What I Eat in a Day

TW: mention of eating disorders & disordered eating

I really didn’t want to write this article. I am pretty open about how I have a lot of dietary restrictions. When I go out to eat with friends, I usually tell them that I follow a strict diet for my Crohn’s Disease. Then they’ll ask if I can have anything on the menu, and I will say No. The inevitable next question is always: So, what can you eat? I’ll list off a few foods like oats, bananas, blueberries, broccoli, chicken, and buckwheat, and that's usually the end of that conversation. I’ve had it so many times; honestly pretty much any time I meet somebody new.

I tend to think that when I give people that list that they just assume I stop listing things because it would get excessive if I named every food I could eat. I imagine that they might think I am going through a typical day, and maybe other days look different than the short food record I have given. I don’t think that anybody really considers what it feels like to eat the same 5-10 foods over and over and over and over again. But I do. I do because that has been my life since January of 2019 when I entered “remission”.

Remission for me has always been rocky. I noticed really quickly that while I felt better overall (you know, my body wasn’t trying to set records for lowest hemoglobin and highest CRP simultaneously), I still had some symptoms. I decided to take the advice I give a lot of my IBD patients these days and start a food journal to try to find my trigger foods. Slowly I started feeling better as I cut back on the foods that I noticed were giving me hives, acne, bowel cramps, diarrhea, and a whole host of other symptoms. 

So I got to a baseline diet with some foods I knew I felt good on and did that for a bit. It was wonderful, as long as I ate these foods, I felt pretty much “normal” and could do all the activities I wanted. But I wanted to find more things I could eat, so I started to do food reintroduction. I would try a new food for one meal and see how I felt afterwards. If I felt worse, I knew that food wasn’t a good fit and I’d mark it as a trigger food.

Fast forward to 2+ years of trying a new food every weekend and you’d expect my diet to be all normal and varied with only a few restrictions. Haha I wish. I’m pretty sure after all this time it has gotten worse. I guess the problem really is that my body thinks pretty much everything other humans call edible is unfit for consumption, and it lets me know that loud and clear.

That all is the much needed background to my current diet. I guess I should share what it looks like at some point as that is the main reason I wrote this article, so here goes:

Breakfast

• 3 cups of cooked rolled oats with ½ sliced banana and ½ cup blueberries.

• 1 Orgain Nutritional Shake

Snack

• 1 Orgain Nutritional Shake

Lunch

• 2 cups of cooked buckwheat, ½ sliced banana, and ½ cup blueberries

• 1 Orgain Nutritional Shake

Dinner

• 2 cups of cooked buckwheat, 1 ½ cups cooked broccoli, ½ a cooked chicken breast.

So…..yeah. I’ve pretty much been eating that or some slight variation (I used to eat a lot of plantains too) day in and day out for a few years now. Pretty messed up right? I am pretty sure from the outside this looks like at least disordered eating if not a full blown eating disorder. But, like, what am I supposed to do? It's not like I am not trying to expand my diet, I just can’t without Crohn's kicking my butt. Also I promise I’ve told every GI doc I’ve had about this and unfortunately there hasn’t been anything they have been able to do to help.

I decided to write this article because during the few years I’ve had these issues with all these trigger foods I’ve never really found anything online that mirrors what has happened to me. My hope is that if there are more people with IBD out there who struggle with these food issues as much as I do, that you at least feel validated that you aren’t the only one going through this. It sucks, and maybe one day we will have an answer as to why it happens. 

Until then, if you are having issues with foods triggering your disease, bring it up to your doctor or dietitian. Spread the word. Even if, like in my case, the doctors or dietitian isn’t able to fix the problem, at least we are fostering awareness and discussions that will bring about solutions in the future.

Digestive Disease Week: Positive Gluten Sensitivity Seriologies and the Impact of Gluten Free Diet in Patients with IBD

There are a lot of strong opinions surrounding gluten free diets. Some view them as a fad diet, popularized by media and celebrities. Others report real improvements in their GI symptoms when going gluten free. And of course there are those with Celiac Disease, for whom a gluten free diet is a life changing therapy. Throughout my time as an undergrad studying dietetics, I have learned about the gluten free diet from all angles. I think a lot of the confusion surrounding the gluten free diet in IBD comes from two sources. First, there appears to be a difference between what patients report and what the limited research has shown. Second, this limited research and lack of conclusive evidence has created a difference of opinions among healthcare professionals themselves. It is a difficult situation where providers using their clinical judgement can recommend for or against IBD patients going on a gluten free diet, and both recommendations would be completely justifiable. 

In this article, I plan to give some background on the gluten free diet, and the current evidence for and against its use for patients with IBD. Then, I will summarize the wonderful study I learned about during DDW 2021 presented by Dr. Maria Moomal Dahar titled: Positive Gluten Sensitivity Seriologies and the Impact of Gluten Free Diet in Patients with IBD.

What is a Gluten Free Diet?

Gluten free diets are designed to eliminate the protein gluten from one's diet. Gluten is a storage protein found in some grains, including wheat, barley, and rye. Gluten is an important protein for baked goods, as it forms a sticky network that gives dough its characteristic stretch and elasticity. I don’t want to go too much in depth, as there is already an amazing article on the CCYAN website written by Leah Clark that describes the gluten free diet. If you desire to learn more about the specifics, her article can be found here.

The Gluten Free Diet and IBD

The main reasons to follow a gluten free diet are Celiac Disease, non celiac gluten sensitivity, and wheat allergy. 

Previously, there had been conflicting data regarding whether IBD patients are at a higher risk of developing Celiac Disease than healthy people. Some older, smaller studies have found increased risk, while others have found no increased risk or even decreased likelihood of having Celiac Disease.1 A recent, larger study has shown that IBD patients have an increased risk of having celiac disease. 

Non celiac gluten sensitivity is characterized by abdominal pain, discomfort, bloating, changes in bowel habits, fatigue, or depression after consuming gluten. The prevalence of non-celiac gluten sensitivity in IBD patients surveyed is reported to be between 5-28%.1 Those IBD patients who reported non-celiac gluten sensitivity were more likely to be following a gluten free diet. One thing I found interesting was that IBD patients were more likely to report gluten sensitivity if they also had a flare in the past 60 days. This points to the possibility that gluten sensitivity might be worsened in patients who are currently flaring or who have recently had a flare up of their IBD. 

Most research on the gluten free diet in IBD patients has been done through survey based studies. Unfortunately, these types of studies can only provide weak evidence at best. The surveys did find that of IBD patients who had tried a gluten free diet, about 2/3 reported an improvement in one of abdominal pain, bloating, diarrhea, nausea, or fatigue. About 40% of patients following a gluten free diet reported less severe or less frequent flares. Contrary to those positive results, a different survey study found that there were no significant differences in disease activity, hospitalization, or rate of surgery in IBD patients following a gluten free diet versus those who were not. 

A few different organizations and guidelines have weighed in on the gluten free diet and IBD:

• The International Organization for Inflammatory Bowel Diseases currently states that in IBD “there is insufficient evidence to recommend restriction of wheat and gluten.”

• The Crohns and Colitis Foundation states that “some IBD patients have found that a gluten-free diet reduces their symptoms, but researchers have not proven that it reduces IBD inflammation.”

• The Asain Working Group guidelines on diet and inflammatory bowel disease state that “a gluten-free diet is not of a proven value in patients with inflammatory bowel disease.”

There are also some confounding factors when discussing gluten free diets. Gluten is often paired with fructans in foods, which are a type of fermentable carbohydrate that is associated with gastrointestinal symptoms. One study showed that 80% of patients with suspected non-celiac gluten sensitivity couldn’t be diagnosed after a gluten challenge.2 This points to the possibility that something found alongside gluten might be the culprit. Fructans offer a convincing alternative cause for why some might experience GI symptoms while eating gluten containing foods. Indeed, research has shown that in patients with suspected non-celiac gluten sensitivity, eating fructans was associated with more gastrointestinal symptoms when compared to eating gluten.3

Positive Gluten Sensitivity Seriologies and the Impact of Gluten Free Diet in Patients with IBD

When I first noticed this study as a part of DDW I was excited. I think that the study design is well thought out. The term “Celiac serologies” means that antibodies to proteins associated with consuming gluten were found in patients’ blood. These patients have immune systems that have already falsely identified these specific proteins as foreign invaders. By studying patients with positive celiac serology, the researchers were able to look at the effect of a gluten free diet in the patients that were likely to experience the greatest benefit from going gluten free.

The goal of this study presented by Dr. Maria Moomal Dahar was to determine if there were any differences in clinical outcomes between IBD patients with positive celiac serologies following a gluten free diet compared to those who were not following a gluten free diet. Out of the 1537 patients IBD patients looked at, only 89 had positive celiac serologies. Of these 89 patients, 29 reported adhering to a gluten free diet.

One interesting finding was that of the 89 patients with positive celiac serologies, those who were not on a gluten free diet were more likely to have a high ESR (measure of inflammation) and eosinophilia (associated with inflammation and infection).

Based on this study, the authors recommend testing for celiac serologies in patients with IBD. They also suggest a trial of a gluten free diet in IBD patients with confirmed celiac serologies. 

My Closing Thoughts

It is so important that research is being done to evaluate the gluten free diet in IBD. Any time where a large majority of patients report improvement following a dietary trend, that should at least warrant some investigation into whether or not those improvements can be replicated in a randomized controlled trial. I am thankful for researchers like Dr. Dahar and her colleagues who are making efforts to further our knowledge in regards to the gluten free diet and its use in IBD. 

One thing I also want to note is that the majority of therapeutic diets studied in IBD (IBD-AID, CDED, EEN, and SCD) all exclude gluten containing grains. Some of these diets show real promise in treating inflammation or alleviating symptoms of patients with IBD, and it is a trend worth noting. On the contrary, the mediterranean diet has also shown similar promising results, and includes gluten containing grains. 

In my opinion, current literature is frustratingly inconclusive. Like many nutrition topics, there isn’t enough evidence to be able to make any strong recommendations one way or another. In light of that, I think that the best approach is the same one I echo all the time: Find out what works for you individually. You know your own body better than any study, scientist, or doctor ever will. So if you notice feeling better on a gluten free diet, maybe that is something you decide you want to continue even if the evidence isn’t quite there yet to show benefit in IBD patients.

Meal Replacements and Oral Nutrition Supplements

Sometimes eating sucks. When my body hurts, I'm tired, and my gut is bloated, the last thing I usually want to do is add fuel to the fire by eating a meal. This is an unfortunate situation to be in because eating is one of those things we kind of have to do to survive. Luckily, there is a way to meet our needs without really eating. Enter the oral nutrition supplement. Calorie dense nutrition shakes designed to give you all the vitamins and minerals you need for livin’ in as little volume as possible. You can down one of these bad boys in under a minute and not have to worry about figuring out how you might fit an entire meal in your distended abdomen.

There are a lot of different nutrition supplements on the market, and it can be difficult to try to figure out which to buy. There are so many factors to consider, it can almost be overwhelming. In this article, I have tackled a few of the more common factors people consider when looking for supplements. Hopefully I have been able to provide some clarification on the differences between some of the common choices for meal replacement shakes.

Calories

The amount of calories I look for in one of these supplements depends on why I am using it in the first place. Am I trying to replace a meal? Then I would probably reach for something with a higher amount of calories. I usually try for at least 250 calories per shake, but closer to 500 calories is probably better. If I am using the shake to replace a snack, maybe 200-300 calories would be more desirable. 

Some nutrition supplements come as a powder that you can mix with water or another liquid. The benefit of these supplements is that you can add as much powder as you want and customize the amount of calories to the situation. Products like Modulen IBD, Huel, Garden of Life Raw Organic Meal Shake, and Super Fuel all come as mixable powders. Garden of Life is one of the lowest calorie options I have seen, coming in at 120 calories per serving. 

Most ready to drink supplements also have higher calorie options available. Ensure and Boost both make higher calorie versions of their regular nutrition shakes. You can usually tell a higher calorie shake because it will have the word “plus” in the name, i.e. Ensure Plus or Boost Plus. The big downside of these higher calorie versions is that a lot of the extra calories come in the form of sugar.

Fat

Fat is a tricky one. Often demonized, fat plays an important role as a source of energy, absorption of certain fat soluble vitamins, and managing inflammation. Certain fats are even essential, which means that we must get them from our diet. The type of fat in nutrition supplements matters. In most supplements, the fat content will be from vegetable oils. Animal fats are unusual or minimally used due to their tendency to be solid at room temperature.

Certain fats in vegetable oil, such as the Omega 6 fatty acids, are sometimes mis-labeled as pro-inflammatory. While these fats can be used by the body to create inflammatory molecules, research has shown that omega-6 fats are associated with lower or unchanged markers of inflammation. If you are somebody who is concerned about these fats, choose a supplement higher in monounsaturated fats such as Orgain or Huel. Looking for the words “high oleic” in the ingredients list is a good way to know that the oil used is high in monounsaturated fats. One supplement, Super Fuel, actually lets you add the fat to your shake yourself, so you can choose the exact type of fat you want!

Carbohydrates

There are a lot of considerations when looking at the carbohydrates in nutrition supplements. Some of the important things in my opinion are the sugar content, presence of artificial sweeteners, presence of maltodextrin, and fiber.

Sugar is an interesting one. The International Organization for the Study of Inflammatory Bowel Disease (IOIBD) says in their guidelines that there is insufficient evidence to recommend any specific change of intake of complex carbohydrates or refined carbohydrates or refined sugars and fructose. Therefore, any reason to limit sugar would have to be based on the known effects of high sugar consumption on heart health, gut health, weight gain, and other markers of health. Many of these supplements are high in added sugars, so it might be prudent to look for some of the lower sugar options such as Super Fuel, Huel, Orgain, or Garden of Life.

Some supplements contain ingredients that might be harmful in IBD patients. Specifically, maltodextrin and artificial sweeteners. Some of the low sugar supplements, such as Premier Protein, use artificial sweeteners like sucralose to replace sugar as a source of sweetness. Most supplements found in stores, including Ensure, Boost, and store brands such as Equate contain maltodextrin as a source of carbohydrates. In the IOIBD guidelines, the researchers note that it may be prudent to limit intake of both maltodextrin and artificial sweeteners. The authors also note, however, that the evidence for maltodextrin is theoretical and mostly based on animal models. Nutritional therapies that involve consuming nutrition supplements with maltodextrin have been found to be effective in IBD, so the jury is still out on maltodextrin.

Fiber is also a hot topic in IBD. Many foods considered healthy contain fiber, but many IBD patients who are flaring consider fiber to be something that aggravates their disease. Many of these supplements contain very small amounts of fiber, usually between 1-2 grams per serving. Some supplements, such as Huel, Kate Farms, and Super Fuel contain a higher amount of fiber. The general consensus from what I have researched appears to be that if you tolerate fiber, more is better. Like many other factors in IBD, fiber seems to be something to consider on an individual basis. Of note, Walmart’s brand Equate was the only supplement I looked at that had 0 grams of fiber per serving.

One thing to note is that some supplements include blends of fruits, vegetables, and other plant compounds. Orgain, Garden of Life, and Kate Farms all include these special blends, likely to try to mimic the benefits of eating whole foods. Other supplements, such as Huel and Super Fuel are made primarily from whole foods.

Protein

The protein needs of an IBD patient are increased during a flare. Protein is needed to help repair damaged tissue and maintain muscle mass, among many other functions. I think it is important to make sure that the nutrition supplement you choose has the protein your body needs to function optimally.

Most supplements have enough protein to meet your body's needs. A little trick I use is to try to shoot for 20% of calories from protein. You might need to whip up your phone calculator in the store, but the math isn’t too hard. First you would take the grams of protein and multiply it by 4, because there are 4 calories in every gram of protein. Then, all you need to do is divide the number of calories of protein by the total calories and multiply by 100 to get the percent!

Let's do an example with Orgain’s Nutritional Shake:

Looking at the bottom, we see Orgain has 16 grams of protein per serving.
Step one would be to multiply 16g by 4 to get the number of calories, which would be 64 calories of protein.

Step two, would be to divide the number of protein calories by the number of calories in a serving, which can be seen at the top of the nutrition facts label.

We would do 64 calories divided by 250 calories and get 0.256.

The final step, to get a percentage, would be to multiply by 100 to make that number a percentage. So, .256 multiplied by 100 is 25.6%. 

25.6% is more than 20%, so Orgain would pass my little test!

Some of the higher protein supplements out there are Huel, Ensure Enlive, and Premier Protein, and Garden of Life. It is important to note that if you aren’t in a flare, your protein needs are likely no higher than the rest of the population. 

Carrageenan

Carrageenan is an emulsifier used to help the ingredients in shakes mix smoothly. It has also been shown to cause a variety of negative effects in animal models, such as increased blood in stool, increased inflammatory markers, and lesions in the bowel. For these reasons, and some small scale human research, IOIBD also states that it may be prudent to reduce intake of processed foods that contain carrageenan in both UC and Crohn’s Disease. Most of the supplements found in stores, such as Ensure, Boost, and store brands such as Equate use carrageenan in their nutrition supplements. If carrageenan is something you wish to avoid, you can usually locate it at the bottom of the ingredients list. You can see it is the last ingredient in Ensure Plus.

To Conclude

I wish I could add more detail, but I don’t want to break your scroll wheel. The most important thing to do when looking for an oral nutrition supplement is to take a look at the nutrition facts label and make sure you are comfortable with the nutrition content and ingredients in your shake. I usually try to look for higher protein and fiber, and lower added sugars while avoiding sucralose, maltodextrin, and carrageenan. Oh and the shake has to taste good too. Could you imagine not wanting to eat anything and reaching for a shake that didn’t even taste good? Neither could I. Considering all that, I usually go for Orgain nutritional shakes. They fit my goals as far as cost, taste, and nutritional content are concerned. 

Another option is to try to make your own shake in a blender. It can be pretty easy to toss some oats, a banana, and a few scoops of peanut butter together and have a tasty, nutritionally dense smoothie to sip on. You even save some money that way too! At the end of the day, store bought shakes or homemade, oral nutrition supplements can be a great way to give your body the fuel it needs to function when you don’t feel like making or eating a meal.

What is a Healthy Diet?

Back when I was in college, I had a professor who hated the word “healthy”. She argued that the word had no real definition. At first, I am not sure if I agreed with her. Surely it was safe to say that something like spinach was a healthy food, right? It has fiber, loads of vitamins and minerals, and is low in calories - perfect health food! As time went on, and I thought about it more and more, I discovered she was right. There really is no one definition for the word healthy, because it applies differently to each of us.

Every person has their own goals as far as their health. For a bodybuilder, gaining muscle might be considered healthy. For a sprinter, something healthy might improve their times on the track. For others, healthy is eating in a way that will help extend their life. You can see that it isn’t as simple as slapping the label “healthy” on a food and calling it a day. 

One of my favorite examples is birthdays. It doesn’t take a nutrition expert to know that birthday cake doesn’t improve physical health, but what about mental health? The goal on birthdays has never been to help you sculpt that hot summer body, but rather to celebrate with friends and family. It is a time to feel joy that we have made it another year on this Earth. If taking the birthday cake away harms that goal, well then the only conclusion I come to is that birthday cake is health food. Don’t tell anybody at the hospital I work at I just wrote that.

What about for people with IBD? What does a “healthy” diet look like for us? Having an interest in nutrition as well as IBD, I wrestle with this question a lot. I know that for the general population, foods like broccoli and brussel sprouts have been shown to reduce cancer risk, among other benefits. Therefore, they would generally be considered “health food”. But for somebody in an IBD flare, you might be better off roasting a package of nails at 350 in the oven for dinner. All that roughage is just going to result in pain and irritation as it passes through the inflamed intestine. For an individual with IBD who is in a flare, broccoli and brussel sprouts might be the furthest thing from healthy food they can eat.

That is why I think it is so important that we all understand the temporary and individual nature of the word healthy. It is not set in stone, what is healthy for you to eat today might not be healthy for you tomorrow. You should never be ashamed because you are not eating what the average person would call a “healthy” diet with this disease. That isn’t to say that you shouldn’t pay attention to diet at all. Your definition of a healthy diet will depend on your goals, which will most likely be very different from the friends, family, and coworkers you interact with on a day to day basis. Don’t compare apples to oranges. Take the time to define your health goals, and then determine what foods will help you reach those goals. Find your healthy diet.

IBD Diets: Gluten Free for Crohn's and Colitis

By Leah Clark

Because of the popularity of Hollywood fad diets, the term 'gluten-free' has become more and more popular over the past decade. While not necessarily intending to do so, this trend actually brought great change to individuals suffering from celiac disease, non-celiac gluten sensitivity, and inflammatory bowel diseases. With new food products coming to market and more menu items coming to restaurants, it has provided a new way for people that cannot eat gluten to experience food. As someone that was diagnosed with both celiac disease and #Crohn's disease ten years ago, I can confidently say I know my way around a nutrition label. That being said, not everyone that is on a gluten free diet, or that is planning on starting one, knows what to do. When discussing your treatment plans for your IBD with your doctor, discussing diet changes should not be forgotten. So, is going gluten free right for you?

Bacon, eggs, potatoes...who says living a gluten free lifestyle means giving up your favorite breakfast foods!

What is gluten?

With all these terms of gluten free, gluten sensitive, wheat-free, gluten-friendly, and more, it can be confusing to know what it all means! Isn't flour gluten, or is it any grain? To start with the basics of a gluten free diet, one has to know what to look for. Gluten is the proteins found in wheat, rye, and barley. So when on a gluten free diet, wheat, rye, and barely are the foods to avoid.

How to read labels

Okay, so know that I know what to avoid, what are the necessary steps to ensure that I don't eat the wrong foods? Check labels on everything. Even if you think something may be gluten free, it never hurts to read the nutrition labels. Certain foods don't have labels, such as fruits and vegetables; however, these foods do not consist of any other ingredients other than what they are called-apples, carrots, oranges, etc. Foods that are made with other ingredients, such as cereal, pasta, and crackers, are foods that need to be checked. Luckily, most companies are good about food labeling, so boxes will often say "Gluten Free" or "Contains: milk, soy, and wheat."

However, sometimes there are tricky labels that you need to look out for. For example, the cereal Rice Krispies is not #glutenfree. The ingredients include rice, sugar, salt, malt flavor, and vitamins and minerals. The key word here is malt. Although the other ingredients are okay, the malt flavor is not. Malt is a tricky word because it is not wheat, rye, or barely; however, malt is a derivative from barley. Therefore, Rice Krispies are not gluten free. Words like malt extract, malt flavoring, barley malt, wheat-germ, and non-gluten free oats, are words to look out for.

What foods can I eat?

A good rule of thumb is to stick to foods that are labeled gluten free, or are"natural" foods. By natural, I mean foods that are not made with large amounts of ingredients. A good starting gluten free grocery

list could include:

• Fruit-apples, bananas, kiwi, oranges, grapes, strawberries, raspberries, blueberries, plums

• Vegetables-carrots, corn, green beans, lettuce, spinach, broccoli, radishes, celery, zucchini

• Milk-can be almond, dairy, soy, cashew

• Protein-lean meats, chicken, eggs

• Dairy products-cheese, gluten free yogurt, butter, cottage cheese

• Grains-white or brown rice, gluten free oatmeal, gluten free breads and pastas

Gluten free pizza? Yes please! Restaurants have gotten better at properly preparing gluten free dishes, including delicious pizza, to make it easier for people to enjoying going out to eat.

Gluten free diet can not only be good for your gut, but also for other parts of your body because of how healthy a gluten free diet can be. Many of the foods listed are healthy in their nature, like lean meats, fruits, and vegetables. However, just because something says "gluten free," does not mean it is part of a healthy diet. Sure, chocolate is gluten free, but if all you ate was chocolate, would that be the best way to go on a gluten free diet? Probably not.

But I thought gluten free foods always tasted bad?

A common misconception about gluten free food is that it tastes gross. While yes, there are some bad gluten free food products out there, this is no different than there being bad gluten food. It all depends on your preferences and experimenting with different brands. Making home-made gluten free brownies is not as simple as using a Pillsbury box recipe of 'normal' brownies (although, there are some Pillsbury gluten free baking products that taste great). The point is to try new brands and baking techniques that work for you. I've spent the last ten years of my life finding my favorite brands of pastas, crackers, and bread, and I can honestly tell you, it wasn't I traveled to an entirely different country and tried their gluten free bread that I found my favorite. Gluten free food can taste just as good, if not better, than the food you're used to! It just takes some time and preparation.

How do I know if gluten free is right for me?

Honestly, it all depends on what you and your doctor think is best for you. I had to go gluten free because I was diagnosed with a disease that literally required me to. Yet, I know several people with Crohn's or colitis that have gluten free diets that do not also have celiac disease. In short, if eating certain foods make you feel bad, do not eat those foods! There are other foods I avoid even though they are gluten free, such as popcorn and caffeinated sodas, because I know they upset me. It truly depends on each person and if it is going to help with your treatment for IBD.