Purpose

Dietary fiber only comes from plants and grains, never from animal foods. it helps to maintain a plant structure. Cellulose, hemicellulose, polysaccharides, pectins, gums, mucilages and lignans are all dietary fibers, mostly of interest to the plant chemist. More broadly, most fiber can be broken down into insoluble and soluble fiber. Neither of these, nor in fact any fiber, is digested by the body in the small intestine. Rather, they arrive in the colon, where they exert a profound function for the body and, indeed, our very health.

Function of the Colon

Every field of medicine has progressed enormously over the past 10-15 years. Our understanding of the colon and how if functions is no exception. What we now know about the colon and how it functions is simply staggering to us gastroenterologists who, in medical school, thought we knew all there was to know about the colon. Back then, it was viewed as a container that dehydrated liquid stool that entered it, stored it and then evacuated the stool when convenient.

But this is only a small part of what the colon does even though it is the only one that the average person will see and feel. Do I have a soft, regular bowel movement every day? If so, my colon must be functioning okay. Well, not so fast. Now we know that the colon is a hot bed of thriving community of densely-packed bacteria. We know that most of these bacteria are our friends and when they are fed purposely with the right foods and plant fibers that they need, some truly spectacular health benefits occur.

The Importance of Dietary Fiber

There are now at least 13 known, medically researched health benefits when the right types of fiber are ingested. These benefits can and do occur in the otherwise healthy person when adequate amounts of fresh vegetables, fruits, whole grains or fiber supplements are used. More specifically, most of these benefits occur when significant amounts of the newly discovered prebiotic fibers are consumed.

Prebiotic Fiber Health Benefits

• Increase probiotic growth
• Improve bowel regularity
• Increase calcium absorption
• Increase bone density
• Enhance immune system
• Reduce colon polyp/cancer factors
• Reduce triglyceride level
• Reduce cholesterol level (only psyllium fiber)
• Reduce allergies and asthma
• Control appetite and weight
• Increase good colon bacteria
• Decrease bad colon bacteria
• Decrease flatus smell

Nutrition Facts

Fiber is not digested as a calorie as it moves through the small intestine. However in the colon, under the influence of the bacteria that live there, some beneficial energy and calories are produced. However, this is a very small amount and the health benefits of dietary fiber far outweigh the few extra calories produced in the colon.

Fiber can best be understood as insoluble and soluble. Insoluble fiber does not dissolve in water and is not used by colon bacteria as a food or fuel. However, it does hand onto water avidly and so promotes regularity and a soft bowel movement.

Soluble fiber, on the other hand, does dissolve in water, and to varying degrees, is the fuel that promotes the best growth of the best colon bacteria. The soluble fibers, which by far have the most science behind them, are called prebiotics. These prebiotics, especially the ones known as inulin and oligofructose (FOS) have the most research.

You are referred to Prebiotics for further details on this key part of the fiber picture. To get a list of any foods and of the insoluble and soluble content.

Fiber in the Healthy

Eating fresh vegetables, fruits and whole grains is a mantra we have all heard forever – from our mothers, friends and the media. In the past, we didn't know why. Now we do. All plant material is a mix of soluble and insoluble fibers of many types and different percentages. When a variety of these foods are eaten on a regular basis, you are almost certain to get the right combination of insoluble, soluble and prebiotic fibers. 25-35 grams a day is the goal. When this happens and when other health parameters are followed – i.e. no smoking, adequate exercise, no stress, etc., then the best outcome and health benefits can be expected. Studies on people who consume this type of a high fiber diet as part of their overall health care plan simply live better and longer than those who do not.

Fiber in Irritable Bowel Syndrome (IBS)

IBS is a chronic disorder of the bowel, principally the colon. It is now known that there are numerous factors that contribute to IBS and its symptoms, such as genetics, diet and stress. Recent research has shown that the bacterial makeup within the colon is different in IBS people than it is in others. This means that there are different bacterial species and numbers of bacteria in the colon. We still do not know what this means. However, we do know that the bacteria within the colon rely on the foods we eat and especially the food fibers for their own health. So, changing the colon bacterial makeup may make sense for some IBS patients. This needs to be done carefully so as to avoid gas build-up.

Fiber and Colon Polyps/Cancer

A significant factor leading to colon polyps and cancer is in your genes. You can not change your genes so if anyone in your family or blood relatives has had colon polyps or cancer, you need to see your physician and get surveyed for this preventable cancer. Colon cancer can be prevented if polyps are removed before they get big. It can be cured if a colon cancer is found early. Diet is next. The regular ingestion of 25-35 grams of fresh vegetables, fruits and whole grains is the key. When significant amounts of plant fibers are ingested, particularly the newly discovered prebiotic fibers, it seems to lead to a reduction in certain carcinogenic (cancer causing) factors in the colon. This has been shown in animal and some early human studies.

Fiber, Cholesterol and Triglyceride

We have known for many years that a diet low in saturated and trans-fats, as well as high in fresh vegetables, fruits and whole grains is critical to maintaining a good cholesterol and triglyceride blood level. Other health factors such as not smoking, exercise, normal weight and lack of stress are equally important. Regarding fiber, we know that two fibers are helpful in managing and preventing heart disease and atherosclerosis.

Psyllium is a plant fiber that has long been used as a bulking agent. It comes in many dietary supplements over the counter. It has been found that when 7 grams of psyllium is ingested each day, the blood cholesterol can fall. So, if the cholesterol benefit is what you want, then you need to increase the dose. Our Prebiocil product is a mix of psyllium, prebiotics and wheat bran. The psyllium dose is 3.5 grams so you would need to add additional psyllium to get the full cholesterol benefit.

Prebiotics are the second fiber. Triglyceride levels generally fall when weight is reduced and simple carbohydrates and sugar are restricted in the diet. Prebiotics can contribute to triglyceride control.

Fiber Gas and Flatus

Most colon gas and flatus comes from the bacteria that grow in the bowel. The normal passage of flatus is 15-20 times a day, less in females and in those who just eat less food. However, there is now a great deal known about which bacteria produce the gases. Some make the odorless hydrogen and methane gases. Others make the smelly sulfide gases. Fiber can be a factor here.

Fiber and Diverticulosis

Prolonged, vigorous contractions of the colon, especially in the left side of the abdomen, may result in diverticulosis. This increased pressure causes small and eventually large ballooning pockets to form. When these pockets become infected, diverticulitis occurs, a nasty infection. In the past, physicians thought that seeds, nuts and popcorn could rattle around inside these pockets and cause damage. I, personally, never bought into this idea and had always recommended these foods because of their high fiber content. Now, science has shown that seeds, nuts and popcorn not only do not cause diverticulosis and its problems but also are good for you as a fiber source. The important consideration for patients with diverticulosis to know is that food and fiber supplements increase stool bulk and thereby reduce the colon pressure and development of diverticulitis.

Fiber and Inflammatory Bowel Disease (Crohn's Disease and Ulcerative Colitis)

In the past, there was not too much we could tell these patients about their diet. We would recommend trying almost any food and then evaluate the individual response. If the symptoms did not worsen, then it was okay to use that particular food. Now, there is considerably more known about diet in dealing with Crohn’s disease and ulcerative colitis. In particular, plant type foods such as fruits, vegetables, and whole grains, seem to be helpful. The newly discovered prebiotic plant fibers, especially, have come under scrutiny by medical researchers. In some instances, these prebiotic fibers may show benefits for patients with inflammatory bowel disease conditions.

Fiber Supplement

Most people take fiber supplements for one reason only. They want to have bowel regularity including a soft, easy-to-pass bowel movement. Beyond this, they simply don’t think too much about their lower bowel or colon. Soft regularity is a goal that every gastroenterologist wants for their patients. This occurs when enough fiber, especially the insoluble type, is ingested. This includes the fiber, psyllium, which is not available as a food but only as the fiber supplement. Psyllium contains mucilage and, along with most insoluble fibers, retains water and so promotes soft regularity. However, the soluble fibers play a role here as well. These fibers, including the newly discovered prebiotic soluble fibers, promote regularity by dramatically stimulating the growth of good colon bacteria. You add the bulk provided by the growth of good colon bacteria to that of water retaining insoluble fiber and you get the full fiber benefit.

The prebiotic soluble fibers provide a host of health benefits you cannot feel but are occurring nevertheless. These act very much like vitamins in the sense that you cannot feel them working in your body, but you know that science has shown their good health value.

Special Considerations

Select these foods for maximal fiber benefit.

• Whole grain breads and rolls so as to get the fiber along with its vitamins and minerals.
• Fresh fruits, including skin and pulp. Wash fruits thoroughly to remove any residual pesticides or buy organic.
• Dried or stewed fruits, such as prunes and apricots.
• Root vegetables such as carrots, turnips and yams, which are also rich in antioxidants.
• Cruciferous fresh vegetables such as broccoli, Brussels sprouts and cabbage. These high fiber foods also contain sulforaphone (search it on Google), a strong anti-cancer agent.
• Cereals – Many cold cereals will contain sugar, evaporated cane juice, which is nothing but sugar, or high fructose corn syrup (HFCS). I refer you to my essay on sugar and HFCS. These are added calories that are used simply because the public will usually not buy a non-sweetened cereal. Read the labels. I would recommend avoiding cereals with these sugary sweeteners or other ingredients you do not recognize.
• Finally, when 25-35 grams of total fiber a day is hard to reach, you can always use Prebiotin or Prebiocil supplements for significant amounts of fiber with both health benefits as well as soft bowel regularity.

The thriving healthy mix of bacteria within the colon does not happen without the production of some gases. Most of these gases are odorless - hydrogen, oxygen, carbon dioxide and methane. Nitrogen is also present from swallowed air, which then moves down into the colon. So, bacteria produce most of the gases that are passed as flatus. The tiny amount of the remaining gases are the sulfide ones. These are the smelly gases that are made by just a few species of bacteria specialized for this process. These rascals rely on sulfur in the water, food, beverages, and indeed, some medications we swallow to make these sulfide gases, including hydrogen sulfide.

What Is Normal?

Believe it or not, there is really a limited amount of information in the medical literature on this socially important question. Everyone will have her or his own idea of what normal is. Here is some general information that medical texts provide.

• The amount of colon gas produced per day ranges from one pint to several quarts.
• The number of flatus passages per day may be as low as 7 in females and up to 20 or more in males. An average is probably 10-13 flatus passages per day.
• Men create more colon gas than females.
• So do smokers. Don't ask why. We don't know.
• Beer drinkers have smellier flatus, probably because most beer contains significant amounts of sulfur.

Plant Fiber

There are two main types of fiber, insoluble and soluble, and almost every plant will have some of each. Insoluble fiber does not dissolve in water, is not acted on by colon bacteria and so does not create colon gas. It is an important fiber, however, in that it hangs on to water within the colon, promoting a larger, bulkier stool and improved regularity. The second type of fiber is soluble, meaning it does dissolve in water and is fermented by colon bacteria. Some of these bacteria, then, create colon gas.

Most plants have both fibers to varying degrees. As examples, the fiber in wheat is mostly insoluble while those in oats and beans are mostly soluble. A special type of recently discovered soluble fibers are the prebiotic ones, especially inulin and oligofructose. These fibers have had a great deal of research done on them lately and multiple, very significant health benefits have been found to occur with them. Still, they are soluble and, as such, do produce colon gas just like all soluble fibers will if too much is taken.

The key is to get a good balance of these fibers. The recommended total fiber intake per day is 25-35 grams, depending on your sex, age and weight. At this level, multiple health benefits occur. However, if excess colon gas and flatus is the problem, then cutting back on soluble fiber should be done first.

Insoluble Fiber

As noted, this fiber, also known as roughage and bulk, does not dissolve in water but paradoxically does hang onto water in the large bowel. This creates a larger, softer and bulkier stool. It promotes regularity and seems to be associated with reduced chance of getting colon polyps and cancer, as cancer inciting agents such as carcinogens are swept through the bowel in a more rapid manner. In addition, it may promote weight loss and enhances diabetic control. These fibers are not fermented by colon bacteria and so do not produce colon gas. Foods that are particularly high in insoluble fiber are:

Soluble Fiber

This plant fiber does dissolve in water. In the colon, it provides food for the enormous numbers of bacteria that thrive there and, in so doing, provide many health benefits. Those fibers also promote regularity by increasing the growth of the colon bacteria. However, soluble fibers are the ones that some coon bacteria metabolize and so produce some colon gas. Foods that are particularly high in soluble fiber are:

Flatus Odor and Sulfate

Sulfate is the culprit. It is also a very necessary element in the diets as our body needs it for many functions. The problem with noxious flatus odor is that certain bacteria in the colon make sulfide gases in very tiny amounts, but certainly enough to be noticeable. It is pretty simple. The more sulfate you ingest, the more of it is available for colon bacteria to make sulfide gases. So where is the sulfate we ingest?

• Drinking water - up to 20% or more may come from drinking water, depending on where yours comes from. City water is monitored so there won't be too much, but well water can vary significantly.
• Beverages - beer, red and white wine, cider, apple, grape and tomato juice, and even cow's milk have significant amounts of sulfate.
• Foods - the following have moderate amounts of sulfate
  

  almonds breads cruciferous vegetables - broccoli, cauliflower, Brussels sprouts, cabbage dates dried apples, apricots - dried fruits are very high in sulfate

  wheat pasta peanuts prunes raisins

• Animal Protein - There are only two amino acids, methionine and cystine, that contain sulfate but these are present in all animal products. The more meat, fish, and poultry you eat, the more sulfate enters your colon.
• Supplements - chondroitin sulfate, glucosamine sulfate and MSM (methylsulfonylmethane) are used by many people for bone and joint disorders. These have significant amounts of sulfate. So does carrageenan, used as a thickening agent in many prepared foods. Read the labels.

So the first step to controlling flatus smell is to moderate the amount of sulfate containing foods and supplements you take. The second step is to acidify your colon.

Colon Acidity and Prebiotics

A little known fact, even to those in the medical field, is that the sulfide producing bacteria in the colon can't grow in an acid environment. So, the trick is to acidify the colon by providing certain plant fibers that other good bacteria use to make acidic substances called short chain fatty acids. These fatty acids are a food source for the colon's own cells. The plant fibers that do this best are the prebiotics. These can and should be obtained in certain foods as listed in prebiotics. These can also be obtained in our prebiotic supplements. My own research on family and friends shows that while these prebiotic fibers will not change the amount of colon gas, they will reduce and even eliminate the malodorous flatus smell. You should use enough to reduce or stop the smell but not so much as to get too gassy. So, to reduce noxious flatus smell:

So, to reduce noxious flatus smell

• Reduce sulfates in beverages, food, dietary supplements and pills
• Use prebiotic foods or our supplement prebiotic products to acidify the colon.

Final Flatus Factoids

• If you have no or little flatus, then you likely are not getting an adequate amount of soluble prebiotic fiber in your diet. The good benefits of these fibers can't be obtained without a minimal amount of gas production.
• Chewing gum - When you chew gum, you swallow more often and some air goes down into your stomach with each swallow. What you don't belch up goes into the colon, where it can contribute to flatus.
• Beans contain special types of carbohydrates that some colon gas forming bacteria love. These carbs are not part of the prebiotic family that are so good for the colon and for general health. However, beans are a great source of protein and other fiber, so it can be dilemma for some people. Soaking and/or overcooking beans may help reduce gas formation. Do the experiment and see.
• Beano is an over-the-counter product touted for helping reduce flatus. It is an enzyme that works only on the carbohydrate in beans and only if it mixes with the chewed up beans in the stomach. So, you need to take the pills, and usually a lot of them, while you are eating beans. You can try taking the pills after eating but the results may not be as good.
• Gulping food or eating fast may result in more air being swallowed, which results in more of this air in the colon. So, slow down and chew your food well.
• Over-the-counter remedies - Gas-X and other similar preparations are simethicone, which is a chemical that breaks down small intestinal bubbles into big ones. I m not sure of the benefit as it does not get rid of gas. Charcoal tablets are reputed to absorb the bad sulfide smell. It has never been proven very well. Reducing sulfur in food and acidifying the colon with prebiotics foods and supplements makes more sense.
• Odor eating underwear - Yes, you can get these online. They seem a bit of a stretch and inconvenience for a physiologic event that can be controlled in other, more natural ways.

Summary

The amount of colon gas and flatus can be controlled by modifying the amount of soluble fiber in the diet. You should not eliminate soluble fiber entirely because it provides so many health benefits to the colon and body.

The smell of flatus can be controlled by reducing the amount of sulfur containing foods and beverages and by making the colon more acidic using an adequate amount of prebiotic soluble fiber.

So, it is a balance. It is recommended to use enough soluble fiber so that your colon gas and flatus is tolerable to you. When the noxious smell of flatus is gone, then that is the right dose.

IBS is a very common disorder.
The large bowel or colon is the site of many beneficial bacteria. However, the colon is the site for many of the symptoms in IBS patients. Since this organ is where all fiber and other food remnants arrive, it would seem logical that some parts of food we eat might play a role in the symptoms of IBS, which for the most part, are a reflection of an overly sensitive colon.

IBS is currently seen as falling into several major types. Patients will frequently overlap their symptoms or even swing from one type to another. In each case, the diet may play an important role. So there is always some experimentation that each patient must undertake to see which dietary changes work best.

Abdominal Discomfort, Cramps, Bloating

The gut has been called the second brain because it has so many nerve cells within it. IBS patients have an increased nervous sensitivity built into their intestinal tract. This means that minor changes in the way the intestines contract can be perceived as discomfort, whereas in other people it is not. At times, there may be excessive production of colon gas resulting in bloating and discomfort. It is important that you understand how this occurs, namely that colon bacteria ferment soluble plant fibers in the food you eat and some of these bacteria will create harmless gases. You need to understand the difference between soluble fiber and insoluble fiber in your foods.

All fiber goes through the small intestine unchanged. Soluble fiber as is found in foods such as oats, beans and fruit pectins is fermented by the colon bacteria. It is used as a food by these bacteria which, in turn, provide significant health benefits. Some benign colon bacteria will create intestinal gases, mostly hydrogen, which then can move on down and become flatus. Insoluble fiber, on the other hand, is not fermented by colon bacteria and is evacuated relatively unchanged. No colon gas occurs with insoluble fiber.

Constipation Dominant

Constipation occurs when the colon just does not contract well enough or often enough. The stool within it becomes dehydrated and hard. Why does the colon become so lazy and what can be done about it? The diet may be important. Insoluble fibers such as wheat and wheat bran are not fermented by colon bacteria so they do not produce colon gas. At the same time, they retain water and create a large, bulky stool. This, in turn, often stimulates the colon to contract and provide easier evacuation. The first step then is to gradually increase the amount of insoluble fiber up to 10-15 grams a day or even more.

Soluble fibers, on the other hand, are trickier since they are used by colon bacteria as a food source and some of these bacteria make colon gas. Still, these fibers, especially the newly discovered prebiotic ones, produce many benefits within the colon. So, the IBS patient should eat enough soluble fiber to create its health benefit but not enough to produce crampy bloating and flatus.

Methane Constipation

Methane is just one of the gases in the colon along with hydrogen sulfide (odor), hydrogen, carbon dioxide and oxygen. There is some early research that suggests that the colon gas, methane, may promote constipation. Prebiotic plant fibers can change the acidity of the colon to an extent that these particular methane producing bacteria can't grow. Were I still in practice, I would encourage my constipation dominant IBS patient to eat prebiotic containing foods. Or they could take prebiotics supplement powders in gradually increasing doses - 1 gram a day for a week, then 2 grams and so forth. If excessive colon gas and bloating or cramps occur before constipation improves, then the test did not work. If it did, then that amount of prebiotic food or supplement is right for you. A signal to look for is to evaluate the malodorous sulfide smell of your flatus. Like the methane producing bacteria, the bacteria that make these sulfide gases also can not grow in an acid environment. If your flatus has no or little smell, your colon may be at the right acidity and so prevent the methane producing bacteria from growing.

Diarrhea Dominant

There are many causes of diarrhea. Your physician will want to be sure there is not a correctible cause present. For instance, some patients chew sugar free gum, which is high in the sweetening agent, sorbitol. This can lead to diarrhea. Read the labels. Others may have lactose intolerance, meaning they don't digest the milk sugar, lactose. The lactose ends up in the colon where it can promote colon gas and diarrhea. There may be chronic infections, such as the parasite, Giardia, residing in the small bowel. Celiac sprue may be a concomitant or even the major problem. When all of these and more are ruled out, then diarrhea dominant IBS can be diagnosed with confidence.

The next step is to consider the types of fiber in your diet. Increasing insoluble fiber in the diet or with a dietary supplement is worth a try as these can bulk up the stool which, of course, is desirable. Soluble fibers can aggravate diarrhea. However, they, along with probiotic bacteria, can also change the bacterial makeup of the colon in such a beneficial way that it may reduce the diarrhea.


I suggest gradually increasing the insoluble fiber in the diet up to 10 grams or more a day. Following this, I would add prebiotic fibers, either in foods or a dietary supplement in very gradual increasing doses. If there were no change in symptoms, then I would add a probiotic at the direction of your physician. There is no secret here. What works for one IBS patient with diarrhea may not work for another. Judicious trial and error is recommended.

Colon Bacteria in the IBS Patient

We, in medicine, are in a new era regarding what we know about the colon and its inhabitants. What we have known for a long while is that the density and numbers of bacteria within the human colon are greater than any other place in the animal kingdom or, in fact, any place in the world. There are more bacteria within the colon by a factor of 10 than there are cells in the entire body. This is amazing! There is likely a reason and, yes, a good healthy reason for this. We have always thought that there were around 400-500 different species of colon bacteria. We were wrong. The number just discovered in 2007 is closer to 1,000 different species.

A key and likely a very important fact, again just discovered in 2007, is that IBS patients have a significantly different colon bacterial makeup than those people without IBS. This has been a startling finding but, thinking it through, it should not have come as a great surprise. Bacteria flourish in the colon and they provide huge numbers of benefits for us. They rely on the foods we eat and what we used to call waste products for their health. However, in some way they may be a problem as well. Can changing the bacterial makeup of the colon change the symptoms in IBS patients? This is a key question. A recent research study showed that a certain probiotic formula may reduce the symptoms of cramping and bloating in some IBS patients. We will await more research on what these interesting findings mean for the IBS patients.

Changing Colon Bacteria

This may be difficult but not impossible. A change in the foods you eat is central.

Gradually reduce animal foods - meat, poultry, fish to a more balanced diet with increasing fresh fruits and vegetables. You can
Add probiotics to your diet. There is no consensus yet on which are the best ones. There is still much research being done. The three types of bacteria which have been studied most are the Bifidos (Bifidobacterium), the Lactos (Lactobacillus) and streptococcus. You can get these in many low calorie dairy products and yogurt as well as over-the-counter pills.

Increase prebiotics in the diet with specific foods that contain them. The main ones are inulin and oligofructase. North Americans generally have a very low consumption of these, getting most in wheat and onions. An easy way to add prebiotics is with a dietary supplement .

Summary

There are no specific and right answers for every IBS patient. There will always be some trial and error necessary to see what is right for you. Still, there are some general principals that may apply to most patients.

1. Gradually reduce animal protein, especially red meat and increase the vegetables and fruit content proportionally. Select a balanced mix of soluble and insoluble fiber, aiming for 25-35 grams a day.
2. You can try adding a probiotic. The product with some evidence behind it for improving cramps and bloating is VSL#3. There are likely other healthy probiotics that work but we just don't have the evidence for them yet. There are likely beneficial bacteria in many yogurt and dairy food preparations. The ones that have been best studied are the Bifidos (Bifidobacterium), Lactos (Lactobacillus) and certain streptococcus species. Always check with your physician before using probiotics.
3. Increase prebiotics fibers in the diet by eating specific foods (Sources of Prebiotics) and/or a supplement .

Evidence based care is something we in medicine always seek. It means that each treatment we select is carefully measured with evidence to be sure that it is helpful. With medications, in particular, we insist that the benefit strongly outweigh the risk. However, there are many areas of medicine where the final data is just not there, so physicians do the best they can, using the available research as a guide and always assessing any downside risk to a particular treatment.

Diet for ulcerative colitis falls into this uncertain area because the disorder is an inflammatory one of the colon. This is where the fiber and food residue we eat ends up. Is it not possible that the foods we eat or don't eat may be part of the problem? Studying this is difficult because animal and plant food contain hundreds, no, thousands of different chemicals. When these multiple natural substances interact in our intestines with the over 1,000 different bacteria in the colon with a total bacteria count of many trillions, some very strange things may occur, both good and bad.

I present two sections. One is the standard dietary recommendations that are found in our gastroenterology textbooks and on the web site of our prestigious organizations such as Crohn's and Colitis Foundation and The Mayo Clinic.

The second section, Additional Views on Dietary Therapy for Ulcerative Colitis, is a learned look at newer things that are happening in the ulcerative colitis dietary field. Some of it is close to being evidence based. All of it has some science behind it. Very little or none of it has much risk. I view ulcerative colitis care as a partnership between the physician and the patient. The physician brings the best science and medication to the table. Patients learn and then make the necessary changes in their diet.

Standard Dietary Recommendations

The key to good health for all ulcerative colitis patients is to work with the physician to get the disease under control, usually with medications. Without this basic achievement, the full benefit of any dietary program becomes difficult to achieve. The following are crucial key goals:

• Maintain a good weight by ingesting enough calories, minerals and vitamins.
• Protein - The amount of protein you need per day will depend on your weight, age, exercise, pregnancy and, especially, on the activity or seriousness of the colitis process. The formula for the healthy person is 0.36 grams of protein per 1 lb of body weight. For the 150 lb person, the number is about 54 grams of protein.
  
  If you do serious exercise, if you are a large person or if your ulcerative colitis is active, you may need additional protein. Much of this protein can and should come from vegetables and fruits. Many nutritionists and physicians think we, as a nation, eat too much animal protein. For ulcerative colitis patients, in particular, too much red meat may increase the odoriferous gas, hydrogen sulfide, in the colon (see below).
• Carbohydrates - In general, you should avoid the low carb craze. The bulk of your calories should come from complex carbohydrates as in whole grain, brown rice, and fresh vegetables and fruits. Plain sugar, high fructose sweeteners, as in soft drinks and many of the processed foods, have large amounts of these simple sugars that do not have much health benefit.
• Fats - The body needs a certain amount of fat, especially the mono and unsaturated vegetable oils, such as olive oil. The high saturated fats in meat, creams, and all trans fat products should be used sparingly.

Vitamins

• Multiple vitamin with minerals - Many authorities recommend a daily multiple vitamin for the general population. Patients with ulcerative colitis need to discuss vitamin/mineral use with their physicians.
• Vitamin D - Vitamin D is important for bone health. Ulcerative colitis patients may be particularly susceptible to early osteoporosis, especially if they take steroids such as prednisone. Newer information has shown that there are vitamin D receptors or attachment points on the cells of many organs in the body including the colon. There is likely a reason for this. Additionally, vitamin D deficiency has been found to be much more widespread than originally thought. Some authorities are, therefore, recommending 800-1200 IU/day rather than the standard 400 IU/day. Check with your physician.

Minerals

• Calcium - Even if you live in the sunbelt and your skin make lots of vitamin D, you still need an adequate amount of calcium by mouth. Milk, dairy products, shellfish, green leafy vegetables, canned fish and, if needed, calcium supplements are the main sources. The goal is at least 1200 mg of calcium a day.
• Iron - Many ulcerative colitis patients have low iron levels which may lead to anemia. Your physician may check the iron blood level periodically.
• Selenium - Some authorities believe that selenium acts like an antioxidant in the body, providing health benefits. Certain medical studies show that selenium may be low in ulcerative colitis patients and that they do better when they take a selenium supplement. 200 mg per day is recommended. Check with your physician.

Fish, Fish Oil and Herbs

• Fish and flaxseed oil - Fish oil has been found in medical studies to be helpful for some ulcerative colitis patients. Flax seed oil has the same type of oil as in fatty fish. We still do not know the full benefits. Fatty fish (blue, mackerel, salmon, and sword), fish oil capsules and flaxseed oil can all be recommended. In some of the published studies, the patients took up to nine capsules per day of fish oil. This is a lot and could give you a fishy regurgitation smell.
• Herbs - Herbs are dried plants that are ground into powders. Because something is labeled an herb, does not transform it into a magical medicine. All plants contain hundreds of different chemicals, many of which are still not known to science. We cannot be sure what effect these known and unknown chemicals have on the inflammation process of ulcerative colitis. Until good data is available on the benefits of herbs, it is best to avoid them.

General Advice

Here are the general recommendations that we gastroenterologists generally give to our ulcerative colitis patients.

• Smaller, more frequent meals - The lower intestine may handle foods better when smaller portions arrive there more frequently. Your body will let you know if 4 or 5 smaller meals work better for you.
• Fluids - Adequate fluid intake is a must if diarrhea is a significant symptom. For most people, the body tells you when you are thirsty and need fluid. Some authorities recommend eight glasses of water per day. The evidence for the need of this much water is sketchy.
• Caffeine - Caffeine in coffee, tea, soft drinks, and,power drinks, stimulates the colon to contract and promotes more bowel movements. Caffeine by itself is not known to damage the intestine or colon.
• Alcohol - Red wine and beer contains sulfates and may contribute to the malodorous smell of flatus.
• Allergies and food intolerance - True food allergies (hives, trouble breathing) is rather uncommon. Shellfish and peanuts can induce such serious problems in the allergic person. However, intolerance to certain foods is very common. If a certain food disagrees with you, avoid it.
• Junk food - Most fast food restaurants offer a variety of healthy choices. Dairy products, such as milk, milkshakes and yogurt are available. Pizza provides considerable protein and calcium.
• Lactose and dairy products - Milk and dairy products provide lots of good nutrition and calcium. If you think you are lactose intolerant, you may consider a simple test. Drink 16 oz. of fat free milk on a Saturday or Sunday morning and eat or drink nothing more. If symptoms of bloating, cramps or diarrhea do not occur in 3-4 hours, you likely are not lactose intolerant.
• Celiac Disease or sprue - This is a disorder whereby the gluten protein in wheat and certain other grains damages the small intestine. This disorder is much more common than we have thought in the past. The symptoms may be similar to those of ulcerative colitis. A simple blood test can usually screen for this disorder. Ask you physician about Celiac Disease.

Fiber

Fiber is a special consideration for ulcerative colitis patients. Food fibers are healthy and should be well understood so they can be used in an effective and healthy way. All plants rely on fiber for their structure. Each plant food has both insoluble and soluble fiber. Some will be predominantly one type or the other. For instance, wheat is mostly insoluble fiber, oats are about half and half and psyllium powder is 90% soluble. Our prebiotics powders are 100% soluble.

Insoluble fiber does not dissolve in water; it is not digested by the small bowel and is not fermented by colon bacteria. It does, however, retain water and so produces large, bulky stools. Soluble fiber, on the other hand, does dissolve in water. It is fermented by the colon bacteria and is used as a fuel source to maintain a healthy environment in the colon. However, if too much is taken, soluble fibers will promote harmless colon gas and flatus.

Discuss your food fiber intake with your physician. Fiber Content of Food provides specific information on the amount of soluble and insoluble fiber in most foods.

Additional Views On Dietary Therapy For Ulcerative Colitis Patents

Probiotics

Probiotics are bacteria in food such as yogurt, other dairy products and now in pill form. There are some early medical studies that show that certain types of probiotics given in pill form can favorably influence the course of ulcerative colitis. However, the study of bacteria in the colon is difficult. Here are a few facts. The human colon has the most densely packed collection of bacteria anywhere in the world. There are over 1,000 different types of bacteria and the total number of bacteria in the colon are many trillions. The commercial probiotic preparations use from one up to six different bacteria and usually claim to have 5-10 billion organisms per pill. This sounds like a lot. But compared to trillions, it is small. Still, there are some favorable medical studies coming out, so stay tuned to the probiotic field. It also should be noted that the bacteria makeup of the colon returns to its previous state 2-3 weeks after probiotics are stopped. You need to stay on then long term if they are effective. People with immune deficiencies, such as HIV, AIDS and chemotherapy, should probably not take probiotics. Otherwise, probiotics seem to be safe, although ulcerative colitis patients should always discuss this with their physician.

Prebiotics

Prebiotics are the soluble food fibers that feed the healthy bacteria in the colon. The term was coined in 1995, so the field is rather new. Researchers are evaluating many prebiotics, but only inulin and oligofructose have shown consistent results. The key thing that these two prebiotics and, hopefully, others do, is to stimulate the colon's good bacteria to grow. Inulin and oligofructose cause certain bacteria to produce acidic substances called short chain fatty acids (SCFA). SCFAs are used by the colon's own cells as a fuel source. They are what make the colon's own cells, the very site of ulcerative colitis, healthy. We still don't know just how this all works but simple reasoning would say that SCFAs are likely good for ulcerative colitis patients.

For a full essay on prebiotics, please click here.

Hydrogen Sulfide (H2S) - The Gas

The H2S gas is made in the colon. It is a nasty customer. It is mostly what gives flatus its foul smell. We avoid the smell when we can and make fun of it. But, there is nothing funny about H2S. Consider these facts about H2S, all medically documented.

• Half the normal population makes H2S gas in their colon. The other half makes methane gas.
• However, 90-100% of ulcerative colitis patients make H2S. That's an interesting fact, isn't it?
• H2S is a toxic gas. In higher doses, it can irritate the eyes. In even higher concentrations, it is as damaging as hydrogen cyanide. In the normal colon, there are cells that contain an enzyme that detoxifies the H2S gas.
• There is some evidence to suggest that this enzyme is deficient in ulcerative colitis patients, so that the H2S may linger and damage the colon wall.
• Most patients have ulcerative colitis in the left side of the colon where the H2S gas is mostly made.
• Certain bacteria in the left side of the colon use sulfur in our foods, water and especially in meats, to make the H2S gas.
• The good bacteria in the colon make certain acid substances, (see SCFA above) thereby acidifying the colon contents.
• Here is a possible key point. These H2S producing bacteria do not grow in an acid environment. Keeping the colon acid may be important.

Sulfate and Sulfides

Sulfate is a necessary element in the diet as our body needs it for many of its functions. However, the H2S gas producing bacteria in the left colon rely on ingested sulfur to make the sulfide gas, H2S. The more sulfate you ingest, the more of it is available for colon bacteria to make sulfide gases. So where is the sulfate we ingest?

• Drinking water - up to 20% or more may come from drinking water, depending on the source. City water is monitored so there won't be too much, but well water can vary significantly. You need to measure sulfate in well water.
• Beverages - beer, red and white wine, cider, apple, grape and tomato juice, and even cow's milk have significant amounts of sulfate.
• Foods - the following have moderate amounts of sulfate:
  • eggs
  • cheese
  • milk
  • dates
  • dried apples, apricots (dried fruits are very high in sulfate)
  • almonds
  • wheat pasta
  • breads
  • peanuts
  • cruciferous vegetables (broccoli,cauliflower, Brussels sprouts, cabbage
  • raisins
  • prunes
• Animal Protein - There are only two amino acids, methionine and cystine, that contain sulfate. These are present in all animal products, but especially in red meat. The more meat you eat, the more sulfate enters your colon.
• Supplements - chondroitin sulfate, glucosamine sulfate and MSM (methylsulfonylmethane) are used by many people for bone and joint disorders.

These have significant amounts of sulfate. So does carrageenan, used as a thickening agent in many prepared foods. Read the labels.

Summary

Were I still in gastroenterology practice, I would recommend that ulcerative colitis patients follow the guidelines in the first part of this section. Additionally, I would consider:

• Reduce sulfur-containing foods in the diet, especially red meat, cruciferous vegetables (broccoli, cabbage, Brussels sprouts) and sulfur containing wine and beer. Check well water for sulfur.
• Increase foods that are high in inulin and oligofructose.
• Consider using a dietary supplement to get a significant dose of the beneficial prebiotics, inulin and oligofructose, into the colon every day.

The goal is to make your colon more acidic and inhospitable for the H2S gas producing bacteria. If your flatus no longer has a malodorous smell, then the H2S producing bacteria likely are not growing.

One final point. This information has some research behind it. Some of it is not conclusive, but it is at this time the best we have. Finally, check with your physician. She or he knows your case best. This information is for background use only. Prebiotic supplements are not meant to prevent, treat or mitigate any disease.

Purpose

A diet of clear liquids maintains vital body fluids, salts, and minerals; and also gives some energy for patients when normal food intake must be interrupted. Clear liquids are easily absorbed by the body. They reduce stimulation of the digestive system, and leave no residue in the intestinal tract. This is why a clear liquid diet is often prescribed in preparation for surgery, and is generally the first diet given by mouth after surgery. Clear liquids are given when a person has been without food by mouth (NPO) for a long time. This diet is also used in preparation for medical tests such as sigmoidoscopy, colonoscopy, or certain x-rays.

Nutrition Facts

A clear liquid diet is not adequate in calories and nutrients. It should not be used for more than five days unless high-protein gelatin or other low-residue supplements are added.

Purpose

Wilson's disease is a hereditary disorder in which the body retains too much copper. Copper is a trace mineral in the body. This means it is essential for good health, but only a tiny amount is needed. When excess copper accumulates, it is stored in the eyes, brain, kidneys, and liver. Excess copper collecting in the liver causes cirrhosis of the liver, which is a serious, life-threatening condition. However, Wilson's disease is treatable.

Copper is found in different amounts in a wide variety of foods. Therefore, dietary restriction alone is usually not enough to control Wilson's disease. Medicines such as Cuprime and Depen (generic name: D-penicillamine) and Syprine (generic name: trientine) are used to help excrete excess copper with the urine. Still, it is helpful to avoid copper-rich foods as much as possible. The dietary intake of copper should be less than 1.0 mg per day.

Nutrition Facts

A low copper diet is generally adequate in all the nutrients necessary for good health. However, patients taking D-penicillamine may develop a deficiency of vitamin B-6 (pyridoxine), and the physician may prescribe a supplement of 25 mg daily.

Purpose

This diet helps to prevent a condition called "dumping syndrome," which occurs in some patients who have undergone stomach surgery. The symptoms include bloating, nausea, diarrhea, dizziness, weakness, sweating, and rapid heartbeat. They may occur 30 to 60 minutes after eating a meal and then again, 2 to 3 hours after eating.

The early symptoms are caused when concentrated sugar passes too rapidly from the stomach into the intestine. The body dilutes this sugar mixture by bringing fluid from body tissues into the intestine, giving a sense of fullness, cramping, and occasionally, diarrhea. The loss of water from tissues can produce a temporary drop in blood pressure, with resulting weakness and faintness.

The later symptoms are caused by the rapid absorption of sugar into the bloodstream, which raises the amount of blood sugar. A high level of blood sugar signals the body to produce more insulin. The excess insulin, in turn, drives blood sugar levels down. The low blood sugar (hypoglycemia) produces the weakness, hunger, and rapid heart rate that may occur about two to three hours after eating. This diet is really a regular diet with frequent small meals and reduced simple sugars.

Nutrition Facts

Depending upon individual tolerances and food selection, the Anti-Dumping or Post-Gastrectomy Diet is adequate in all nutrients according to the National Research Council's Recommended Dietary Allowances (RDA). Depending on the type and extent of gastric surgery performed, poor absorption of nutrients, vitamins, and minerals may occur to a significant degree. Some patients may become deficient in iron, calcium, folate, and B-12. The physician may prescribe vitamin/mineral supplementation and B-12 injections.

Purpose

Dysphagia means difficulty with chewing or swallowing food or liquid. To understand how this might happen, it is important to know something about how swallowing occurs. First, food must be chewed thoroughly. Then it is moved to the back of the mouth by tightening the cheek muscles and pressing the tongue against the roof of the mouth. From this point on the process becomes automatic -- it is a reflex that people do not actively control. In "rapid- fire" succession, the soft palate closes the nasal airway to prevent food from backing into it, the airway into the lungs is closed, and the esophagus (food pipe) relaxes allowing food and liquid to enter it. The muscular esophagus then contracts in a wave-like action, sweeping the food along into the stomach. A blockage or a malfunction anywhere in this part of the body or in the nervous system controlling swallowing can result in dysphagia. There are two types:

Esophageal dysphagia occurs when food/liquid stops in the esophagus. This happens most often because of consistent stomach acid refluxing (backing up) into the esophagus. Over time, the reflux causes inflammation and a narrowing (stricture) of the esophagus. Food and eventually liquids feel like they are sticking in the middle and lower chest. There may be chest discomfort or even real pain. Fortunately, physicians can usually dilate (widen) this narrowing, and there is now treatment available to keep it from returning. Cancer, hiatus hernia, and certain muscle disorders of the esophagus are less frequent causes of esophageal dysphagia. Solid food is usually more of a problem than liquids

Oropharyngeal dysphagia involves difficulty moving food to the back of the mouth and starting the swallowing process. This type of dysphagia can result from various nerve or brain disorders such as stroke, cerebral palsy, multiple sclerosis, Parkinson's and Alzheimer's diseases, cancer of the neck or throat, a blow to the brain or neck, or even dental disorders. Depending on the cause, symptoms may include drooling, choking, coughing during or after meals, pocketing of food between the teeth and cheeks, gurgly voice quality, inability to suck from a straw, nasal regurgitation (food backing into the nasal passage), chronic respiratory infection, or weight loss. Liquids are usually more of a problem in oropharyngeal dysphagia.

The first step in treatment is to make the proper diagnosis. This involves a medical history and various tests to find the cause of the dysphagia. Often a team approach to treatment is needed. Several types of health care providers -- physicians, registered dietitian, psychologist, speech pathologist, occupational therapist -- work together to develop the best program.

An important part of the treatment is helping the patient get adequate nutrition, while protecting against complications such as pneumonia from food or liquid getting into the lungs. Obviously, this requires a specialized diet. There are five different diet levels from puréed (level 1) up through modified regular food (level 5). The diets vary in texture and consistency, and are chosen depending on which would be most effective for a specific patient.

Nutrition facts

These diets are all nutritionally adequate. However, some patients may have difficulty taking enough fluid and food to get all the energy and nutrients they need. In this case, an adjustment to diet or treatment will be required.

Liquids

Fluids are essential to maintain body functions. Usually 6 to 8 cups of liquid (48-64 oz) are needed daily. For some dysphagia patients, this may present problems because thin liquid can be more difficult to swallow. In this case, fluid can be thickened to make it easier to swallow. However, close monitoring by the dysphagia team is required for anyone drinking less than 4 cups of thickened fluid a day or anyone not progressing to thin liquids within 4 weeks.

Calories

The greater problem for some patients is eating enough calories. The whole process of eating simply becomes too difficult and too tiring. However, calorie and protein intake can be increased by fortifying the foods the patient does eat.

• Fortify milk by adding 1 cup of dry powdered milk to one quart of liquid milk. Use this protein fortified milk when making hot cooked creamed soups, sauces, milkshakes, and puddings. Also add margarine, sugar, honey, jelly, or puréed baby food to increase calories.
• Add strained baby fruit to juices, milkshakes, and cooked cereals.
• Add 1 jar of strained baby meat to soup, such as strained chicken noodle soup. Also add strained baby meats to sauces and gravies, and mix with strained vegetables.
• Add juice to prepared fruit, cereal, or milkshakes.

Purpose

The full liquid diet is often used as a step between a clear liquid diet and a regular diet, for example, after surgery or fasting. It may also be used after certain procedures, such as jaw wiring. This diet may also be appropriate for patients who have swallowing and chewing problems.

Nutrition Facts

The full liquid diet is low in iron, vitamin B12, vitamin A, and thiamine. It should not be used for a long period of time unless vitamins, iron, or liquid nutritional supplements are added. This diet has 1800 mg of calcium, so extra calcium is not needed.

Purpose

Gastric bypass is a type of surgery in which the stomach is reduced in size by one of several methods. This smaller stomach is then reconnected or bypassed to the small intestine. Having a gastric bypass can help speed weight loss by making it difficult to eat too much food at one time and to feel satisfied after very small meals.

After a gastric bypass, the volume the new, smaller stomach can hold is reduced from about 1 quart to about 1 ounce, or 2 tablespoons. Over time, the stomach pouch will stretch until it can hold 4 to 8 ounces, or about 1/2 tm 1 cup, at a time. The shze of the opening created between the stomach and small intestine is smaller, too&emdash;roughly 1/4 inch wide&emdash;which slows the rate at which food is emptied fpom the stomach )nto the small intestine.

Gastric bypass is usually performed only after many other methmds of weight loss have been tried and failed. However, the surgery is not an end in itself. It is important to work closely with a physician and registered dietitian (R.D.) to start a program of new eating habits to ensure that weight loss is safe and successful. A regular, simple exercise program and psychological support are often recommended to create a better self-image and a whole new attitude to food.

Nutrition Facts

The gastric bypass diet is designed to bring about significant weight loss. Learning new eating habits and following the diet correctly will help to maintain this weight loss over time. In general, the gastric bypass diet includes foods that are high in protein, and low in fat, fiber, calories, and sugar. Important vitamins and minerals are provided as supplements.

Protein is the nutrient that the body uses to build new tissue. It is important to get enough protein right after surgery, to make sure that wounds heal properly. Over the long term, protein in the diet will help preserve muscle tissue, so that weight can be lost as fat instead. Foods like lean red meat or pork, chicken or turkey without the skin, fish of almost any type, eggs, and cottage cheese are high in protein and low in fat.

Sugary foods include candy, cookies, ice cream, milkshakes or slushes, soda pop, sweetened juices or gelatin, and most desserts. The gastric bypass diet is low in sweet and sugary foods for three reasons. First, these foods are high in calories and fat. Even in small amounts, they could make weight loss difficult. Second, eating sweet or sugary foods promotes "dumping," a reaction which can occur after the gastric bypass operation. Experiencing the unpleasant symptoms of dumping syndrome may limit the desire to eat sweet foods. Finally, most sweet and sugary foods don't provide many vitamins or minerals for the calories they take up&emdash;and since calories are so limited on the gastric bypass diet, it is important that every food contribute its fair share of nutrients.

Fat may be difficult to digest after gastric bypass surgery. Too much fat delays emptying of the stomach and may cause reflux, a back-up of stomach acid and food into the esophagus that causes heartburn. Fat may also cause diarrhea, nausea, or stomach discomfort. High-fat, fried foods and fatty meats are common offenders.

Fiber, found in foods like bran, popcorn, raw vegetables, and dried beans, is also limited on the gastric bypass diet. There is less space in the stomach to hold these bulky foods, and less gastric acid available to digest them. Some kinds of fiber could get stuck in the pouch itself, or block the narrow opening into the small intestine. Do not take any fiber pills or laxatives without the advice of a physician.

Vitamins & Minerals are an important part of the gastric bypass diet. Since the diet allows only small amounts of a limited variety of foods, it may be difficult to get enough vitamins and minerals from food alone. Deficiencies can develop in a matter of months. Iron, folate, vitamin B-12, and calcium are the nutrients most affected. Most physicians require their gastric bypass patients to take a multivitamin/mineral supplement.

The Gastric Bypass Diet

The gastric bypass diet unfolds in several stages, from "liquids only" to small meals of soft, high-protein foods. Meals on the new menu will be much smaller than normal, and the foods eaten must be very smooth in texture. On all stages of the diet, it is especially important to drink enough water, and to take vitamin and mineral supplements as prescribed.

1. Clear Liquids -- The first stage of the gastric bypass diet, clear liquids (meaning beverages that you can almost see through), usually lasts for a day or two after the operation. The clear liquid diet starts with sips of water, and then allows foods like sugar-free juice, diet gelatin, boullion or clear broth, and flat (no fizz) diet soda in small amounts, usually 2-3 ounces at a time.
2. Low-Fat Full Liquids -- If no problems are experienced with clear liquids, the gastric bypass diet advances to high-protein liquids like diet Carnation Instant Breakfast™, Ensure™, or Sustacal™. This stage of the diet is started before discharge from the hospital and lasts for 1 to 2 weeks. Most patients also begin taking a chewable multivitamin/ mineral supplement at this stage.
3. Soft/Purée Diet -- The physician will indicate when it is time to advance to the soft or purée diet. Some patients are able to start this diet after they have been out of the hospital for about two weeks. Others may need to wait longer. The purée diet includes very soft, high-protein foods like scrambled egg, low-fat cheese or cottage cheese, or blenderized lean meats like tuna fish, chicken, or pork. Some patients find it more convenient to use strained baby foods. It is important to make sure that all foods are puréed or extremely soft and smooth in texture.
4. Regular Diet -- The regular diet starts about 8 weeks or later after gastric bypass surgery. While this diet includes all 5 food groups, it is important to start with high-protein foods, like lean meats or milk, at every meal. Each meal or snack should be small, with liquids consumed in between meals. Ask a dietitian for advice on planning an individualized regular diet pattern.

Purpose

Gastroparesis is the medical term for delayed stomach emptying. During the process of digestion, the stomach must contract to empty itself of food and liquid. Normally, it contracts about three times a minute. This empties the stomach within 90-120 minutes after eating. If contractions are sluggish or less frequent, stomach emptying is delayed. This results in bothersome and sometimes serious symptoms, as well as malnutrition, because food is not being digested properly.

Gastroparesis may be caused by various conditions such as diabetes mellitus, certain disorders of the nervous system, or certain drugs. Often however, no cause can be found although a viral infection is suspected in some. Usually, the physician prescribes medication to stimulate the stomach to contract. The purpose of the gastroparesis diet is to reduce symptoms and maintain adequate fluids and nutrition. There are three steps to the diet.

Nutrition Facts

The STEP 1 Gastroparesis Diet is inadequate in all nutrients except sodium and potassium. It should not be continued for more than three days without additional nutritional support. STEP 2 and STEP 3 Gastroparesis Diets may be inadequate in Vitamins A and C, and the mineral iron. A multi-vitamin supplement is usually prescribed.

Purpose

The esophagus is the tube that carries food from the throat to the stomach. However, it is not just a simple tube. The lower esophagus has a specialized muscle around it that usually stays tightly closed, opening only to allow food and liquid into the stomach. It acts to prevent the reflux of stomach acid into the esophagus.

Symptoms occur when this specialized muscle weakens and allows stomach acid to splash up into the esophagus. These symptoms include heartburn, chest discomfort, and bitter fluid flowing up into the mouth. Chest discomfort can occur. If the stomach juice trickles into the breathing tubes, hoarseness, cough, and even shortness of breath can occur. This entire problem is called GERD (Gastroesophageal Reflux Disease). A number of factors, including certain foods, may cause the lower esophageal muscle to relax, causing GERD.

Nutrition Facts

A diet designed to prevent or reduce acid reflux is usually easy to follow. The basic food groups of cereals, vegetables, fruits, dairy products, and meats can be eaten with only a few limitations. So, this diet generally meets the Recommended Dietary Allowances (RDA) of the National Research Council. A vitamin C supplement may be needed if an individual does not tolerate citrus foods such as orange, tomato, etc.

Purpose

Gluten is the protein part of wheat, rye, barley, and other related grains. Some people cannot tolerate gluten when it comes in contact with the small intestine. This condition is known as celiac disease (sometimes called non-tropical sprue or gluten sensitive enteropathy).

Celiac disease is now clearly known to be genetically determined.  In other words, if you or your close relatives have a certain gene, then it is more likely that you will get celiac disease some time in your life.  Of great concern and interest is the fact that nine out of ten people with celiac disease do not known they have it.  A simple blood test can give the physician the first clue to this disease.

In patients with celiac disease, gluten injures the lining of the small intestine. This injury can result in weight loss, bloating, diarrhea, gas, abdominal cramps, and/or vitamin and mineral deficiencies. When patients totally eliminate gluten from the diet, the lining of the intestine has a chance to heal.

Gut Bacteria

The primary area of injury in celiac disease is the small bowel but there may be a relationship between what happens in the small bowel and the colon or large bowel.  There are very large numbers of bacteria in the colon. Most of these are beneficial and actually confer health benefits.  When these good bacteria thrive, they suppress the bad bacteria, which are present in the colon.  What has been found is that celiac patients have an altered make-up of bacteria in the colon which favors the unwanted bacteria.

Prebiotic Plant Fiber

A prebiotic is not a probiotic, which are beneficial bacteria taken by mouth.  These probiotics are present in yogurt, other dairy products and pills.  Prebiotics, on the other hand, are the necessary plant fibers that contain both oligofructose and inulin.  These two fibers are the main nourishment for the good bacteria that reside in the gut.  These fibers are rich in chicory root, Jerusalem artichoke, leeks, asparagus and others.  Gluten containing wheat and barley also contain these prebiotics.

Health Benefits from Prebiotic Fibers

There is now ample information in the medical literature to indicate that a prebiotic rich diet leads to demonstrable health benefits.  These include:

• Increased calcium absorption
• Stronger bones and bone density
• Enhanced immunity
• Reduced allergies and asthma in infants and children
• A lower blood triglyceride level
• Appetite and weight control
• Lower cancer factors in the gut

The Celiac Wheat-Prebiotic Dilemma

Nature has played a trick on celiac people.  Wheat and wheat products provide over 80% of the prebiotics that North Americans ingest.  Yet, celiac patients must assiduously avoid wheat, barley and rye.  How do they then feed their good colon bacteria and get the health benefits, as outlined above?  They must favor the other vegetables and fruits, as listed in the prebiotic section below.  Additionally, they should consider a gluten free prebiotic supplement such as Prebiotin.

Special Considerations

Removing gluten from the diet is not easy.  Grains are used in the preparation of many foods.  It is often hard to tell by a food's name what may be in it, so it is easy to eat gluten without even knowing it.  However, staying on a strict gluten-free diet can dramatically improve the patient's condition.  Since it is necessary to remain on the gluten-free diet throughout life, it will be helpful to review it with a registered dietitian.

The person who prepares the patient's food much fully understand the gluten-free diet.  Read food labels carefully:

• Do not eat anything that contains the following grains: wheat, rye and barley.
• At one time, oats were thought to contain some gluten.  It has now become apparent, however, that oats frequently were processed in machines that also processed wheat.  Most manufacturers no longer do this, although if there are any questions, a person should get reassurance from the manufacturer by mail, email or phone.
• The following can be eaten in any amount: corn, potato, rice, soybeans, tapioca, arrowroot, carob, buckwheat, millet, amaranth and quinoa.
• Distilled white vinegar does not contain gluten.
• Malt vinegar does contain gluten.

Grains are used in the processing of many ingredients, so it will be necessary to seek out hidden gluten.  The following terms found in food labels may mean that there is gluten in the product.

• Hydrolyzed Vegetable Protein (HVP), unless made from soy or corn
• Flour or Cereal products, unless made with pure rice flour, corn flour, potato flour or soy flour
• Vegetable Protein, unless made from soy or corn
• Malt or Malt Flavoring, unless derived from corn
• Modified Starch or Modified Food Starch, unless arrowroot, corn, potato, tapioca, waxy maize or maize is used
• Vegetable Gum, unless made from carob bean, locust bean, cellulose, guar, gum arabic, gum aracia, gum tragacanth, xantham or vegetable starch
• Soy Sauce or Soy Sauce Solids, unless you know they do not contain wheat

Any of the following words on food labels often mean that a grain containing gluten has been used.

• Stabilizer
• Starch
• Flavoring
• Emulsifier
• Hydrolyzed
• Plant Protein

The following are lists of various foods that do not have gluten, may have gluten and do contain gluten.

Prebiotic Plant Fiber Oligofructose and Inulin

Milk and Milk Products

Meat or Meat Substitutes

Breads and Grains

Fats and Oils

Fruits

Vegetables

Snacks and Desserts

Beverages

Soups

Thickening Agents

Condiments

Seasonings

Prescription Products

Sample Menu

The above sample diet provides the following: 1748 calories; 77 gm protein; 225 gm carbohydrates; 62 gm fat; 1577 gm sodium; 2934 potassium

Purpose

Iron is a mineral essential for life. Found in red blood cells, iron's primary role is to carry oxygen from the lungs to the rest of the body. Without oxygen, the body's cells cannot function normally.

If the body's iron stores become too low, an iron-deficiency anemia can occur. This is characterized by weakness, lethargy, muscle fatigue, and shortness of breath. In severe cases, a person's skin may become pale due to a lack of red blood cells in the body.

In adults, iron deficiency is most commonly caused by chronic blood loss, such as with heavy menstruation or intestinal bleeding from peptic ulcers, cancer, or hemorrhoids. In children, iron deficiency is usually the result of an inadequate iron intake.

Nutrition Facts

The recommended dietary allowance (RDA) for iron in healthy adults is 10 milligrams per day for men and 15 milligrams per day for premenopausal women. Premenopausal women's needs are higher than men's needs because women lose iron during menstruation.

It is generally easier for men to get enough iron than it is for women. Because they are usually bigger, men have higher calorie needs and will most likely eat enough food to meet their iron requirements. Women, on the other hand, tend to eat less. This makes it more difficult for them to meet their iron needs. It is, therefore, particularly important for premenopausal women to eat foods high in iron.

Pregnant women will need as much as 30 milligrams of iron per day. The main reason is because the unborn baby needs iron for development. As a result, it will draw from the mother's iron stores. This can quickly deplete a woman of iron if she is not eating enough iron rich foods.

The following table lists foods high in iron. In general, meat, fish, and poultry are excellent sources. Other sources of iron include beans, dried fruits, whole grains, fortified cereals, and enriched breads.

There are some instances in which a high iron diet can be harmful. For example, those suffering from hemochromatosis need to avoid iron rich foods. Hemochromatosis is a common hereditary disorder where the body loses its ability to regulate the amount of iron that is absorbed and stored. Without a regulatory process, dangerously large amounts of iron can build up. This can lead to severe damage to the liver, heart, and pancreas.

Chronic liveR disease, from many causes, can result in excessive amounts gf iron being stored in the liver. In rome instances, this actually aggravates the damage to the liver. In the treatment of chronic hepatitis C, for example, it is now known that reducing iron ctores by removal of blood actually improves treatment.

Purpose

Lactose is the simple sugar found in milk and milk products. It can also be found in a variety of other foods and even as a filler in some pills and capsules. The enzyme lactase, present in the lining of the small intestine, splits lactose into two simple sugars. These simple sugars can then be absorbed by the body and used as nourishment.

In infants, milk is the main part of the diet, so it is natural and normal for lactase production to gradually decrease as the diet becomes more varied. This tends to occur in childhood and adolescence in African Americans, Native American Indians, Hispanics, Arabs, Jews, and Asians. Northern European white races seem to keep lactase production the longest.

When lactase is absent, lactose passes through the intestine to the colon (large bowel), carrying extra fluid with it. In the colon, bacteria break down lactose into lactic acid and certain gases. Lactic acid is an irritant and laxative. It can cause symptoms such as bloating, diarrhea, abdominal cramps, and gas or flatus.

Lactase activity is reduced in people with certain intestinal conditions such as Crohn's disease and celiac disease (gluten enteropathy). Patients taking certain drugs and alcoholic patients may also be lactose intolerant. Finally, patients with surgical removal of part of the stomach or a large portion of the small intestine may need to reduce lactose in the diet.

It is important to remember that while lactose intolerance can cause quite uncomfortable symptoms, it does not cause damage to the intestine. The purpose of this diet is to eliminate lactose or reduce it to tolerable levels.

Nutrition Facts

Dairy products are important sources of calcium, riboflavin, and vitamin D. Some lactose-intolerant people are able to tolerate certain dairy products in small amounts, and their diets may provide enough of these nutrients. However, the physician or registered dietitian may recommend certain vitamin supplements and/or a calcium supplement for some patients.

Purpose

For a regular healthy diet, it is recommended that of the total calories eaten, no more than 30% should come from fat. However, certain diseases and medical conditions can make it difficult for the body to tolerate even that much fat, so a low-fat diet may help people with these conditions.

Gallbladder Disease: Bile secreted from the gallbladder helps the body break down and absorb fats. When gallstones or gallbladder diseases are present, a low-fat diet is often used to prevent complications.

Delayed stomach emptying (Gastroparesis) is a condition in which the stomach empties food into the intestine too slowly. This can cause bloating, nausea, and even vomiting. Normally, fat in foods delays stomach emptying, so fats make gastroparesis worse.

Diarrhea can be caused by many conditions. When it occurs, it can be aggravated by eating fatty foods.

Malabsorption of nutrients: Absorption is the transfer of nutrients into the bloodstream from the intestine. In some diseases of the pancreas and small intestine, patients have trouble absorbing nutrients from the diet, including fat. A low-fat diet may help to control symptoms until the cause of malabsorption can be diagnosed.

Fatty Liver: For a number of reasons, fat may accumulate in the liver. Fat is not normally stored in the liver, and in some cases this can cause damage to the liver. A low fat diet and weight reduction may be helpful.

Nutrition Facts

In most cases, this diet provides all the nutrients required by the National Research Council's Recommended Dietary Allowances (RDA). In some cases, however, the physician may prescribe supplements. Women of childbearing age and those people with malabsorption may need to take certain vitamin and/or mineral supplements.

Purpose

Protein is a nutrient needed by the body for normal growth, wound healing, and the ability to fight infection. People with severe kidney or liver disease often must limit the amount of protein they eat because their bodies cannot use the protein properly. Dangerous waste products can build up in the blood from eating too much protein.

The major food sources of protein are:

Highest Amount of protein

• Meat, fish, poultry, eggs
• Milk, yogurt, cheese, peanut butter

Small Amount of Protein

• Vegetables
• Starches such as breads, cereals, and pasta (the protein in these foods is of poorer but still good quality)

Trace Amount of Protein

• Fruits
• Fats
• Sugars

Nutrition Facts

For the healthy person, between 40-60 grams of protein are needed each day to achieve and maintain good health. This, of course, will depend on the weight and health of an individual. A person recovering from an illness or injury often needs more. It is satisfactory to eat less than this amount for a short period of time, depending on health and diet objectives. If you are instructed to begin a low protein diet, discuss with your physician the maximum amount of protein permitted. Use the following tables to calculate the amount of protein in your diet.

Purpose

A diet that avoids stomach irritants is for those patients who suffer from symptoms of peptic ulcer disease or non-ulcer dyspepsia. In peptic ulcer disease, the patient has one or more ulcers in the stomach or duodenum (the first part of the intestine beyond the stomach). Non-ulcer dyspepsia refers to these same symptoms but without the presence of an ulcer. These symptoms, which include discomfort or burning in the upper abdomen, often occur an hour or so after eating and may be relieved by milk, food, or antacids. In the past, diet was considered very important in treating ulcers. Now physicians know that foods do not actually cause an ulcer. There are a few foods, however, that can aggravate ulcer symptoms or delay healing.

Nutrition Facts

Depending on individual food selection, this diet meets the National Research Council's Recommended Dietary Allowances (RDA).

Purpose

Surgery is often needed to treat certain conditions of the colon (large bowel). Sometimes the surgeon must make an opening on the abdominal wall through which intestinal waste (feces) can pass. This surgery is medically known as colostomy and ileostomy. The opening itself is called a stoma. A lightweight, disposable bag is then worn over the stoma. This condition is often permanent. However, in certain cases it is a temporary detour that can be reversed at a later time.

There are two forms of this surgery where a bag may not be needed. Sometimes a rectal pouch can be created from the small intestine, forming a reservoir for the stool behind the stoma. A tube is put in place so the reservoir can be emptied when needed, usually once a day. This procedure is no longer very common. In another procedure, all of the colon is removed except for the last part of the rectum. A pouch ( Ileal-Anal Pouch) is created from the small intestine and it is attached to the rectum so liquid stool can pass normally through the anus (opening to the outside of the body) about 3 to 7 times a day.

After all of these surgeries, the stool consistency, amount, and frequency will depend on the type and amount of foods eaten. So, this diet is to help patients gain adequate control of their bowel movements.

Nutrition Facts

Generally, colostomy and ileostomy patients can easily maintain a balanced diet to provide all the vitamins, minerals and calories needed for good health. In those cases where certain foods have to be restricted to control stool patterns or stool consistency, the physician may prescribe a vitamin-mineral supplement.