Depression is a very common illness. It would be surprising if you did not know someone who has lived with depression since approximately 1 in 5 women and 1 in 10 men will experience a major depression at some point in their life. Depression is different than normal sadness or discouragement because it has a wider range of effects on feeling, thinking, and physical function and because, if not treated, it usually persists for weeks or months.

 

People who live with chronic diseases, such as IBD, are at increased risk of experiencing depression. There are probably many reasons for the increased risk. The losses and frustrations that come with living with a disease; the biological effects of inflammation (since many of the body's chemicals that increase immunity and inflammation also have effects on the brain); and the effects of medications, such as prednisone, may all contribute to depression.

 

Recognizing the symptoms of depression when it occurs is very important because depression usually responds well to treatment. Some of these symptoms may be hard to interpret when you have ulcerative colitis or Crohn's disease. Most people experience one or two of these symptoms some of the time, without being depressed. Some can be caused by physical illness without being depressed. However, if symptoms persist and seem out of proportion to your usual experience of illness, talk to your doctor about the possibility of depression.

 

 

If it is not treated, depression adds substantially to the burden of illness. People with chronic disease who are also depressed tend to experience more pain, fatigue, and other symptoms. Depression makes it harder to keep up your motivation to see the doctor when IBD symptoms emerge and to stick to your treatment plan. If you are depressed, you are less likely to be able to work and you are less likely to be effective in all of your efforts to cope with IBD. The result is that depression and IBD can make each other worse in a vicious cycle.

 

 

Depression can be effectively treated with antidepressant drugs or with certain forms of psychotherapy. Very often these forms of treatment are most effective if used together.

 

 

There are many effective antidepressant drugs available now. Your doctor can help you to choose the drug that is best suited to your situation.

 

Treating depression requires daily use of antidepressants for several months, often longer. However, depressive symptoms usually start to improve after taking an antidepressant for about 2 weeks, although it may take up to 12 weeks to feel the full benefit.

 

With modern antidepressant drugs, side effects (such as tremor, difficulty sleeping, or upset stomach) are usually not difficult to tolerate. Side effects are usually strongest shortly after starting a new medication or increasing the dose, and tend to settle down after a couple of weeks. Your doctor can help you to find a drug that is compatible with your IBD symptoms and its treatment.

 

 

Some forms of psychotherapy (talk therapy) are as effective as antidepressant drugs for treating moderately severe depression. Cognitive-behavioral therapy and interpersonal therapy, for example, has been found to be highly effective in many studies of depression. Other forms of psychotherapy may also be effective.

 

In cognitive-behavioral therapy, you learn to identify patterns of thought that tend to lead to depression or that tend to make depressive feelings worse. It is very common for people with depression to evaluate their experience in a way that leads to negative conclusions. Seeing things as black or white (all good or all bad), for example, means that many experiences and events are labeled as being bad, just because they aren't perfect. Many depressed people find that they pay close attention to negative or unhappy events and do not pay the same degree of attention to positive events, which tends to reinforce a pessimistic view. Patients work with their therapist to recognize their typical patterns of thought, to re-evaluate how accurate they are, and to develop alternative modes of thought. Typically cognitive-behavioral therapy occurs weekly for 3 or 4 months, sometimes longer.

 

In interpersonal therapy, patients work through, with their therapist, the feelings that are associated with an important life event linked to the current period of depression. Typical examples are grief over the death of a loved one, dealing with the mixed feelings of making a critical developmental transition (such as moving from living with family to living on your own), dealing with conflict in a partner relationship, or coping with social isolation. Interpersonal therapy also typically occurs weekly for 3 to 4 months, sometimes longer.

While stress does not cause Crohn's disease or ulcerative colitis, these conditions do cause stress for patients and their families. Coping with the pain and fatigue, as well as complicated decisions about treatment, clearly can be stressful, but some of the strongest sources of stress for people with IBD are less obvious.

 

Patient perception of the role of stress is also split. About 1 in 3 people with IBD believe that stress or psychological factors had something to do with getting the illness in the first place. About 3 in 4 people believe that stress affects the course of their disease.

 

In determining if stress is a factor in your IBD, try to distinguish between experiencing common gut symptoms and active inflammation (a flare of disease). An increase in symptoms does not always mean that the intestine is inflamed. You can experience increased fatigue, pain, or diarrhea for many reasons other than IBD. In fact, these symptoms of an irritable bowel are quite common in IBD even when there is no active inflammation. There is some evidence that once a person's bowel has been affected by repeated occurrences of inflammation and healing, it is more likely to respond to stress with diarrhea and pain, even if a flare of inflammation doesn't occur.

 

Until there is better evidence upon which to base decisions, the best policy seems to be to know yourself and trust your experience. If you believe from your own experience with IBD that the stresses in your life (or the way that you react to them) have an impact on your symptoms, then it makes sense to try to modify the ways that you respond to stress. If your experience is that your disease course doesn't seem to depend on what is happening in your life, then you are probably right.

Once considered by some health-care professionals as psychosomatic illnesses, we now know that Crohn's disease and ulcerative colitis are not caused by personality or other psychological factors. Although we have learned a great deal about the experience of living with inflammatory bowel disease, there is much that we don't yet understand about the relationship between mind and body. One thing is certain, if you have inflammatory bowel disease, you should pay attention to what is happening to you emotionally during the course of your illness and how the illness affects your life and your relationships.

 

The range of psychological issues relevant to IBD is large. Some challenges affect almost everybody with IBD to some extent. These include finding ways to live with the uncertainty inherent in the disease. Other common challenges are tolerating physical symptoms, such as fatigue and pain, and dealing with the ways the disease affects relationships, ranging from concerns about the way that embarrassment may affect day-to-day relationships to concerns about burdening friends and family at times when you need to depend on them. Some challenges may not affect all people with IBD but require extra attention, such as the role of stress in triggering a flare of inflammation or complications leading to depression.

 

Developing strategies for relieving and preventing stress and depression is important for managing IBD and improving your quality of life. The fundamental strategy is to know yourself. Think about your experience with health problems and with other challenges in your life. What have you done that has helped in the past? What has been less successful? Who in your life has been most supportive? Where can you turn for support? We'll help you answer these questions.

The symptoms of Crohns disease can be very difficult to live with, especially for those who suffer from severe attacks. Some have even withdrawn from active social lives and jobs because the attacks are too much to deal with. Add to this the fact that flare-ups are often unpredictable and it is easy to understand why some people's lives seem to be controlled by Crohns disease.

 

It is not just the symptoms of Crohns disease that are frustrating to deal with. The condition has no known cure because it is still unclear as to what causes it. In some cases, a person may not even think they suffer from the condition since they may go for long periods of time with no attacks. Others may suffer from attacks that are so severe that surgery is often the only option. Even then, there is no guarantee that the disease will not come back again.

There are many 'fickle factors' when it comes to this disease, which means that it often hard to differentiate if the person actually suffers from Crohns disease or something else. This is because the symptoms of Crohns disease are very much akin to other inflammatory bowel disorders or even ordinary tummy troubles. Especially for those who don't have attacks very often, it's easy to assume that they are simply suffering the effects of something that just didn't agree with them.

 

There are however a number of tell-tale symptoms of Crohns disease that can be easily recognized. First of all, an attack can often happen for no reason at all. These flare-ups are accompanied by abdominal pain, diarrhoea and fever. The patient will also experience nausea, loss of appetite and weight loss. Other symptoms include mouth ulcers, rashes on the skin and joint pain.

The fact that Crohns disease has no cure can be disheartening for many people but learning to live with the condition and even controlling it to a certain extent is something that is possible. Remember to always consult with a doctor about treatments for this disease- if you are about to start a new diet regime or are curious about alternate forms of therapy, clear it with your physician first. There are a number of treatment options currently available. The most common is medication- in some cases, where medication seems to have no effect, surgery is suggested.

 

Since the symptoms of Crohns disease severely dehydrate and malnourish the body after every attack, it is of the utmost importance to make sure the patient eats a healthy diet. This should be rich in vitamins and minerals, enabling the person to stock up on essential food energies so they can handle subsequent attacks. It is also a good idea to keep a food journal- when you suffer from an attack, make a note of what you ate prior to it. There are also a number of foods you can avoid right off the bat- these include things like alcohol, caffeine, milk products, sugary foods and products that contain gluten. This may be difficult for some people, especially when it seems like this kind of diet means cutting out all the foods that you love. However, this can make a world of difference to your health and your ability to weather further attacks.

 

Crohns disease is not something that should rule anyone's life. With the proper medication and diet, it is possible to lead a satisfying and fulfilling life without worrying about the symptoms of Crohns disease. 

While there is no standard diet for Crohn's Disease, diet modifications can help with symptom management. Diet restrictions are usually temporary during times of disease activity or during post-operative recovery periods.

 

Any diet modifications should be discussed with your doctor or dietitian. Changes to usual food choices need to be practical and realistic,while taking into consideration individual choices for reasons of religion, culture, ethnicity, beliefs, personal food preferences, tolerances, allergies, phobias, lifestyle, employment, sports, and financial considerations. This is why diet modifications aren't just about changing something like fiber in your diet; they are individualized recommendations that work for you as an individual living with IBD.

Many people are hopeful that nutrition may play a role not only in treating but also in preventing IBD. There are several areas of research that hold this promise.

 

 

Synbiotics refers to both prebiotics and probiotics, which contribute to maintaining the health of the intestinal bacteria and keep a sufficient number of 'good' bacteria in the intestine.

 

Bacteria in the intestinal tract are important factors in maintaining an appropriate balance within the body's immune system. The inflammatory response is actually a natural protective mechanism, but can be damaging if it is overactive or uncontrolled. It is thought that some of the 'good' bacteria normally present in the intestine contribute to maintaining the appropriate balance of the immune response.

 

There are food sources of both prebiotics and probiotics, but how much and how often you should eat these foods to experience benefits is not known.

 

 

Prebiotics are non-digestible carbohydrates that are fermented by colonic bacteria. The process of fermentation provides energy for the growth of 'good' bacteria, which, in turn, produce short-chain fatty acids, which are a fuel source for the cells lining the large intestine. Prebiotics also promote water and electrolyte reabsorption.

 

Prebiotics known as fructo-oligosaccharides (FOS) can be found in everyday foods, such as onions, bananas, tomatoes, honey, garlic, barley, and wheat. Some nutrition companies are adding these prebiotics to their food supplements in drinks and puddings.

 

 

Probiotics are any number of different 'good' bacteria that are administered by mouth, in a capsule or in a drink or food. The bacteria then establish themselves and grow within the intestine, a process called colonization. They are thought to provide immune system balance by down-regulating inflammation.

 

Probiotics are most easily found in yogurts, where active or live bacterial cultures have been added. Unfortunately, there is no standardization regarding the bacterial strains or amount of bacterial colony forming units (CFUs) added. Similarly, the amount of remaining live bacteria when you consume the product will be affected by the processing, transport, and storage conditions. Live bacteria need to be kept in a refrigerated environment. Probiotics must also arrive alive in the gut, so they must be acid- and bile-resistant.

 

Examples of probiotic species include Lactobacillus acidophilus and Bifidobacterium. When buying yogurt, look for those that "contain" active cultures as compared with those that are "made with" active cultures to be sure you're getting as much of the live bacteria as possible.

 

 

This rapidly expanding area of nutrition is of interest wherever there is an inflammatory component to disease (for example, arthritis, cardiovascular disease, IBD). Immunonutrition involves modulating the inflammatory response through diet. The type of fat we eat is directly related to the fat that makes up our cells, which influences a cell's ability to produce eicosanoids and cytokines. These are hormone-like compounds that affect the body's immune response to injury and infection. By eating more anti-inflammatory fats, we can directly influence production of these anti-inflammatory mediators.

 

There are a few different kinds of dietary fats, including trans fats, saturated fats, monounsaturated fats, and the essential polyunsaturated fats (omega-3 and omega-6). Two important omega-3 fatty acids are eicosapentanoic acid (EPA) and docosahexaenoic acid (DHA).

 

 

The optimal amount of omega-3 in the diet has not been defined in IBD. In cardiovascular disease, the optimal intake has been defined at 1000 mg EPA plus DHA per day. For the general public, some recommendations in the medical literature suggest an intake of 400 to 500 mg per day as being optimal.

 

To put this in perspective, one omega-3 egg has roughly 5 mg EPA and 75 mg DHA. Omega-3 milk has roughly 15 mg DHA per 250 ml (one cup). Some of these products have added costs, so be sure to read the label to determine if the additional omega-3 is significant enough to add to your daily totals.

 

 

The area of antioxidants and IBD looks promising, but studies are still at a biochemical level and cannot yet be translated to specific recommendations for people. Antioxidants include vitamin E, vitamin C, carotenoids, glutathione, and selenium.

 

 

There is also a so-called low microparticle diet being studied for relief of symptoms in Crohn's disease. This diet involves avoiding inert inorganic non-nutrient microparticles. There are natural contaminants, such as soil and dust, as well as food additives, such as aluminosilicates and titanium dioxide used as brightening agents or anti-caking agents. The diet also focuses on avoiding processed foods, such as processed meats and processed cheese, or anything that could have soil residue. There is not yet strong evidence to support its use in clinical practice.

 

 

Trophic (growth or anabolic) factors, such as glutamine, have also generated interest. Glutamine is an amino acid (building block of protein), which the body can make on its own. During times of stress, it is considered 'conditionally essential' because the body cannot produce enough for the demand. Because it is a fuel source for intestinal mucosa and immune cells, glutamine has been proposed to help with Crohn's disease and short bowel syndrome, but research has not demonstrated any benefit to date. There are limited human studies, and stability is an issue with some supplement forms of glutamine.

If there is risk of developing malnutrition or progression of malnutrition, sometimes a more intensive and defined form of nutrition, called nutrition support, is required. There are two types of nutrition support, total enteral nutrition (tube feeding) and total parenteral nutrition (intravenous feeding).

 

 

By itself, total enteral nutrition (TEN) can reduce the amount of inflammation in the intestine and thereby avoid the need for medications, such as steroids, that may have numerous undesirable side effects. It also has the added benefit of enhancing growth.

 

A relatively soft small tube is passed through the nose and through the esophagus, ending up in the stomach or upper part of the small intestine. Tube feeding can be delivered by using gravity drip or a pump to deliver a precise volume per hour. Tube feeding does not preclude taking other fluids by mouth, so you can continue to drink even while you have the tube inserted.

 

Children often learn how to place this tube themselves. They insert the tube every evening before going to bed, administer the feeds overnight while they sleep, and take the tube out in the morning before going about their usual activities during the day.

The procedure should to be supervised by your health-care team to ensure that possible side effects of tube feeding (bloating, cramping, diarrhea) are monitored and properly addressed. There is also a cost associated with tube feeding, which is not always covered by governments or third parties, such as insurance companies.

 

 

Total parenteral nutrition (TPN) is a specialized form of nutrition delivered via an intravenous line. A PICC line (peripherally inserted central catheter) is an example of a type of line that is commonly placed in order to deliver the concentrated nutrients to a large blood vessel, which rapidly dilutes the solution. In this kind of nutrition support, the gut can rest because no absorption is required while nutrients are delivered directly into the bloodstream.

 

TPN may be required before surgery if you are very ill and cannot consume enough nutrition by mouth or by tube feeding. Sometimes after surgery the bowel is slow to work; TPN can be provided until this resolves and you are eating well again. With multiple surgeries for Crohn's disease, some individuals don't have enough intestines left to absorb adequate nutrients and maintain stable weight, fluid balance, and electrolyte balance. These people may need TPN permanently, in which case there are home TPN programs available in many communities to prescribe and monitor the administration of TPN.

 

This may seem like a perfect solution to avoid the discomfort of gastrointestinal intolerance symptoms from eating. Beside the high cost, there are, however, risks that need to be taken into account before making a decision to use TPN. These include a higher risk of infection, blood clots (deep vein thrombosis), and metabolic intolerance. Because this is an artificial way to provide nutrition, your body often has difficulty processing the nutrients, and you could develop problems with your liver or gallbladder or abnormalities of cholesterol, triglycerides, and sugar levels in the blood as a result. Some people do not feel hungry while on TPN because the intravenous solution is giving them enough calories, but they sometimes do psychologically miss eating food and want to eat.

 

A specialized nutrition support team can help to avoid these complications while monitoring and adjusting the TPN to account for blood values that are unstable or abnormal.

For a short time following surgery, while experiencing obstructive symptoms, or during a flare, you may need to follow a fluid diet to relieve your symptoms by eliminating most indigestible food matter (also called residue). You might also be asked to follow a liquid-only diet if you have a fistula.

 

Even though you don't have much of an appetite under these conditions, you may find that you are able to drink fluids. However, while on a fluid diet, it may be difficult to consume enough calories to maintain your weight.

 

 

Unfortunately, clear fluids are not a balanced source of nutrition, especially lacking in calories and protein. A clear fluid diet should generally be limited to no longer than several days. On this diet, you can easily develop taste fatigue and boredom with the lack of variety, texture, smell, and taste.

 

Examples of clear fluids are strained vegetable or meat broths, tea, coffee, clear popsicles, Jell-O, clear juices or cocktails, such as apple or cranberry, fruit punch, and other sweetened drinks, soda pop, and specially prepared nutritional products, such as Resource Fruit Beverage. Clear fluids flavored or sweetened with strained lemon juice, honey, sugar, or artificial sweeteners are considered to be fine.

 

 

Slightly more nutritious is the full fluid diet because of the addition of some dairy products or alternatives, such as soy milk for lactose intolerant individuals or vegans (when all animal products are avoided). Still, it is difficult to meet protein requirements on the full fluid diet.

 

Examples of full fluids are milk, cream, soy milk, strained hot cereals (oatmeal, cream of wheat), puddings, custard, ice cream, sorbet, gelato, strained cream soups, fruit juices, vegetable juice, and nutritional products that are 'creamier' in texture (for example, Ensure, Boost, Resource, and pharmacy house brands).

 

 

The more fluid you lose in stool, the more likely you are to experience dehydration. If you have had your colon removed (where fluid and electrolytes are primarily absorbed), your small intestine will partially adapt to take over this function, but this takes time, and the stool will become pasty at best. When passing frequent liquid stool, be sure that you are getting adequate fluids and replacing electrolytes.

 

 

Fluids that are best absorbed match the concentration or osmolality of your body fluids. This allows for the best absorption or transfer of fluid across the cell membranes in your intestine. An example of a good replacement fluid would be Gastrolyte for adults or Pedialyte for children. Milk, juices, and sports drinks (for example, Gatorade) are not absorbed as well due to their higher sugar content and consequent higher osmolality (a measure of the concentration of molecules dissolved in water).

 

Water may be better absorbed than the sugary drinks, such as juices. When there is a high sugar concentration in a fluid, drinking it results in fluid shifting into the intestine from the tissues, instead of out of the intestine into the tissues and the bloodstream, thereby leading to more watery stool. You can try diluting concentrated sugar sources, such as juices and sports drinks, and sip them slowly in order to avoid the problem of increased diarrhea. There also are some reduced sugar sports drinks available; these are sweetened with artificial sweeteners instead of sugar.

 

Also beware of fluids that are known to increase urine production and loss of water from the body — otherwise known as a diuretic effect. Examples of these fluids include caffeinated beverages and alcohol. There is even a combination of these two diuretics — a new kind of beer on the market that has added caffeine. Caffeinated beverages include dark colas (Coke, Pepsi, house-brand colas, root beer) and clear soft drinks (Mountain Dew), coffee, tea (including green tea), chocolate (and hot chocolate). Some medications, such as over-the-counter cold and flu remedies, also contain caffeine.

 

 

Sodium and potassium are two electrolytes critical for regulation and balance of body fluids. They can be found in many foods in small amounts, but it is best to target higher sources on a regular basis if there is any concern with dehydration risk.

Sometimes modifying fiber isn't enough to slow down bowel movements. This can be the case during a flare or following multiple bowel resections if you have a high-output stoma or a pelvic pouch for ulcerative colitis. It is then appropriate to try some other diet strategies, provided you are receiving appropriate medical treatment for your condition.

 

There are many diet strategies that can be explored to help slow stool frequency and increase stool consistency. When making changes, try only one strategy at a time and for a few days. This way if there is any benefit, you know what diet change is responsible. Conversely, you may find that you experience no positive effect, and you can then resume your usual intake and try other tips that might be helpful. Be sure to consult with your doctor or dietitians while trying these strategies.

 

 

Anti-diarrheal medications are another strategy that can provide some relief and help you regain some quality of life. For instance, if you are not able to sleep throughout the night due to high-stool outputs, medication can be used temporarily to reduce frequency so you can sleep a little longer. Sleeping better may in turn help you to cope better. Examples of medications that can help to slow high-stool outputs are Imodium, Lomotil, Questran, and codeine phosphate.

Dietitians and physicians usually recommend increasing fiber in your diet for overall good health. Fiber is important for weight management. Fiber may help manage blood sugar in diabetes; it may help manage diverticulosis; it may help reduce cholesterol; and it may help protect against some kinds of cancers. While eating fiber, you feel full sooner and may eat less. Despite these clear health benefits, your doctor or dietitian may ask you to limit fiber in your diet because you have IBD. The priority when you have an IBD flare is to recover, return to better health, and have improved quality of life. This may require adjusting or reducing your fiber intake.

 

 

In clinical practice, a low-residue diet limits foods that increase the amount of undigested food matter and the amount of stool produced. Low-residue diets allow soluble fiber, but limit insoluble fibers and foods that could potentially contribute to food-related obstructions.

 

This fiber-restricted diet is intended only to be a short-term diet to help you feel more comfortable by decreasing gastrointestinal intolerance symptoms from a flare or from a change in the normal anatomy after surgery. This not a fiber-free diet; rather, there is a compromise by allowing soluble fiber until you can comfortably include sources of insoluble fibre in your diet again. The goal is for you to return to a regular diet once your disease and symptoms have improved. In the meantime, be sure to plan meals in advance so that you can find acceptable alternatives and have them available to you when you are hungry.

 

 

 

There are times when a low-fiber diet needs to be followed over longer period of time. Such is the case when you have narrowing of the bowel due to scar tissue or stricturing of the intestine in Crohn's disease. When there is narrowing, the bowels must push hard to pass undigested food matter through the narrowed area. This causes cramping, pain, and, in some cases, abdominal bloating and nausea.

 

Similar situations of bowel narrowing occur with inflammation from active Crohn's disease and bowel-wall swelling following surgery. This is usually temporary because the swelling decreases with treatment or time and the size of the opening of the bowel returns to normal. Unfortunately, scar tissue remains despite treatment with medication. In that case, the narrowing is permanent, unless it is surgically removed or corrected.

 

Long-term compliance with a low-residue diet brings unique challenges for ensuring that vitamins, minerals, and trace elements are adequate considering the many restrictions to the fruits and vegetables food group. The key is to rely on fruits and vegetables that are canned, well cooked, squeezed into juices, or blenderized and strained. Sometimes a multivitamin and mineral supplement is needed.