The LOFFLEX Diet CHRON'S TREATEMENT

The LOFFLEX Diet

‘LOFFLEX’ stands for - LOw Fat/ Fibre Limited EXclusion diet

Although it may seem daunting to have to follow a liquid diet for 2-3 weeks, in fact this is usually fairly straightforward, as it is clear just what you should be eating at each meal. Most people find that symptoms may temporarily get worse as bacteria in the bowel die off because they lack substrates to live on, but after the first few days their symptoms steadily improve. Such improvement is very good for morale, and makes the difficulties of dieting seem well worth-while!
However it is not realistic to stay on an elemental diet indefinitely, and the next phase of food testing may be quite demanding.  The foods which cause problems may vary greatly from one person to another and there is unfortunately no simple test which might show which foods to eat and which to avoid. Food reactions in Crohn’s disease (CD) are not due to allergy and the usual allergy skin and blood-tests are therefore not helpful. We introduced the LOFFLEX diet to try both to simplify and to speed up the process of food testing.

Our work with elemental diets had shown us that fat (especially long-chain triglycerides) is a problem, and we knew that fibrous foods were often fermented by the intestinal micro-organisms. We also had experience of the foods which had upset people who were using the Elimination diet to sort out food intolerances.  This enabled us to construct the LOFFLEX diet.
‘LOFFLEX’ stands for - LOw Fat/ Fibre Limited EXclusion diet. This diet excludes all those foods which are most likely to cause food intolerance and must be followed for approximately 2-4 weeks. The LOFFLEX diet limits fat to 50g per day, fibre to 10g, and also excludes a few foods which are neither fatty nor fibrous, but have been shown sometimes to cause difficulties, such as yeast and coffee.
A diary needs to be kept during this period recording food eaten and symptoms suffered. Liquid diets such as Elemental 028 Extra remain useful as supplements if weight gain is desired or if the full range of recommended foods is not being eaten.
However, it is important that if you are considering dietary treatment of CD you do it with the agreement of your doctor, and with the supervision of a registered dietitian.
Most people find that they can move on smoothly from the elemental diets to the LOFFLEX diet. This considerably reduces the time they need to stay on a liquid diet, and reduces the number of foods which must subsequently be tested. These foods can therefore be tested more slowly, taking 4 days for each, and a whole week in the case of wheat which is often particularly slow to produce symptoms.
However, it must be appreciated that the LOFFLEX diet is based on probabilities rather than certainties and that a small minority of patients may be upset by foods which are allowed. The diet must therefore be followed for two to three weeks, to ensure that there are no unexpected reactions, and during that time it is important to keep an accurate food and symptom diary to enable the source of any symptoms which may develop to be accurately identified.
If the patient is symptom free at the end of the LOFFLEX diet period, food testing may begin. If severe symptoms arise on the LOFFLEX diet it is sometimes necessary to go back to the liquid diet and then restart food testing once the symptoms have settled again.
We have found that apart from its use in CD, the LOFFLEX diet may be very valuable in other disorders which involve abnormal bacterial overgrowth in the alimentary tract.  These include persistent pouchitis after ileo-anal anastomosis, and oro-facial granulomatosis.  Patients suffering from pseudo-membranous colitis caused by Clostridium difficile may also be much more comfortable following the LOFFLEX diet until the antibiotics taken to eradicate the infection have their full effect.
Further details of the LOFFLEX diet can be found in Inflammatory Bowel Disease: The Essential Guide to Controlling Crohn's Disease, Colitis and other IBDs by Professor Hunter.

Crohn’s Disease – Drugs or Diet?

by Professor Laurence Lovat BSc MBBS PhD FRCP, Professor of Gastroenterology and Biophotonics

Can a change in diet help Crohn’s disease?
Most people with Crohn’s disease ask their doctor whether changing their diet can help control their disease. They tend to get conflicting advice. Many doctors say that diet makes no difference but some doctors, particularly those looking after children, will recommend dietary interventions.
My first degree was in nutrition and I have always taken a special interest in diet and its’ relation to disease. We now know that the bacteria in the gut may be directly relevant to the development and sustaining of active Crohn’s disease. Professor Segal at University College London has demonstrated a primary abnormality in the innate immune system which prevents the body from completely destroying bacteria that manage to get through the bowel wall. This leads to a chronic inflammation which we recognise as Crohn’s disease.
It is not difficult to envisage that reducing or changing the bowel composition inside the gut may have an effect on disease activity. Professor John Hunter from Cambridge spent many years investigating this link and demonstrated an approach to diet, which I have seen works in many patients.
The LOFFLEX Exclusion Diet
The scientifically validated dietary approach to Crohn’s disease involves three stages:

1. The person stops eating normal food and replaces this with a nutritionally complete liquid feed. Symptoms usually disappear within 2 to 3 weeks. Sometimes this step can be shortened by giving the person a course of broad-spectrum antibiotics.
2. Foods are then reintroduced step-by-step. The approach is called the LOFFFLEX diet. The diet is low in fat and is fibre limited. Foods are reintroduced one by one and if any food causes symptoms it is then excluded from the diet certain foods tend not to cause any trouble at all but others such as sweetcorn cause problems for many people and have to be avoided.
3. Once all foods have been reintroduced, those that created problems previously are tried again to ensure they really do cause symptoms. If so they are removed from the diet long-term. The dietician then reviews the entire diet to make sure that it is nutritionally complete and safe to follow.

I have seen patients who have followed this approach and managed to avoid powerful medication which they otherwise would have needed to take. I have also seen some people avoid surgery although if there is significant stricturing or fistulae, surgery may often be the best way forward.
Can diet be used alone as therapy in Crohn’s disease?
The answer of course is yes for some and no for others. Diet does not work for everyone. Many people with Crohn’s disease require drugs to control their condition and prevent it progressing. Indeed early aggressive control disease can prevent long-term problems. Diet may or may not be appropriate as the only therapy, but is often extremely useful as an adjunct to other treatments and minimises the need for evermore powerful drugs.
Does diet work for everybody?
There are certain people for whom diet is very unlikely to work. It tends to work well in small bowel disease. If the disease affects the large bowel (colon), diet is less successful and if the patient has rectal disease only, diet tends not work at all. For these people, the triggering factors are much less likely to be bacteria and more likely to be other contents of the stool.
Does diet work in ulcerative colitis?
Unfortunately this approach to diet does not make any difference in ulcerative colitis. It is very important to continue a well-balanced diet. Approximately one in 10 people find that milk products containing lactose make their colitis worse. The majority of people however do not notice any difference when changing their diet, although some people have claimed benefits from a diet known as ‘Breaking the Vicious Cycle’. There are however, no hard scientific data to support the use of this diet at present.
Trying the Dietary Approach in Crohn’s Disease
Perhaps the most difficult aspect of dietary control in Crohn’s disease is the need to be careful about food intake over a long period of time. In particular people worry about not being able to eat normally on Shabbat. This is indeed an issue but there are certainly ways around it. Some people have enough self-motivation to manage their diet very successfully. Most require the support of a specialist dietician. Some decide that they would rather not try this approach at all. But given the potential benefits, it seems very worthwhile to at least give it a try.