Questions and Answers with Dietician Aoife McDonald

By Clara Caslin

Aoife McDonald is a dietician, who has set up her own clinic called The Digestive Health Clinic. It is located in Cork, Ireland and is launching in the Summer of 2019. Aoife studied BSc. Nutritional Science at University College Cork (UCC) and then went on to do a Postgraduate Diploma in Nutrition and Dietetics at the University of Chester, UK. She has three years experience working in the NHS and has a special interest in gastroenterology. A digestive health programme has been designed by Aoife to help people with Inflammatory Bowel Disease and Irritable Bowel Syndrome to manage their symptoms through diet and lifestyle changes.

What types of food do you recommend for people with Inflammatory Bowel Disease (IBD)? 

There are no foods that are specifically recommended for those with IBD, therefore it is advised that people with this condition aim to follow the dietary guidelines for the general public. These guidelines are based on the principles of a Mediterranean diet, which is largely based on high-fibre plant-based foods such as wholegrains, nuts and seeds, fruits and vegetables, legumes, and olive oil. It also encompasses plenty of seafood such as oily fish, moderate amounts of eggs, moderate intakes of poultry and dairy products (cheese and yoghurt) and low quantities of red meat. 

What types of food do you not recommend?

There is no one particular food that all those with IBD should avoid completely, as sensitivities can vary from person to person. If you have IBD and suffer from digestive discomfort when in remission, I would recommend keeping a strict food and symptom diary to help you to identify any problematic foods. 

Studies have shown that the incidence of IBD is higher in countries where a 'Western Diet' is consumed. This dietary pattern is characterised by refined carbohydrates, high intakes of red meat and regular consumption of processed foods, which often contain additives such as emulsifiers and sweeteners. Adhering to a Mediterranean diet as outlined above may be beneficial to those with IBD, as it inherently limits intake of these types of foods.

What portion sizes should people with IBD eat?

People with IBD should eat 'normal' portions, but 'normal' can mean different things to different people! A good rule of thumb is to fill half your dinner plate with vegetables or salad, one quarter with a wholegrain such as brown rice or quinoa, and the other quarter with a protein source such as lean meat, fish, eggs or legumes. Take a look at the Healthy Ireland guidelines for further advice on portion sizes http://www.healthyireland.ie/health-initiatives/heg/

You may wish to have smaller portions when in a flare-up, or if you experience IBS-like symptoms when in remission, reducing your portion sizes can help with symptom management.

Should IBD patients stay away from fibre?

In general, patients with IBD do not need to avoid fibre, and should aim to have at least 30 grams per day. However, tolerance to fibre can vary significantly from person to person. If you are planning on increasing your fibre intake, always do so slowly, and ensure you are drinking plenty of water too.

Many people with IBD consume low fibre foods when in a flare-up as these are easier to digest, and can reduce the frequency of bowel movements. Once symptoms have improved, patients can slowly begin to reintroduce fibre to their diet, up to their personal level of tolerance. The one exception is in those with stricturing Crohn's Disease, where a low fibre diet may be recommended long term to reduce the risk of bowel obstruction.

Apparently, dairy is bad for IBD. Is that true?

No, dairy is not bad for IBD. Some people may experience transient lactose intolerance if their IBD affects the small bowel, as this is where the enzyme needed to break down lactose is found. When their IBD is back under control and their bowel has had time to heal, these patients are normally able to reintroduce dairy foods back into their diet.

However, if you find that dairy does not suit you,  always ensure that you are replacing these foods with non-dairy alternatives such as fortified soya or almond milk, and soya or coconut yoghurt. Other foods such as tinned fish, green leafy vegetables, beans, soya products, figs, oranges, seeds and some nuts are also good dietary sources of calcium. IBD patients have an increased risk of developing osteoporosis, therefore adequate calcium and vitamin D intake is particularly important.

Would IBD patients benefit from a gluten free diet?

A gluten free diet is generally only recommended for people with Coeliac disease, which affects about 1% of the population. In saying this, many people with IBD find that removing gluten-containing foods from their diet makes them feel better.

If you find that gluten does not suit you, consider the types foods you are eating. For example, pizza and cake contain gluten, but these foods are also highly processed and high in fat, so it may be these components of the foods that are causing discomfort rather than the gluten.

In the 30% of people with IBD who also suffer from Irritable Bowel Syndrome (IBS), removing gluten containing foods from the diet may help to improve digestive discomfort. Foods such as bread and pasta are high in FODMAPs (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols) which can cause symptoms in those with a sensitive gut. In this case, the reduction in FODMAPs rather than gluten can lead to symptom improvement. Your dietitian may take you through the Low FODMAP Diet process if you also have IBS. 

Should IBD patients avoid alcohol and caffeine?

Patients with IBD do not need to avoid alcohol and caffeine, unless an individual finds that it triggers symptoms for them. Reducing caffeine intake can be useful if you have persistent loose stools as caffeine acts as a stimulant. 

Overall, there are no specific guidelines for caffeine and alcohol consumption among IBD patients, therefore I would recommend adjusting caffeine and alcohol intake on a individual basis. The alcohol guidelines for the general population can be found at www.alcoholireland.ie

What are common problems that you see coming up with your IBD clients?

In clinic, one of the common problems that comes up is Irritable Bowel Syndrome (IBS).  I help patients to manage their functional gut symptoms through diet and lifestyle changes, as well as therapeutic diets such as the Low FODMAP Diet. This diet involves reducing intake of FODMAPs (poorly absorbed carbohydrates) for 4-6 weeks, followed by a systematic reintroduction process. About 60% of IBD patients with IBS achieve clinically significant symptom improvements on a Low FODMAP Diet. For accurate results, this therapeutic diet should only be carried out with patients who are in remission, and under the guidance of their dietitian.  

Other patients I see in clinic may not be able to manage solid foods when in a flare-up. These patients sometimes require exclusive enteral nutrition (liquid diets) followed by a slow reintroduction process called the LOFFLEX diet (Low Fat/Fibre Limited Exclusion diet), which is used when patients are transitioning from a liquid diet back to solid foods. This diet helps patients to identify foods they are sensitive to, and therefore may need to avoid long-term.

On the wards, I see patients who require parenteral nutrition, which is a type of nutrition that is given intravenously. This is normally only needed short-term until the patient can safely eat and drink again.  I also provide dietary advice to patients following surgery who have a new colostomy or ileostomy. 

You can contact Aoife by email:

thedigestivehealthclinic@gmail.com

Instagram: @digestivehealthclinic

Website: www.thedigestivehealthclinic.com

Disclaimer: The information provided is not intended to replace medical advice or diagnosis from a physician or other medical provider. Please speak with your IBD team/dietitian if you are planning on making changes to your diet. 

Questions and Answers with Consultant Gastroenterologist Professor Stephen Patchett

By Clara Caslin

Professor Stephen Patchett is a Consultant Gastroenterologist who works in Beaumont Hospital in Dublin. He also works in The Bon Secours hospitals and is an Associate Clinical Professor in the Royal College of Surgeons Dublin. He graduated from UCD and began his training in Dublin before moving to London to train in St Bartholomew's and The Royal London Hospitals. 

He was a Senior Lecturer in St Barts in 1996 and then returned to Ireland to take up his current position in Beaumont in November 1998. He has a focus on diagnostic and therapeutic gastrointestinal endoscopy and therapeutics of inflammatory bowel disease. He is the clinical lead for endoscopy services in Beaumont and The Bon Secours. He is currently the chair of the working group for the national QA programme in endoscopy and represents the College of Physicians on the QA Steering group and the Conjoint Endoscopy Curriculum development group. 

Professor Stephen Patchett

What is your role?

Consultant Gastroenterologist.

When did you realise that being a Gastroenterologist was what you wanted to do? 

When I was a second year junior doctor and started working with a very influential gastroenterologist who subsequently became my mentor.

How many IBD patients do you treat (estimate)? 

1000.

What age group are the patients you treat? 

17-85.

Are all cases different or do you see a lot of similar ones? 

Whilst there are similarities, every patient is different both in the manifestation of their disease and their approach to dealing with their illness.

What do you think people can do to help their IBD?  

Look after themselves physically and emotionally. Eat well, exercise, don’t smoke. Learn as much as they can about their disease through interaction with others and IBD societies.

Do you ever think there will ever be a cure? 

I think ultimately yes but this will be some way off. However our ability to control the disease is improving rapidly and living with IBD will not be the challenge that it use to be.

What sort of lifestyle do you tell patients is best for them? 

Important to stay active and eat well (as we all should). This is the same advice that we would give to the general population.

Do you think IBD is one of the hardest diseases to live with? 

Difficult question as there are many difficult diseases. It really depends on the severity of an individual’s disease.

What would you say to someone who was newly diagnosed? 

Apart from explaining the nature of the disease and its treatment, I would stress that in the vast majority of cases, treatment is very successful and that a very fulfilling and active life is possible. I think a positive outlook is very important.

Image Credit: beaumont.ie

My Experience Of Having A Colonoscopy!

Hi everyone,

If you read my blog then you'll know that I was diagnosed with Crohn's Disease just over four years ago. In August, I was in the hospital for a routine check-up and met a new doctor on the team. We were chatting about my case for a while and all seemed ok. Two weeks later, I received a letter in the post informing me that I had an appointment to have a colonoscopy done two days later! I had an appointment the day that it was scheduled so I had to reschedule it. I received another letter a few days later from the doctor that I met telling me that the team had discussed my case and wanted me to have a couple of tests done quite urgently. 

For anyone that doesn't know what a colonoscopy is, it's a test where they place a camera up your you know what so that they can see your rectum and entire colon. It can also reach the last part of the small intestine called the ileum. I've dodged having a colonoscopy done for years but this doctor wasn't letting me away with it! Everyone always thinks it's so strange when they find out that I've never had one done before but the reason I didn't have one done was because there was too much inflammation in my intestines when I was sick and they didn't want to chance that any perforation would occur during the procedure. 

My appointment date came and it was scheduled for last Tuesday which was the day before I started in Dublin City University (DCU). I was quite anxious about it because I didn't know how I would be after the test and I didn't want to miss my first day of a new college. I'm sorry for what I'm about to say to anyone who is going to have a colonoscopy done but I'm going to be completely honest. KLEAN PREP IS THE MOST VILE THING THAT I HAVE EVER HAD TO GO THROUGH. Your preparation starts a week before you have to go for the colonoscopy. You have to avoid certain foods which was grand and then at 3pm the day before the test you have to start drinking Klean Prep. 

You have four sachets that you dilute with a litre of water each and you're supposed to drink 250ml every ten minutes so that your bowel is clear for the procedure the next day. The only way to describe the taste is like swallowing vanilla scented salt water. You can dilute it with mi wadi but I ended up having to drink straight mi wadi before I could take a taste and then I washed it down with more straight mi wadi. I started at 3 15pm and I was still up at 3am finishing it and by finishing it I mean that I got through two and a half sachets in 12 hours!! 

I was annoyed at myself for struggling so much with it but it literally reduced me to tears after half a glass at the thought that I was going to have to struggle through four litres of this crap. Once the Klean Prep starts working, I advise you to stay very close to a bathroom! I gave up at 3am after the two and a half sachets because things were clear (if you get me) and I was really tired too. I wasn't scared about having the colonoscopy, I was more anxious that they would find anything! 

I was in chatting with some women in the dressing room when a nurse came looking for me. I went out and was brought into a room to have the cannula put into my arm and sat up on a bed. It was only after around five minutes of chatting to the nurse that I realised I was in the procedure room! A few minutes later, the doctor put some sedation in the cannula and I felt a bit relaxed but I was still completely aware of what was going on. The colonoscopy began and I watched everything that was being done on a screen and asked about 1,0000 questions (the poor doctor)! There were a few moments of cramping and discomfort but they didn't really bother me as they passed after a few seconds.

My biopsies won't be back for a few weeks but there were no signs of any inflammation anywhere which I was delighted about! That was my experience of having a colonoscopy. In short, Klean Prep is evil and the colonoscopy is absolutely nothing to be worried about! 

Clara 

My Story About Being Diagnosed With Crohn's Disease

Hi everyone, I’ve decided to share a personal blog post as World IBD Day is today, May 19^th 2016 and I wanted to share awareness about living with Inflammatory Bowel Disease. I had an extreme fear of doctors, which made me hide the fact that I was extremely sick in 2011. I tried to get out of a moving car once when I was told that I was being brought to the doctor! It got to the stage where I couldn’t avoid it any longer because I was in excruciating pain. My weight was dropping rapidly and I was hiding food because I wasn’t able to eat. I didn’t want to worry anyone around me but it was obvious to others that something was wrong. My symptoms started when I was 12, I noticed that I would pass a lot of blood when going to the toilet. It would happen on and off and I’d just pass it off even though I knew that it wasn’t right.

September 9^th  2011 was the day that my Crohn’s disease began to flare. I was in Manchester at the time and I remember feeling like my stomach was going to burst open. I was suffering with extreme cramps, fever and diarrhea. In the coming months my weight began to drop rapidly because I couldn’t eat without getting cramps and diarrhea. I’m a happy, bubbly person and people thought that I was suffering from depression and an eating disorder. I realise now that I was slowly dying and I was letting it happen but that’s how bad my fear of doctors was.

In December 2011 people were saying that I looked like a skeleton. I could see the shock on people’s faces when they would look at me and see a different person to the Clara that they all knew. I developed a perianal abscess and I was forced to go to the doctor because I couldn’t pass anything from my bowel without looking like someone you see having a baby in a film. It was dramatic to say the least! I went to A&E on the 23^rd of December 2011 and I was admitted immediately and prepped for emergency surgery. The surgeons drained 100ml of poison from the abscess and I was told that I would have died on Christmas Day if I had left it any longer. The poison would have entered into my blood stream and killed me. I got out of hospital on Christmas Day and instead of things getting better, they got worse. I had dressings changed every day in the open wound from surgery for 3 months. The dressings were one of the most painful things I’ve ever gone through. I was still trying to fool doctors when I would go to clinic appointments in the hospital wearing a full face of makeup and a big smile on my face. My mam would plead with me to let them see the girl that she saw every day.

Me in 2016 on the left and April 2012 on the right

In March 2012, my weight had dropped from 56 to 47 kilos. I’m 5ft 7 so I was tremendously underweight. I developed a limp and when I felt a large lump in my stomach I knew it was time to seek help. I was rushed to Beaumont hospital and hooked up to an ECG machine because of how high my heart rate was and sent for numerous scans which showed a mass the size of a melon in my psoas muscle. It was blocking all of my organs. The surgeon told me that they had three options for me and there was no guarantee that any of them would be successful. I asked him if I would live and he said, “I don’t know". It was then that I realised I was at deaths door and I received my last rites. I had a drain fitted internally for two weeks and it drained out the poison from the abscess in my abdomen. The CRP levels (which is the marker of inflammation) in my blood were over 600, normal is between 2-10. I also had Strep G and E-Coli in my blood. After three weeks I was discharged but after a few days, I knew that the mass was back. I remember packing a suitcase at home because I knew that I was going to be in hospital for a very long time and part of me didn’t know if I would ever come back home again.

The next day, I was admitted and brought straight to the ward where I was prepared for surgery. There was no more time to waste. I was put on a feed called TPN and marked up for two stoma bags on the morning of major surgery. I remember being brought down to theatre not knowing what my body would be like when I woke up. After seven hours, I was brought back up to the ICU unit. It’s all a blur because I was on a morphine pump but I remember wires and tubes were coming out of my body everywhere and that the surgeon told me that I had no stoma bag. I struggled for weeks after the major surgery, which included a bowel resection. I had some blood transfusions because of cell levels in my blood and because of what I had lost during surgery. It would take me 15 minutes to sit up and I was unable to eat, wash or walk. My mam was brilliant but my dad passed away when I was 15 so it was hard that he wasn’t around as a support for my mam, brother and me.

After suffering a major reaction to medication, I thought it was the end. I knew that I was going to have to fight to survive. I was vomiting non-stop and couldn’t hold anything in my bowel. In the photo I’ve included I had half of a biscuit in my hand and went straight back up to the ward and vomited uncontrollably. My hair had started to fall out and my weight continued to drop. I was 6 and a half stone and wasn’t able to walk properly. I was always significantly worse at night when there wasn’t enough staff to look after the amount of people that needed help so I used to pray that I’d make it through the night until my mam would come back the next day. Slowly, I started eating some toast and seeing how my stomach would react and just when I thought that things were improving I got bad news about my white blood cells. A surgeon came around and mentioned leukemia and having to open me back up. The next day my white cells had increased slightly. After that setback, I started to improve daily and they felt that they could send me home after being in for a month.

It didn’t last as I was back in after a few days. My temperature spiked and it was back up to 39.5. I was admitted and put into isolation as I had contracted the hospital bug Clostridium Difficile. I felt more myself this time and knew that with the right medicine I could fight because I was building my strength back up. My temperature continued to spike and the surgeons mentioned opening me up again because they couldn’t understand what was wrong. I started eating little bits even if it made me feel sick and slowly but surely I began to build up my strength. I was able to wear makeup for the first time in months and I felt more confident in myself. Day by day I improved and after three weeks I knew that I was getting better. I had an appetite, which was something that I hadn’t had in a year.

After having an MRI scan on May 25^th, 2012, my surgeon told me that I’d won the battle and could go home. I was diagnosed just before my 19th birthday in June 2012 with Crohn's Disease. Since then, I’ve had four surgeries because they found that I had a fistula but I had my final surgery in May 2014 and I haven’t been admitted to hospital since. Soon after I was released, I developed alopecia areata, which is a type of hair loss but my hair eventually grew back where the bald patches were. I have to take autoimmune suppressants every day and have days where I struggle with the symptoms of IBD. Living with Crohn’s can be extremely challenging but I feel blessed to be alive. I also no longer have my fear of going to the doctor!! IBD awareness is so important today because there are so many people suffering from IBD symptoms and they have no idea where to seek help. For more information on Inflammatory Bowel Disease please visit http://www.iscc.ie

Clara