Don't forget to rehydrate!

When clients in my office tell me about their chronic diarrhea, they often complain about how tired and exhausted they feel. I think many people don't realize that dehydration may be the culprit!

It's important to remember that when you have a lot of diarrhea, you are losing water, as well as essential electrolytes sodium and potassium. Extreme losses of these electrolytes can have harmful effects on your body.  Symptoms of low sodium (called hyponatremia) are lethargy, restlessness, irritability, muscle cramps, and in severe cases, coma. Low potassium (called hypokalemia) can cause muscle cramping and dangerous heart irregularities.

The body has a special active transport system to get sodium into the body.  Sodium needs to be coupled with glucose to travel across the cell membrane. That's why all good electrolyte replacements have both glucose and sodium, as well as potassium.

When you have had a bad "diarrhea day", are you replacing your electrolytes? Many people just drink water or slurp down Gatorade. Gatorade is not a bad option, but I have a few alternate choices:

• In a pinch, I like to use Propel. It is mainly water, but has contains some sodium and potassium.
• Pediatric electrolyte (i.e. Pedialyte) solutions are pretty high on my list of rehydration beverages, but let's be realistic here. No one (including kids) likes the taste, and who wants to drive to the store when you have bad diarrhea?  That said, it may be worth it to find a brands you like and keep some on hand.
• My favorite product out there is called Ceralyte. Here is their website for more information: http://www.ceraproductsinc.com/productline/ceralyte.html  The only downside, is you usually have to order it because not many stores readily carry their products.
• Another option is to make your own solution. Some taste better than others. Here are a couple of recipes:
• World Health Organization (WHO)- 1 level tsp salt (sodium chloride),  8 level tsp sugar, 4oz Orange Juice, mixed in 1 liter of clean water.
• The Rehydration Project- 1qt or liter of water, 1/4 tsp salt, 1/4 tsp baking soda, 2 TBSP sugar or honey. Stir until salt and sugar dissolve.
• Electrolytes can also be replaced with food and other drinks, if your tummy will tolerate it. 
• Examples are: canned vegetable juices, canned soups, mashed potatoes, etc.

How much rehydration is needed? Good question. Actually, one of the ways you can tell your hydration level is to watch the color of your urine... if it is dark yellow and malodorous, you are still dehydrated. Continue rehydrating until your urine is pale yellow in color, and you are urinating every 2-4 hours.

Negative for Celiac Disease!

About a month ago, my 6 (almost 7) year old son had an endoscopy.  I am happy to report that his biopsies were negative for Celiac Disease (aka gluten intolerance).  Then, last week I had my primary care MD add the blood test for CD onto my labs.  Yesterday I found out that those were negative as well! Have you been tested??

We will be discussing Celiac Disease in a future post... but here are a few websites to look at in the meantime:
http://gluten.net
www.celiac.org
www.csaceliacs.org

Tip #5 Try Some of these constipating foods!

Increasing the consumption of the following foods can thicken stool and decrease diarrhea:
Fruits: bananas, applesauce
Breads and Starches: oatmeal, rice, pasta, potatoes, pretzels
Proteins: peanut butter, cheese (especially cheddar)
Miscellaneous: jello, boiled milk, cornmeal (used in foods such as corn chips or cornbread), tapioca, marshmallows, and Archway brand coconut macaroons!

Not all of these foods work for everyone (i.e. milk products aren't recommended for those who are lactose intolerant), but it may be worth a try!

Tip #4 Are you Fructose Intolerant?

I previously discussed Lactose Intolerance in some detail. Another less common, but possible cause of diarrhea is dietary fructose intolerance, or fructose malabsorption (FM). (This should not be confused with Hereditary Fructose Intolerance, a rare genetic disorder usually diagnosed in infancy which can lead to liver or kidney damage if not properly treated.)

If you like medical-type reading, here's a great article on FM.  http://www.healthsystem.virginia.edu/internet/digestive-health/nutrition/barrettarticle.pdf

The best test for FM is the hydrogen breath test. Unfortunately, I found out that here in Portland, Oregon, that test can only be conducted at the Pediatric Gastroenterology Department at Oregon Heath & Science University (OHSU).

In fructose malabsorption, dietary fructose from food and drinks is not completely broken down in the small intestine, then is delivered to the large intestine (colon). In the large intestine, it interacts with the colonic bacteria... producing gas, bloating, and diarrhea.


Interestingly, everyone has a different capacity for fructose absorption, meaning some can absorb more than others. Also, it is quantity dependent. That can explain why you get sick with a particular food one day, and can tolerate it without problems on a different day.

I recently became aware of a (somewhat) new diet called the FODMAPs diet. FODMAPs is an acronym for a bunch of things you probably know little about.... Fermented Oligo-Di-Mono And Polyols.

The FODMAPs diet is hottest new diet for IBS, and unlike many diets out there, it has medical research to back it up! I recommend Patsy Catso's Book, "IBS--Free at Last" and website for more in-depth look and diet details. http://www.ibsfree.net/ibsfree_at_last/

Some of the concepts I have been teaching for years... such as avoiding sugar alcohols such as Xylitol, Mannitol, and Sorbitol.  These are known to increase diarrhea. However, I didn't know that they fit into the FODMAPs diet under Polyols.

It's definitely worth a try... especially if you feel like you have tried everything else.

Diarrhea-- it recently happened to the diarrhea dietitian!

Well, I am ready to blog again... life has been hectic as usual (i.e. kids, taxes, PTA, etc.) and then to top it off, I got this very icky stomach bug from my kids. For them, it was a 5-8 day stomachache--nothing else. By the time it got to me, I was much sicker, with intermittent stomach pain, nausea, vomiting, diarrhea, and chills with no fever. It was awful. I micromanaged my symptoms at home as best I could... but after 5 days gave up and went to the ER for some IV Zofran (powerful anti-nausea drug) and a liter of fluids. It still took a few days until I was feeling better.

Here are some of the strategies I used at home...

1. Drank 1-2 oz of Propel (water with added electrolytes) every 15 minutes.
2. Ate strained Cambell's Chicken Noodle Soup, for lunch, sometimes with oyster crackers (Replacing essential electrolytes Sodium and Potassium is very important after episodes of vomiting/diarrhea.)
3. When the nausea was better, I made sure to get as many clear liquids in as possible... in the form of water, Propel, chicken broth, and jello (it is actually considered a fluid!).
4. Took two tablets of Imodium once a day.
5. Spent one whole day just on clear liquids. Once feeling better, I slowly reintroduced simple foods such as chicken (small bites, chewed well), applesauce and canned fruit, lots of plain toast, bread, crackers, and white rice. I also avoided dairy products, high fat and spicy foods, vegetables, raw fruit, and sweets.
   

Tip #3 Are you lactose intolerant?

Lactose intolerance is very common, particularly in certain ethnic groups. I did some research and Wikipedia (once again) had a great table with the prevalence on lactose intolerance in certain ethnic and geographic groups. Did you know that lactose intolerance may affect 95-100% of Southeast Asians, and 90% of Asian Americans?

What is lactose intolerance?
Technically it is a deficiency of lactase activity. Lactase is the enzyme that breaks down lactose, the sugar found in milk. Lactase is produced in the first part of your small intestine. When you consume a milk product, the milk sugar lactose should meet up with the enzyme lactase. The lactase helps break down the lactose, so it can be absorbed by the body.

There are several types of lactose intolerance...

1. Primary- Usually found in societies where milk and dairy products are not available commercially. Once a child is weaned from mother's breastmilk, the body loses it's ability to digest the lactose.
2. Secondary- Caused by another disorder, such as Celiac Disease or other type of small intestinal malabsorption. Many times, once the initiating disease is healed and the malabsorption is corrected, the ability to produce lactase (and thus digest lactose) returns.
3. Congenital- a genetic disorder an infant is born with, usually discovered shortly after birth.

If you have lactose intolerance and you consume lactose, the milk sugar is not properly broken down. So, when it gets to your colon, the bacteria in your colon try to ferment the excess sugar. They are overpowered, which results in the gas and bloating. Then, the intestine senses the concentrated sugar in the colon and sucks in extra water from cells outside to thin out the sugar. This results in the watery diarrhea that occurs with chronic lactose intolerance.

How is it diagnosed?
I read a lot about Hydrogen breath tests. That being said, I haven't been able to find a Gastroenterologists in the Portland Oregon area that has this test available.

The easiest test is a Lactose Challenge. It's simple to do. Three or four days of no lactose at all. None. Then, three or four days of maximum lactose (think daily ice cream, cheese, milk, yogurt, etc.) Keep a food journal and note your symptoms on all of the days. Did you feel significantly better with no gas, bloating, or diarrhea on the lactose free days? Did you feel awful on the high lactose days? You may have your answer.

It is not always clear cut for everyone. Remember, lactose intolerance can be a secondary problem if you have a greater undiagnosed problem, such as Celiac Disease, Crohn's Disease, or Ulcerative Colitis. (I will post discussions on those diseases another day.)

If I do have lactose intolerance, what can be done about it?
You have several options. One option, of course, is to avoid milk products long term. But truthfully, that may not be realistic or practical.

You may need to experiment to determine your particular tolerance level. Many people can consume small amounts of lactose without problems. Such as having a little milk on cereal in the morning. Others are extremely sensitive. They practically look at milk and get diarrhea!

There are lots of lactose free options on the market... like Lactaid milk, soy milk, and rice milk, soy cheese, soy yogurt, etc. Find whatever works best for you, but remember that if you decide to avoid milk products, you will definitely need supplemental Calcium and Vitamin D long term.

Another modified option is to use the Lactaid (or generic brand lactase) enzymes with your food. They merely replace the enzymes your body is lacking. The key is to take them properly, and to take adequate amounts. Many of my patients complain that they don't work, then I find out they are taking either too few, or at the wrong time. They need to be taken at the beginning, then again the middle of the meal to ensure that the enzymes and food are in the intestine at the same time. If you take them 10 minutes before or after the meal, the food and the
enzymes will not be together in the intestine, and they will not work effectively.

I will also point out that milk products have different quantities of lactose. Often, people can eat yogurt without any problems because the active cultures (bifidus, lactobaccilus, etc.) help digest the lactose within the yogurt. The dairy products causing the most problems tend to be ice cream and milk, while others such as cream, cream cheese, and butter, contain little or no lactose and can be consumed without problems. Here's a website with the lactose content of common foods.

http://hsc.virginia.edu/internet/digestive-health/nutrition/lactosecontent.pdf

Tip #2 Avoid Insoluble Fiber

Many people don't know there are two types of fiber, soluble and insoluble.

There's a great review on Wikipedia: http://en.wikipedia.org/wiki/Dietary_fiber. Wikipedia's definition of fiber is as follows:

Dietary fiber, sometimes called roughage, is the indigestible portion of plant foods having two main components — soluble (prebiotic, viscous) fiber that is readily fermented in the colon into gases and physiologically active byproducts, and insoluble fiber that is metabolically inert, absorbing water throughout the digestive system and easing defecation. It acts by changing the nature of the contents of the gastrointestinal tract, and by changing how other nutrients and chemicals are absorbed.

I have read a lot about the benefits of fiber for both diarrhea and constipation over the years. However, in my experience, insoluble fiber tends to make diarrhea worse for many sufferers, while soluble fiber does help "thicken" the stools. Thus, I recommend to decrease insoluble fiber and increase soluble fiber in the diet.

Examples of insoluble fiber are: nuts, seeds, bran, seeds such as flax seed, sesame seeds, and pumpkin seeds, skin of the potato & tomato, and wheat bran

Examples of soluble fiber are: bananas, oatmeal, inside of the potato, beans, soybeans, barley

**Note: I have been working on this post for several weeks now. I'm not sure why I let it stump me so much. I will add more fiber info later as I have time!

Tip #1 Avoid Caffeine

I have a handout I give my patients called, Top 14 Ways to Stop Typical Chronic Diarrhea. I will be posting each of my tips one by one. When the last tip is posted, I will attach the handout to the blog for reference.

Tip #1
Cut back or preferably stop consuming anything that contains caffeine, such as coffee, tea, soda, chocolate, energy drinks or diet pills. Caffeine speeds up gastrointestinal (GI) motility and makes everything move through faster.

Simply stated, CAFFEINE CONSUMPTION = MORE DIARRHEA. I find this to be one of the biggest dietary causes of chronic diarrhea in the clients I counsel. Yet, many do not want to give up that morning cup of coffee.

Introduction - me, diet, and diarrhea

I have been working on a book on Diet and Diarrhea for about 3 years. (I just looked back and my first draft was dated 1-28-07!) Every year I write in my Christmas letter how the book will be finished before the next year. I am being sincere in my desire! Life just gets in the way.

Let me introduce myself. I am a registered, licensed, dietitian specializing in gastrointestinal problems. I provide outpatient nutrition counseling for conditions such as Gastroesophageal Reflux Disease (GERD), Crohn's Disease, Ulcerative Colitis, Celiac Disease, Irritable Bowel Syndrome (IBS), past surgeries where parts of the digestive system have been removed, constipation, and what I like to call "garden variety" diarrhea. This is often chronic diarrhea where no cause has ever been determined. I really enjoy trying to solve those cases.

I have had diarrhea most of my life. It started to get worse when I was in 7th grade. I had my first barium enema (yuck) at 13, then a small bowel follow through, and sigmoidoscopy at age 17. Since they never found anything objective, my doctor shrugged his shoulder and labeled me with Irritable Bowel Syndrome, or IBS.

The digestive system always fascinated me. I remember lovingly coloring my digestive diagrams in high school elective anatomy class. In college, I initially majored Pre-Med, then Pharmacy, before finally graduating with Bachelor of Science in Nutrition and Food Management.

In school, I learned how to teach diabetic, renal, weight loss, weight gain, surgical, and other diets to patients. But no one taught me how to educate patients on what to do if they have gastrointestinal problems. This surprised me! ...it just makes sense-- the food you eat must go through the digestive system before it enters the body. So, it became my passion: to learn how to teach people to eat when their tummy doesn't seem to work like everyone else's.

Flash forward fifteen years. I have worked as a registered dietitian for 13+ years. My approach is three parts: first, my education in human anatomy/physiology and nutrition, secondly, my experience as a dietitian in learning what works for people and what doesn't, and finally, my own personal issues with diarrhea over the years.

I am a pretty straightforward person. I'm not afraid to talk about anything related to poop. I can even say diarrhea in public without my face turning red. One of my goals in life is to convince the world that it is ok to talk about bowels, diarrhea, and gas. It was said best in a children s book, "Everyone Poops". And let's face it, everyone does. If yours aren't normal, this might be a good place to discuss it, with people you may never meet.

My intent is to blog as I write my book. I will try to include bits of wisdom and insight into my blog, and hopefully, into my book. Let's take this journey together.