergies, but has applicability for IBD also).  The food journal needs to be updated with everything you eat (even those quick snacks).  I’d suggest tracking the following items:

·         Time/Date
·         Type of Food (use the food pyramid categories)
·         Food Description
·         Preparation (e.g. Fried, Baked, Grilled)
·         Amount

Each food item should be added as a separate entry, so a steak with mashed potatoes and asparagus should be three separate items.  Don’t forget to include drinks.

You can keep a symptom journal either with the food journal or as a separate entity that you later correlate (very easy if you have two tabs on a spreadsheet).  The symptom journal should track:

·         Date/Time
·         Category (Symptom, Medication, Bowel Movement)
·         Description

After a period of a month or two, you will have enough data to begin analyzing it.  When looking at the data, here are a few tips:

·         Calculate your average number of bowel movements a day (for a baseline). 
·         Calculate the average time after eating before your next bowel movement.
·         Pick a reasonable period (two hours is a good start) and look for any symptoms that appear within two hours of eating a particular food.
·         Identify any foods that have a stronger correlation than others (three times is a simple rule.  For those of you who are statistics-driven, try anything more than 2 standard deviations from average).
·         There will likely be a dose-response curve for foods you can’t tolerate.  As an example, those who are lactose intolerant can generally consume small amounts, with symptoms appearing and worsening as the amounts increase.
·         Eliminate the problem foods and see if the overall numbers change.

There are a few variants on a journal that are more rigid – namely the exclusion diet and the elimination diet.  With an exclusion diet, you remove a particular food from your diet for a period of time (generally several weeks) to see if symptoms improve.  With an isolation diet, you start with a small number of foods that you know do not cause symptoms (e.g. Ensure) and then slowly add items one at a time to determine if they have a symptom impact.  As with the journal, it may take multiple iterations of removal/addition to be sure that a particular food isn’t impacting your symptoms.

There are some downsides to elimination diets.  First, they are notoriously difficult to isolate specific problems – for example you may think that you have an intolerance to chicken and eliminate if from your diet, when in reality it is the peanut oil the chicken is cooked in.  Second, tolerances may change based on your current condition, requiring the diet be revisited periodically.  Third, individuals may have a tendency to remove too much from an already limited diet.  Finally, even though there may be some symptom changes due to food, there is no evidence of food impacting actual disease progression.(1)

Bottom Line


·         Food journals can provide insight into what food trigger symptoms.
·         Elimination and isolation diets can help fast-track food journal results, with some potential pitfalls.
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1.       Pearson, M., K. Teahon, A. Jonathan Levi, and I. Bjarnason. "Food intolerance and Crohn's disease." Gut 34, no. 6 (1993): 783-787.

Sunday, April 21, 2013

Burn, Baby Burn

Spicy Food and Gastrointestinal Distress


Spicy foods are anecdotally responsible for many forms of gastrointestinal distress.   These range from heartburn after a visit to Chipotle™ to diarrhea and rectal burning (“if it burns going in, it will burn coming out”) after an evening of Thai cuisine.  None of this anecdotal evidence helps us get to the bottom of what causes the discomfort – there are too many factors involved.  The distress could be caused by overconsumption, by the presence of any number of spices, by the acid content or by high fat content in the meals.  For this post, we’ll try to look at the evidence that isolates on particular component of spicy foods – capsaicin. 

Capsaicin is the primary irritant in peppers from the chili family.  It irritates primarily by interacting with sensory neuron cells, causing a burning sensation and localized inflammation (though there is no associated tissue damage).(1)  This occurs on the skin, but is most pronounced on the mucous membranes (the eyes, nose, and GI tract).  At high concentrations, capsaicin can be incapacitating – hence it’s use in oleoresin capsaicin (OC) spray for self defense.

The amount of capsaicin varies based on the type of pepper.  The heat of peppers is measured in units called Scovilles, with higher numbers representing “hotter” foods.  Average Scoville units of common capsaicin-containing products are (estimated as they vary by up to 50% in foods) as follows:

Item
Scoville Units
Pure capsaicin
16,000,000
Pepper spray
2,000,000
Custom-bred chili peppers (e.g. Naga Viper)
1,000,000
Habanero pepper, Scotch Bonnet pepper
250,000
Thai Chili peppers
100,000
Cayenne pepper, Tabasco pepper
50,000
Jalapeno pepper, Chipotle pepper
7,500
Banana pepper
750
 As a point of reference, the original Tabasco Sauce™ is rated between 2,500 and 5,000 Scovilles.(2)

The potential for gastrointestinal distress with capsaicin begins in the mouth and the associated mucous membranes present therein.  While individuals can build up a desensitization to the burning (3), most of us will be able to gauge the impact on the rest of the GI tract once a hot food hits our tongue (and the rest of the mouth).  Once irritation occurs, the only method of reducing oral burning is through the ingestion of non-capsaicin containing foods or drinks.  It isn’t water soluble, so plain water isn’t particularly effective (and will just move the capsaicin to other areas of the mouth).  Milk and sucrose solution are temporarily effective at cold temperatures, and eating additional food can mechanically absorb and remove the capsaicin slowly.(4)

Following the mouth, capsaicin impacts the esophageal mucosal lining upon consumption.  Though capsaicin has not been shown to cause heartburn nor to alter stomach emptying or pH values, it has been shown to have a perceived exacerbation.  The theorized reason for this is that the initial consumption of capsaicin causes a sensitization of the esophagus.  Subsequent reflux (including the capsaicin) exacerbates the pain felt by the subject, though it has not shown to have any additional erosive impact.  Additionally, there may be a longer-duration analgesic effect despite the proximal increase in perceived discomfort.(5)

Despite initial thoughts that capsaicin was a stomach irritant, direct viewing of the stomach suggests otherwise.(6)  Prior to the isolation of H. Pylori, eating spicy foods with capsaicin was thought to be a cause of ulcers.  Following the discovery and adoption of the H. Pylori causative reaction, many physicians still perceived capsaicin as exacerbating inflammation, increasing the likelihood of ulcer formation (and worsening it), and increasing acid production.  All of these have been disproven and, in fact, capsaicin is believed to have a mild positive effect on impeding the development of stomach ulcers, reducing acid production, and improving the outcomes for those with ulcers. (7,8) 

Of most interest to those with Crohn’s disease and Ulcerative colitis are the impact of capsaicin on the small and large intestines.  The main impact is the increase in transit time, resulting in less absorption of water and therefore looser stool.(9)  For those with IBD, this can further increase the already loose bowel movements and increase urgency.  While it hasn’t been studied well in IBD patients, capsaicin has been studied in those with IBS.  Specifically, a six week regime of capsaicin (blinded) showed that study participants had more abdominal pain and greater urgency with capsaicin than placebo, but that they developed a desensitization to capsaicin after approximately six weeks, resulting in lower pain and motility when eating spicy foods than those who had only had placebo. (10)  The primary pain associated with spicy foods, that of the “ring of death” and the rectum, is largely due to undigested capsaicin stimulating the C fibers (nerve receptors) in the rectal mucosa, similar to the mouth.

Overall, there has been surprisingly little research on capsaicin and IBD – most of the “spicy food” research is anecdotal.  Additionally, the majority of the research noted above is on small sample sets, and further confirmatory research is certainly warranted.

Bottom Line


·         Capsaicin, in spicy foods, can cause increased transit time (and subsequent diarrhea and urgency) and a burning sensation in the rectum.
·         Capsaicin likely doesn’t have any impact on GERD progression, but may make it feel worse temporarily.
·         Individuals can build up a tolerance to capsaicin over a short period of weeks.  There may be beneficial effect to capsaicin on the intestines, but results are all preliminary and not yet proven.
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1.       Story, Gina M., and Lillian Cruz-Orengo. "Feel the Burn The linked sensations of temperature and pain come from a family of membrane proteins that can tell neurons to fire when heated or hot-peppered." American scientist 95, no. 4 (2007): 326-333.
3.       Karrer, Tracy, and Linda Bartoshuk. "Capsaicin desensitization and recovery on the human tongue." Physiology & behavior 49, no. 4 (1991): 757-764.
4.       Nasrawi, Christina Wu, and Rose Marie Pangborn. "Temporal effectiveness of mouth-rinsing on capsaicin mouth-burn." Physiology & behavior 47, no. 4 (1990): 617-623.
5.       Rodriguez-Stanley, S., K. L. Collings, M. Robinson, W. Owen, and P. B. Miner Jr. "The effects of capsaicin on reux, gastric emptying and dyspepsia." Aliment Pharmacol Ther 14 (2000): 129-134.
6.       Graham, David Y., J. Lacey Smith, and Antone R. Opekun. "Spicy food and the stomach." JAMA: the journal of the American Medical Association 260, no. 23 (1988): 3473-3475.
7.       Satyanarayana, M. N. "Capsaicin and gastric ulcers." Critical reviews in food science and nutrition 46, no. 4 (2006): 275-328.
8.       Abdel-Salam, O. M. E., J. Szolcsanyi, and Gy Mózsik. "Capsaicin and the stomach. A review of experimental and clinical data." Journal of Physiology-Paris 91, no. 3 (1997): 151-171.
9.       Gonzalez, R., et al. "Effect of capsaicin-containing red pepper sauce suspension on upper gastrointestinal motility in healthy volunteers." Digestive diseases and sciences 43.6 (1998): 1165-1171.
10.   Aniwan, S., and S. Gonlachanvit. "Effects of Chili on Abdominal Pain, Abdominal Burning and Rectal Sensation in Diarrhea Predominate Irritable Bowel Syndrome (IBS-D)." Thai J Gastroenterol 13, no. 1 (2012): 29-37.

Sunday, April 14, 2013

Sugar Free IBD


Artificial Sweeteners Redux – The Sugar Alcohols


I previously covered the major artificial sweeteners used as sugar replacements by consumers – aspartame, sucralose, and saccharin.  A second category of artificial sweetener, the sugar alcohol, is frequently used in products ranging from medical compounds to sugar free gum.  Sugar alcohols include mannitol, sorbitol, xylitol, glycol, and methanol (there are many others – these are just the common ones) and are generally less sweet than traditional sucrose (with some exceptions).  Sugar alcohols do not have the same baking or cooking properties as sugar, and as such are not commonly used in prepared foods.

Xylitol is the one sugar alcohol with a sweetness similar to sucrose, and is used frequently in sugar free gums (a misnomer – they have sugar alcohols, and are not completely calorie free either – xylitol has approximately 40% of the calories of sugar).  )  It is derived naturally from the birch tree (the name is derived from the Greek word for wood), and is also used in many sugar free hard candy products.  Xylitol is popular in the dental crowd in that it can reduce calories up to 85% when chewed regularly.(1) Xylitol has also been shown to reduce inner ear infections (due to both the chewing action and anti-microbial properties effecting the Eustachian tubes).(2)

Sorbitol is similarly used in sugar free gums and candies, though it is slightly less sweet than Xylitol.  It is frequently added to diet sodas and ice creams, and used in industrial processes ranging from cosmetic production to model rocket fuel composition.  Medically, sorbitol has been used as a cost effective laxative product.(3)  Similar to xylitol, sorbitol is naturally derived from stone fruits.  Most commonly associated with sorbitol are prunes (hence the laxative effects of prune juice).

Mannitol is an isomer of sorbitol and is found in most plants (though it can be industrially created as well).  Like sorbitol and xylitol, it is used in chewing gums and other products needing a low calorie sweetener.  Mannitol has multiple medical uses also – ranging from the delivery of drugs to the brain due to its facilitation of crossing the blood-brain barrier (4) to oliguric renal failure, though large doses of mannitol can actually cause renal failure through a different mechanism (5).  Mannitol was originally one of the popular colonoscopy preps, until it was found to contribute to exploding bowels.(6) 

Glycol is frequently associated with ethylene glycol, diethylene glycol, and polyethylene glycol.  All three are chemically related and have a sweet taste, but have very different uses and are not metabolized by the body in the same way.  You will often find bad science in alarmist literature ignorantly comparing the different compounds inappropriately in an alarmist manner that associates brake fluid with medical use.(7)  Chemistry doesn’t work that way, fortunately – not only are different chemical compositions metabolized differently, even if they “appear” to be similar, they break down completely differently.  A great example is sodium ferrocyanide – an anticaking additive to table salt.  It’s precursor ligand, cyanide, is highly toxic, but is bound to a metal (iron in this case) and the chemical bonds are not brokwn down by the body in normal circumstances.  As such, sodium ferrocyanide is not particularly toxic in small doses (anything, including water, can be considered toxic in high doses).(8)

Ethylene Glycol is primarily used as antifreeze, and is highly toxic.  Diethylene glycol is used as an industrial solvent (and is part of many brake fluids).  Diethylene glycol (DEG) has been associated with numerous cases of poisoning and is the subject of multiple “adding antifreeze to wine” scandals – technically it is more often DEG than ethylene glycol that has been added(9).  Polyethylene glycol, or PEG, is the most known to those with IBD.  It is the base of the currently used laxatives in colonoscopy preparation, including GoLYTELY™, Dulcolax™ and MoviPrep™. 

Sugar alcohols are very popular amongst diabetics because they are not broken down completely in the intestines and don’t result in the absorption of glucose to the same degree as traditional sugars.   This lack of breakdown is what causes their other less friendly effects for those with IBS, Crohn’s Disease, and Ulcerative Colitis, namely diarrhea and bloating.  Malabsorption depends partially on the genetics of the individual, with some individuals having difficulty when consuming as little as 5g, and just about all individuals having some GI difficulties at 20g.(10) As a point of reference, most sugar free gums have 1.25 – 2 grams of sugar alcohols.  By contrast, a serving of sugar free Jelly Belly™ Jelly Beans, consisting of 35 beans, has 25g of sugar alcohol.(11)  In addition to not being broken down fully, they can cause an increase in intestinal motility, something that is not generally welcome to those with IBD.(12)  Diabetics with IBD will have to weigh the blood-sugar related benefits with the IBD-associated risks.

Although it is not directly IBD related, there is one other concern with pets and sugar alcohols.  They can cause severe hypoglycemia and liver failure in very small doses – a pack of Trident™ or Extra™ gum is enough to be fatal for smaller dogs.(13)  Additionally, pets like the sweet taste of antifreeze, which is similarly dangerous for them to consume.  As such, sugar alcohol-containing products should ALWAYS be kept away from your pets.

Bottom Line


·         Xylitol, mannitol, sorbitol, and other alcohol sugars all have a laxative effect at high doses.  They have all been used medically as laxatives at one point or another, with polyethylene glycol (PEG) being the current gold standard for colonoscopy prep.
·         Sugar alcohols are popular additives to diet soda, sugar free gums, and sugar free candies.
·         A stick of gum here or there won’t impact most people with IBD, but consuming even a moderate amount of sugar free candy can mean great intestinal distress. 
·         Sugarfree candies and gums should be kept in places where your pets can’t get at them.

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1.        Ly, Kiet A., Peter Milgrom, and Marilynn Rothen. "Xylitol, sweeteners, and dental caries." Pediatric dentistry 28, no. 2 (2006): 154-163.
2.       Uhari, Matti, Tero Kontiokari, and Marjo Niemelä. "A novel use of xylitol sugar in preventing acute otitis media." Pediatrics 102, no. 4 (1998): 879-884.
3.       Lederle, Frank A., David L. Busch, Kimberly M. Mattox, Melissa J. West, and Donna M. Aske. "Cost-effective treatment of constipation in the elderly: a randomized double-blind comparison of sorbitol and lactulose." The American journal of medicine 89, no. 5 (1990): 597-601.
4.       Rapoport, Stanley I. "Osmotic opening of the blood–brain barrier: principles, mechanism, and therapeutic applications." Cellular and molecular neurobiology20, no. 2 (2000): 217-230.
5.       Dormán, Henry R., James H. Sondheimer, and PHAVIT CADNAPAPHORNCHAI. "Mannitol-induced acute renal failure." Medicine 69, no. 3 (1990): 153-159.
6.       La Brooy, SusanJ, C. L. Fendick, A. Avgerinos, C. B. Williams, and J. J. Misiewicz. "Potentially explosive colonic concentrations of hydrogen after bowel preparation with mannitol." The Lancet 317, no. 8221 (1981): 634-636.
10.   Powell, Don W. "18 Approach to the patient with diarrhea." Clinical Gastroenterology (2008): 304.
12.   Salminen, Eeva K., Seppo J. Salminen, Leena Porkka, Pete Kwasowski, Vincent Marks, and Pekka E. Koivistoinen. "Xylitol vs glucose: effect on the rate of gastric emptying and motilin, insulin, and gastric inhibitory polypeptide release." The American journal of clinical nutrition 49, no. 6 (1989): 1228-1232.
13.   Dunayer, Eric K., and Sharon M. Gwaltney-Brant. "Acute hepatic failure and coagulopathy associated with xylitol ingestion in eight dogs." Journal of the American Veterinary Medical Association 229, no. 7 (2006): 1113-1117.

Sunday, April 7, 2013

Lavatory Law


Legal Issues and IBD


There are a few unique legal issues surrounding IBD that folks may or may not be aware of.  One is positive (the trend toward bathroom access), the second is negative (the ability of private entities to set their own restrictions on the use of restrooms).  What does this mean for the average IBD patient?

Access to bathrooms is something that is almost always on the mind of anyone with IBD.  It effects when, where, and how we travel, eat, and generally live life.  Most of us have developed restroom-radar – the ability to always know when and where the closest bathroom is.  Unfortunately, not all of those restrooms are legally accessible to those with Crohn’s and Ulcerative Colitis.

Because most restrooms are in private establishments (restaurants, retail stores, gas stations, etc…) their owners are free to establish whatever restrictions they would like on their use.  All states have requirements for restrooms at food establishments that allow dining in, but the owners can choose to limit their use to paying customers only.  There are good reasons (from the business’s perspective) for doing so:  there is a cost to maintain clean restrooms, they may attract undesirable individuals, and may increase liability for the establishment. 

Building codes for restaurants require restrooms be made available, but not necessarily adequate bathrooms for those with IBD.  Virginia State Code, for example, requires the following:

§ 3.2-5109. Washrooms and toilets.

Any place where food is manufactured, prepared, exposed, or offered for sale shall have a convenient washroom and toilet of sanitary construction, but such toilet shall be entirely separate and apart from any room used for the manufacture or storage of food products.

The requirement does expand beyond sit-down restaurants, but doesn't give a lot of detail on how many toilets (or their condition).  For the number of toilets, most states have adopted the International Building Code.  The IBC requires a number of toilets based on the number of occupants and the type of establishment (1 per 40 occupants for a bar, 1 per 75 occupants for a restaurant).  Normally, because the facility counts are the same for men and women, men have more facilities available.  For male IBD sufferers, however, the facilities may substitute a urinal for 50% of the required toilets.  This means that there may only be one toilet for a restaurant with 300 person occupancy.  If that toilet is out or occupied, you may be out of luck (an unfortunate consideration in choosing places to eat).(1)  Because urinals are cheaper and easier to maintain, most restaurants/bars will take this option.

What about non-restaurant establishments?  Until recently, there was no legislation that offered any rights to those with medical conditions access to bathrooms in retail establishments.  Enter Ally Bain. 
Everyone stateside with IBD owes a debt of gratitude to Ally Bain and her mother Lisa.  When she was younger, Ally needed to use the restroom in a retail establishment and was denied by the management.  As a result, she had the same accident many of us have had at one point or another.  Instead of taking it lying down, Ally and her mother fought and passed the first of what is known as “Ally’s Law” legislative changes in Illinois.(2)  Since then, 13 other states have passed similar laws:

·         Colorado
·         Connecticut
·         Illinois
·         Kentucky
·         Massachusetts
·         Michigan
·         Minnesota
·         Ohio
·         Oregon
·         Tennessee
·         Texas
·         Wisconsin
·         Washington

Ally’s Law, or the Restroom Access Act, says something similar in each state:

     Section 5. Definitions. In this Act:
    "Customer" means an individual who is lawfully on the premises of a retail establishment.
    "Eligible medical condition" means Crohn's disease, ulcerative colitis, any other inflammatory bowel disease, irritable bowel syndrome, or any other medical condition that requires immediate access to a toilet facility.
    "Retail establishment" means a place of business open to the general public for the sale of goods or services. "Retail establishment" does not include a filling station or service station, with a structure of 800 square feet or less, that has an employee toilet facility located within that structure.
    Section 10. Retail establishment; customer access to restroom facilities. A retail establishment that has a toilet facility for its employees shall allow a customer to use that facility during normal business hours if the toilet facility is reasonably safe and all of the following conditions are met:
        (1) The customer requesting the use of the employee toilet facility suffers from an eligible medical condition or utilizes an ostomy device.
        (2) Three or more employees of the retail establishment are working at the time the customer requests use of the employee toilet facility.
        (3) The retail establishment does not normally make a restroom available to the public.
        (4) The employee toilet facility is not located in an area where providing access would create an obvious health or safety risk to the customer or an obvious security risk to the retail establishment.
        (5) A public restroom is not immediately accessible to the customer.

    Section 15. Liability.
    (a) A retail establishment or an employee of a retail establishment is not civilly liable for any act or omission in allowing a customer that has an eligible medical condition to use an employee toilet facility that is not a public restroom if the act or omission meets all of the following:
        (1) It is not willful or grossly negligent.
        (2) It occurs in an area of the retail establishment that is not accessible to the public.
        (3) It results in an injury to or death of the customer or any individual other than an employee accompanying the customer.
    (b) A retail establishment is not required to make any physical changes to an employee toilet facility under this Act. 
    Section 20. Violation. A retail establishment or an employee of a retail establishment that violates Section 10 is guilty of a petty offense. The penalty is a fine of not more than $100.

The law is a great addition – I suggest you carry your CCFA card and a copy of the law in your wallet.  While the penalties are not great, the negative publicity may be.

Multiple other states have similar laws in process.  My own Virginia was a disappointment (except Delegate Rob Krupicka, who introduced the bill) – they voted it down last year, and the there was hardly a public outcry (see http://hamptonroads.com/2013/01/bathroom-bill-ends-where-it-belongs-down-drain for a particularly insensitive response).  I suggest y’all write your local delegates in your states to see if there is a similar law on the legislative agenda (or suggest one!)

Aside from trying to get a law passed, if you are denied access to a restroom try contacting the franchise owner or corporate affairs and educate them.  If it is a small business, contact the Better Business Bureau (assuming the owner is the one that denied you – otherwise, talk to the owner and educate them). 
My personal favorite location is hotels – they are open 24 hours, have lobbies that are open and have restrooms that are generally clean.

Bottom Line


·         In general, there aren’t a lot of laws requiring individuals to allow you to use their restrooms.
·         Ally’s Law and a few similar laws provide some relief – if you don’t have a local version, contact your representative.

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http://www.girls-with-guts.org/2012/10/31/the-origins-of-the-restroom-access-act-by-ally-bain/