Author: gidietitian

Exclusive Enteral Nutrition — Week 2 Summary

Week 2 on EEN: Most start to feel better (clinical remission) around this time. I am meeting my nutrition goals, drinking 6 shakes daily, and I seem to be tolerating Orgain well. I have been noticing that I get an energy crash around 4 pm, so sometimes I space my last two “dinner” shakes out a little more (and drink them a little earlier) to help offset the fatigue. This may be due in part to coffee withdrawals, but I should be over those by now. It may be due to slight dehydration. I feel like I’m having to drink a lot more water than usual to stay hydrated. I am listening to my body and drinking more when I feel signs of dehydration: dry mouth, darker urine, fatigue, headache.

I am not having intense food cravings, although I do miss the act of eating. The formula is satisfying my hunger needs. One observation is that I don’t salivate before eating/drinking my Orgain. In fact, I’m not really getting the usual hunger pangs, I am instead nourishing my body based on the time of day: it’s 7:30 am, so I need to drink two shakes; it’s 11:30am so I need to drink two shakes; it’s 5:30 pm so I need to drink two shakes. Nourishment is much more scientific and based on actual need rather than pleasure. I miss the pleasure of eating, the physical response to a meal, I even miss going to the grocery store! I drive by my local Trader Joe’s and a bit of sadness briefly overtakes me. Then, I carry on with the rest of my day trying to focus on things that aren’t food centric. On to week 3!

 

Exclusive Enteral Nutrition (EEN)

Please consult your doctor and dietitian before using information on this page. This is a medically supervised diet and should be done in conjunction with your healthcare team to ensure adequate nutrition for health and healing. Never attempt these diets without the support of your medical team.

Exclusive enteral nutrition (EEN) is a nutritional therapy where 100% of the person’s nutrition needs are met via a formula alone. No other foods or beverages (other than water) are allowed. Many of my patients ask about diets to help reduce IBD inflammation, and EEN is an option that has the most published evidence behind it. Studies show that it helps to reduce inflammation in active Crohn’s disease at a rate equivalent to steroids. How does it do this? There are many hypotheses: via modulation of the microbiota to a less inflammatory state, via reducing dietary antigens, via reducing production of pro-inflammatory cytokines. We know it works. And it tends to work better in children… because they are compliant with it! Research shows that adults are less likely to complete an EEN trial either due to formula intolerance, lack of motivation to continue, lack of provider support, or other reasons.

An EEN trial can vary depending on disease severity, response to the EEN trial, tolerance, and other factors. A period of 4-12 weeks is recommended for EEN. I have decided to go on an EEN trial as a way to support my patients! I know this won’t be easy, but I feel like I should experience at least some of what it’s like to give up food for a month. Several formulas are available for EEN (whole protein, low fat, pre-digested), but the more “intact” or whole the protein is in the formula, the better the taste, and the cheaper the formula. I tried several different formulas before deciding on Orgain for my EEN trial. I liked the taste of Orgain, I tolerated it better than the others I tried, and I liked the ingredients (organic fruit+veggie blend, less sugar than other brands, no maltodextrin or carrageenan, and whey protein sourced from grass fed cows). Full disclosure, Orgain is supporting my EEN trial, but I am keeping my reported experiences as unbiased and honest as possible.

This is week ONE on my Orgain EEN trial. The first day was the hardest — I had to fast in the morning for a procedure, and that resulted in me having to drink all of my shakes within a shorter time frame. I felt full, bloated, uncomfortable. The second day was easier — I spaced my shakes out to regular “meal” periods: 2 for breakfast, 2 for lunch, 2 for dinner. This was much easier to tolerate. I had some gurgling. I also noticed a change in my stool color (much like the chocolate/strawberry Orgain color), kind of tan/orange, and consistency (like baby poop!). The formulas also leave a sort of film in the mouth, and I learned early on to carry a toothbrush around work to help get rid of this after my meals. Food cravings were more intense on days 2-6, and now by day 7 I am feeling more “normal” on the EEN. It’s still hard to smell other’s meals at work or home, but the formula is satisfying my hunger. I am missing texture and decided to celebrate the end of my first week on EEN by making ice pops from the Orgain, and I loved the change in routine and flavor! I am drinking enough to maintain my weight (my goal). Week ONE is DONE! And now on to week two

SCD — Phase 4

Before I get into phase 4, a little background on me: I am currently living in Los Angeles (10+ years), but I was born and raised in Dallas, Texas, and all my family are back there. I try and visit my home state every once in a while, and this made me a little nervous while on the SCD. Once my family learned I was on a special diet, I was taken aback at how supportive they were. I had no expectations for them to cater to me, and was fully prepared to deal with the complexities of the SCD on my own. But the thoughtfulness and effort they showed me really melted my heart. Having a supportive loved one, or entire family, makes diet and lifestyle changes so much easier! I did more experimenting and eating out during phase 3+4 partly because my family encouraged me and cooked with me … and were willing to try my creations!

In addition to the Intro and Phase 1+2+3 foods, I am now adding:

  • Meat/protein: whole nuts
  • Fruit: Raw fruits, dried fruits, persimmons, grapes, coconut
  • Vegetable: raw vegetables
  • Other: SCD legal food bars and snacks

As with the other phases, I purchased my foods while still on phase 3 so I could prep and be ready for phase 4.

Sample Phase 4 Menu:

  • Breakfast:
    • Grainless granola (from Trader Joe’s) with homemade almond milk (you can also buy almond milk — I found Pop and Bottle (at Sprouts) to be SCD legal!)
  • Lunch:
    • Acorn and butternut squash, kale, black beans, cheddar cheese; chicken breast cooked with onion and tomato and seasoned with cumin, garlic, paprika, salt+pepper
  • Dinner:
    • SCD legal pizza (I used almond meal leftover from making almond milk) with parmesan cheese, tomatoes, spinach, mushrooms, and homemade tomato sauce
  • also pictured: almond flour pancakes (yum!!!), an airport meal from Ruby Tuesdays that was SCD legal thanks to the amazing waiter, making almond butter with the family, Americano and LARABAR — staples in my life.

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Loving the diet and not missing my old favorites (chocolate, potatoes, tortillas). But I’ve made it to two months on SCD (as planned), and will begin to liberalize my diet.

 

After a hiatus, I plan on starting Exclusive Enteral Nutrition (EEN). Can I make it to 30 days on EEN??

 

SCD — Phase 3

I’m feeling more liberated on phase 3. I have missed my beans, and am glad to add them back into my diet. I am also excited to add nut flours and begin experimenting with grain-free baking. My upcoming trip home to Texas has aligned well with where I am in my SCD journey. I will be eating more foods, and will be able to experiment with eating out (for the first time in 3 weeks) while traveling.

In addition to the Intro and Phase 1+2 foods, I am now adding:

  • Meat/protein: Bacon, prepared sausage, lunch meats (without sugar, nitrates/nitrates, added hormones, or SCD illegal ingredients); lentils, lima beans, white navy beans, split peas, black beans, kidney beans, chunky nut butters. Limit intake of fatty and processed meats.
  • Fruit: Nectarine, plum, citrus, papaya, melon, cherry, fig, kiwi, kumquat, mango, passion fruit, rhubarb, berries, date, rehydrated dried fruits
  • Vegetable: Celeriac, Chinese cabbage, eggplant, swiss chard, hot peppers, Brussels sprouts, cabbage, beet, broccoli, cauliflower, peas, collard greens, kale, olive, onion, dill pickle, bok choy, celery, leek
  • Other: Nut flours (pecan, coconut, walnut, macadamia, blanched almond + hazelnut), bean/lentil flour can be used sparingly if presoaked, baking soda, SCD legal baked goods

As with the other phases, I purchased my foods while still on phase 2 so I could prep and be ready for phase 3.

Sample Phase 3 Menu:

  • Breakfast (not pictured):
    • Egg, bell pepper, onion, and homemade turkey sausage scramble
    • yogurt
  • Lunch:
    • Open-faced sandwich on grain-free bread: Tuna salad with homemade mayo, spinach, cheddar cheese; melon

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Tips for you to consider: 1. Grain free baked goods are very rich in calories; eat them according to your weight (gain or loss) goals. Experiment with different recipes and cookbooks. I found some grain-free baking very delightful, and other recipes not so … delightful. 2. When eating out, clarify all ingredients before ordering. I ordered chicken “tacos” without the tortilla and a side of beans. When I got my order, I learned the beans were pinto (not allowed!). 3. When traveling on SCD, always carry a non-perishable item (my favorites were individual packs of nut butters and/or fresh fruit, like apples or bananas) to  prevent having to resort to an “illegal” food on-the-go, and to curb appetite until you’re able to sit down to a nice SCD meal. 4. I can’t stress enough how much better batch cooking made my life. Do it if you can.

 

After a few days, or when you feel comfortable (listen to your body!), move on to phase 4.

SCD — Phase 2

My weight has stabilized, I am eating more foods, and I’m feeling great. Winter squash is a big staple in my kitchen. I cook up a big batch on Sunday and keep it in a container in my fridge, scooping a heap into my lunch containers or into a bowl to add to my dinners. It’s more satisfying than I remember, super easy to cook, and packed with vitamin A, B vitamins, vitamin C, fiber, potassium, and magnesium. Including squash, dark leafy greens, and yogurt/cheese is helping me balance my diet while avoiding grains and milk.

On to Phase 2!

In addition to the Intro and Phase 1 foods, I am now adding:

  • Meat/protein: Low lactose SCD legal cheese, creamy nut butters
  • Fruit: peach, pineapple, plum, tomato, apricot, avocado, fruits canned in own juice
  • Vegetable: garlic, asparagus, green beans, mushrooms, artichoke, cucumber, bell peppers, lettuce
  • Other: Vinegar (cider or white), mustard, homemade mayo ingredients (lemon, dry mustard powder, egg, oil)

As with the other phases, I purchased my foods while still on phase 1 so I could prep and be ready for phase 2.

 

Sample Phase 2 Menu:

  • Breakfast (not pictured):
    • SCD legal yogurt sweetened with honey
    • pineapple
  • Lunch:
    • Stir fry with: ground meat, garlic, bell peppers, mushrooms, green beans
    • spinach
  • Dinner:
    • Entree: stuffed delicata squash (meat, farmer cheese, asparagus, garlic, farmer cheese)
    • Dessert: banana, almond butter, honey, cocoa butter shavings (super high in saturated fat, but a little goes a long way!)

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  • Tips for you to consider: 1. Unless you are including a high calcium food (yogurt, low lactose cheese) at each meal, you probably aren’t getting enough to maintain strong bones and may need to supplement — talk to your MD or dietitian about this. Once you’re able to add in other high calcium foods (collard greens, mustard greens) you should be able to cut back on supplementation. 2. Regularly pick lean proteins (chicken breast, egg whites, turkey breast) and cook with vegetable oils (grapeseed oil, olive oil) instead of butter or coconut oil to help maintain a healthy heart.

After a few days, or when you feel comfortable (listen to your body!), move on to phase 3.

Almond Milk

I am used to drinking cow’s milk, but since that is not allowed on SCD I required an alternative for my coffee, smoothies, and other culinary needs. Most almond milks and milk alternatives sold in stores have added emulsifiers, gums, or other non-SCD ingredients. Almond milk is easy to make at home if you have the right equipment. This recipe yields about 1.5 cups of almond milk. Prep time: 20 minutes, plus time for soaking almonds (1 hour up to 24 hours).  (happily sipping a fresh cup of almond milk as I write this post!)

Equipment Needed:

  • Blender or food processor
  • Jar
  • Measuring cup
  • Strainer
  • Cheesecloth or food-grade cloth bag
  • Bowl
  • Spatula

Ingredients:

  • 1 cup of almonds
  • 1.5 cups of water (1 cup for thicker milk, 3 cups for thinner milk)
  • pinch of salt
  • 1/4 tsp vanilla extract if desired

Instructions:

  1. Place 1 cup of almonds into a glass jar and fill with water. Place in fridge. Almonds can soak for 1 hour (if in a rush) or up to 24 hours. The longer the soak, the richer the milk. **note, I used blanched almonds which are recommended in the beginning phases of the SCD. You can purchase almonds blanched, or blanch yourself. To blanch almonds, place in boiling water for 1 minute, then strain and rinse with cool water. Pinch almonds between fingers to remove skin. img_9081  img_9090
  2. After almonds have soaked, drain and rinse well. Add almonds to a blender or food processor.
  3. Add 1.5 cups of water. Process or blend for 2-4 minutes, or until mixture is smooth and no chunks remain.img_9108  img_9116
  4. Line strainer with cheesecloth or cotton bag and place over a large glass bowl. Pour almond mixture into lined strainer. Use spatula to scrape down blender/processor.  img_9122
  5. Lift cheesecloth from strainer and wring out liquid from almond pulp. Once all liquid is squeezed out, reserve the pulp for later use in your baked goods, or add it to yogurt or smoothies. It also freezes well.img_9125
  6. Pour liquid (almond milk) into a glass jar. Feel free to be creative at this point. I suggest adding a pinch of salt and a dash of vanilla extract. But cinnamon, honey, or dates are also nice options.
  7.  Store almond milk in fridge. Use within a couple of days.  img_9130

**Please note that almond milk, although a good substitute for cow’s milk, is comparatively low in calories, protein, vitamins, and minerals. Aim to consume other calcium and nutrient rich foods in your diet to ensure adequacy.

SCD 24 Hour Fermented Yogurt

The SCD eliminates fluid milk, but allows farmer cheese, low lactose cheese, and 24-hour fermented yogurt. Yogurt is rich in protein, calcium (~300 mg per cup), potassium, and phosphorus. Try to eat at least a cup daily. This recipe yields 64 oz of delicious yogurt, or about 8 – 1 cup servings.

Equipment you will need:

  • 2 quart Yogurt maker (cleaned and ready to go)
  • Thermometer, calibrated
  • Spatula
  • Stock pot, or large cooking vessel

Ingredients:

  • 64 oz whole milk (preferably from pasture raised cows)
  • Yogurt starter that is free of bifido bacteria. I used Yogourmet — 2 packets of 5gm yogurt starter.

Directions:

  1. Pour milk into a pot and place over medium heat. Bring to 180 degrees Fahrenheit. *Note* it is important to warm your milk slowly and stir occasionally with spatula to prevent scorching.                img_8982
  2. Once milk reaches 180 degrees Fahrenheit, turn off heat and allow milk to cool to 108-112 degrees Fahrenheit. To speed up the cooling process, you can submerge the pot of warmed milk into an ice bath and stir until it reaches the desired temperature. But be careful not to cool it below 108 degrees Fahrenheit.img_8989
  3. When the milk reaches 108-112 degrees Fahrenheit, remove about 1/2 cup of the milk and place in a small bowl. Add the yogurt starter to the reserved milk and mix thoroughly. Once combined, add mixture back to main pot of warmed milk and mix thoroughly.   img_8994  img_8995
  4. Pour mixture into yogurt maker and incubate for 24 hours. Keep mixture as still as possible to preserve consistency of final product. img_8997 img_9001
  5. After 24 hours, turn off yogurt maker and place yogurt container in fridge to stop the fermentation process and allow yogurt to set.
  6. Enjoy cooled yogurt!

SCD — Phase 1

I have completed the intro phase! It actually wasn’t as bad as I thought. The first day I had symptoms, as expected: stomach pain, nausea, and lots of bloating. One thing to know is the intro phase is very high in protein, low in fiber, and high in sugar. I am not used to consuming so much sugar (and so little fiber) but juice, gelatin, honey were my main carbohydrate/energy sources. I ended up losing ~1.5 lbs over the two days — likely water weight from significantly reducing my carbohydrate intake (carbohydrate storage in the body is coupled with water and this is what accounts for the initial weight loss when following a low carb diet). By the second day I was feeling better.

  • Tips for you to consider: 1. Aim to eat at least 4 small meals daily. I tried to make it work with 3 meals daily but this lead to me feeling stuffed and bloated. 2. Make sure you’re getting enough calories so you don’t lose too much weight on the intro phase. 3. Keep an open mind about trying all foods allowed during each phase. I had never had farmer cheese and was worried I wouldn’t like it, but it turned out to be my favorite part about the intro phase.

On to Phase 1!

In addition to the intro foods, phase 1 includes peeled, cooked, seeded: butternut squash, acorn squash, spinach, ripe banana with brown spots, applesauce, pear sauce, homemade nut milks (coconut, blanched almond, pecan milk), and SCD yogurt. I purchased the items in the photo below — I planned to wait for the bananas to ripen, and blanch the almonds for my homemade almond milk — a nice addition to my weakened coffee 🙂img_9003

I purchased my phase 1 foods on the second night of my intro phase so I could prep my phase 1 meals for the following day. I also received my yogurt maker on the same day, so my kitchen was busy roasting acorn squash, making SCD legal yogurt, cooking spinach, and prepping my breakfast and lunch for the next day. If you’re hesitant to add these new foods, try them one at a time. Add a new food (like acorn squash) to lunch. Continue that same food (acorn squash) at dinner. Then try a new food the next day at breakfast (like ripe banana), and so on, until you’re eating all the foods allowed during this phase. If you experience a set back, hold off on that food for a couple days and then try to reintroduce it again.

Sample Phase 1 Menu:

  • Breakfast (not pictured):
    • SCD legal yogurt sweetened with honey
    • applesauce
  • Lunch:
    • grape gelatin
    • chicken
    • cooked spinach
    • roasted acorn squash
    • farmer cheese

My coworkers — surprised to see me eating something other than a Starbucks Protein box, commented on how good my lunch looked. It was good. And so much more satisfying.

  • Snack: pear sauce
  • Dinner:
    • SCD soup version 2.0 — chicken, mashed acorn squash, homemade chicken broth, farmer cheese
    • grape gelatin
    • um, and some dry white wine (cause election results).

Mixing that farmer cheese into my soup makes it “creamy” and delish!

img_9005  img_9014

  • Tips for you to consider: 1. Again, 4 small meals is key here, unless you are comfortable eating large portions. I have a sensitive stomach and I find this method works best for me. 2. Vary your animal proteins — have some fish, beef, turkey, or lean game meats. I stuck with chicken and eggs, but you don’t have to be as boring as I was. 3. Mix it up! Yeah, you can only eat like 11 things at this point, but presentation is part of eating and helps to excite your mind and taste buds. The example above of my phase 1 lunch and dinner contained the exact same foods, but one was in traditional meal format (veg, protein, carb), and other was in soup format. The different textures and consistencies of the foods kept me satisfied.

At this point, after a few days, or when you feel comfortable (listen to your body!), move on to phase 2.

SCD — Intro Phase

So a few weeks ago I committed to starting the Specific Carbohydrate diet (SCD), a grain free diet low in processed foods, added sugars, and food additives. This is a diet many of my patients use to help manage their Inflammatory Bowel Disease (IBD). It’s supported by preliminary evidence showing clinical remission in pediatric Crohn’s disease (see my page on Nutrition for IBD for references) upon following the SCD. It’s not a diet for everyone, but I find that my patients who choose to follow this diet (under medical guidance) can do really well, and it’s a nice way to integrate nutrition into their IBD management. Please know that eliminating food groups (grains, most dairy) can lead to malnutrition (especially of the B vitamins, calcium, vitamin D and E), so I can’t emphasize enough the need to talk to your MD and RD if you choose to use this to compliment your IBD treatment regimen.

Over the past few weeks I have been accumulating SCD legal pantry items I would need to successfully start and continue my diet. I ordered a yogurt maker online, as well as some almond and coconut flours, gelatin, yogurt starter (which, OMG, is impossible to find a bifido free version in the stores; YoGourmet is a nice freeze dried option), and a little special something (cocoa butter) to help keep me on track (I am a huge fan of dark chocolate which is not SCD legal).

Tonight I am prepping for my Day 1 Intro Phase, which will start tomorrow. The intro phase consists of chicken, beef, fish, homemade broth, gelatin, apple cider or grape juice, carrots, dry curd cottage cheese, eggs, and SCD legal cheese cake (see Breaking the Vicious Cycle, or BTVC, book). As a dietitian, I know my nutrient needs, so I’ve planned my menu to ensure that I’m getting everything I need to stay nourished and feel energized. If you’re not a dietitian, connect with one that your IBD MD recommends, otherwise weight loss and nutrient deficiencies are likely to ensue.

A few tips for the intro phase:

  • Plan ahead! This will make the intro phase SO MUCH easier.
  • Make space in your fridge for the broth, gelatin, juice, and other SCD essentials.
  • When making the chicken/beef/fish/veg broth, use carrot, onion, celery and herbs(!) for a flavorful broth, but only reserve the meat, carrot, and broth for eating during the intro phase.
  • When making gelatin, I used the grape juice (it seemed sweeter to me, and I would be less likely to drink it during the intro phase), but you can use apple cider as well
  • Prep ahead! You’re not going to want to do anything else during the intro phase. Batch cook and portion out meals for the next few days. You will thank yourself! I cooked my chicken stock/soup and gelatin at the same time to prep for my next few days.
  • Be as strict as possible. The full benefits of the diet are really seen when the diet is followed fanatically.

Intro diet (per the BTVC):

  • Breakfast:
    • Dry curd Cottage Cheese (moistened with homemade yogurt)
    • Eggs
    • Apple cider or grape juice diluted 1:1 with water
    • homemade gelatin
  • Lunch:
    • homemade chicken soup
    • broiled beef/fish
    • cheesecake (see BTVC for recipe) without lemon rind
    • homemade gelatin
  • Dinner:
    • variations of breakfast/lunch

The intro diet is meant to be followed for 2-5 days. Here’s my menu:

Sample Intro Menu:

  • Breakfast:
    • farmer cheese moistened with homemade yogurt and sweetened with honey
    • hard boiled eggs
    • apple cider
  • Lunch
    • grape gelatin
    • chicken broth
    • chicken, pureed carrots, farmer cheese
    • apple cider
  • Dinner
    • SCD soup version 1.0 — chicken, pureed carrots, chicken broth, farmer cheese
    • apple cider
    • grape gelatin

img_8954 img_8955 img_8958