“Supporting Nutrition in Inflammatory Bowel Disease

when Patients are ill”

Managing diet & symptomsNACC Spring Meeting 2012

Dr Nicola Burch MBChB MRCP(UK)(Gastro) MSc(hons)

Consultant Gastroenterologist & Clinical Nutrition LeadUniversity Hospitals Coventry and Warwickshire NHS Trust

Tel: 024 7696 6092 (sec)email: nicola.burch@uhcw.nhs.uk

• Basic Facts

• Brief overview of IBD

• Basic overview: protein; carbohydrates; fibre; fats

• Dietary options during a flare up

• Nutrition Support in the acute setting

Objectives

Some basic facts....There is no food that causes inflammatory bowel disease (IBD)

Diet manipulation cannot cure IBD - but can be useful for symptom control

Certain types of food can exacerbate symptoms during a ‘flare-up’

Diet & Bowels are not “One Size Fits All”

Tolerance to certain food types will vary according to degree active inflammation

Understanding some of the basics about nutrition and IBD can help you to manage your symptoms

BUT.... Beware...

Over-zealous dietary restriction will result in weight loss and illness

Overview of IBD

What causes weight loss in IBD?

Increased USE or LOSS of nutrients

Decreased INTAKE due to Symptoms

Abdominal PainBloating

CrampingWind

Fear of causing diarrhoeaNauseaVomiting

Active inflammationMalabsorption

Profuse DiarrhoeaRecurrent Vomiting

Food Terminology

Protein

animal plant

Fibre

soluble insoluble

Carbohydrate

complex simple

Fat

saturated

unsaturated

trans-fats hydrogenated

Protein

Animal Protein (“Complete’): Meat, Fish, Eggs, DairyPlant Protein: Cereals, Nuts, & Pulses. Low amounts of the 10 essential aa.

Harder to digest due to fibre content

Should make up approximately 15% calorie intake

Made up of amino acids

Body uses amino acids to make proteins and for repair and growth of body tissue

Hormones, Enzymes, & Antibodies are types of proteins

Insufficient protein intake decrease immunity and affects ability to heal

More protein required during illness/ after surgery for the body to regenerate tissue, heal wounds, and rebuild damaged tissue

Protein & IBD

Increased protein loss due to inflammation & malabsorption

Recommended protein intake: 0.75g/kg body weight. In IBD better to aim for 1.2g/kg

Tips: - Ideally more from animal sources - Lean cuts of meat - Plant protein: not well absorbed - especially in small bowel. Leads to increased ‘bloating’

Dairy Products

Excellent source of protein, ‘milk sugar’ (lactose), calcium, vitamins

May contribute to bloating & abdominal pain esp in SB inflammation, lactose intolerance

Temporary lactose intolerance during ‘flare-ups’

Not wise to avoid dairy completely (unless good medical reason) - instead consider lactose free dairy products or lactase enzyme supplements

NB: lactose found in ready meals, margarine, mayonnaise as well as dairy products milk & ice-cream

CarbohydrateConverted to glucose by digestionCells utilise glucose to make energy - thus ‘fuels the body’Contain starch and sugars which may be difficult to digest

COMPLEX - eg Starch & Fibre

PotatoesRoot vegetablesCerealsLegumes - peas, beans, lentilsRicePastaBread

SIMPLE - Sugars

Natural: Milk; Fruits; Vegetables

Refined: Cakes; Biscuits; Pastries

Raffinose - esp. in vegetables such as beans; cabbage; brussel sprouts; broccoli & asparagus

Fructose - esp. in onions; artichokes; wheat; most fruits

Lactose - Natural milk sugar

CarbohydrateSmall bowel inflammation or rapid transit through SB (eg. post operatively) decreases ability to digest CHO

Results in increased delivery of CHO to colon

Normal intestinal bacteria then digests (by fermentation) CHO producing gas (carbon dioxide, hydrogen, & methane)

Abdominal Pain

BloatingFlatus ++

TIPS

White rice - entirely digested in SB. Thus not gas producing

Difficult to digest CHOWholemeal bread; brown rice; wholemeal pastaPeas; beans; lentils; corn; wholegrain cereals; seeds; nutsThe Cabbage Family: broccoli; cabbage; cauliflower; brussel sproutsOnion; garlic; chivesGrapes; melons; dried fruits

Even more difficult to digest if Fatty - eg chips; crisps; fried veg; chocolate; bicuits; cake etc

FibreCarbohydrate from Plant-Based foodsNot absorbable - thus no nutritional value

SOLUBLE (dissolves in H20)Completely broken down by gut bacteria in colonLess gas formingLess likely to irritate colon

Thus...Better for patients with colonic inflammation

INSOLUBLE“High fibre diet”Generally good for health but not in IBD with colonic inflammationNot digestible by gut but intestinal bacteria partially digestRemainder passes through colon causes irritation if already inflamed

Peeled fruit & veg (no skin/seeds)White rice

White pastaProcessed cereals: porridge;

cornflakes; puffed rice

Wheat bran; wholemeal breadCabbageBroccoli

SweetcornLegumes

Skins & seeds of fruit & veg

Abdominal Pain

BloatingFlatus ++

DiarrhoeaUndigested food in

stool

FatGood source of energy - but more complicated to digestShould not constitute >1/3 of our energy intake in dietImportant for brain, nervous system, immune system, hormone metabolism, healthy hair, nails & skinVitamin absorption: A, D, E, KThermal regulation

SATURATEDAnimal & dairy products

UNSATURATEDVegetable sources & oily fish

TIPS

Patients with IBD need easy to digest food - thus low fatHigh fat foods

Unsaturated fats healthier than saturated

Hydrogenated Fats - modified fats used in food industry to prolong shelf-life; flavour; stability. Creates trans-fats that are harmful to health

Trans-Fats - Margarine; snack foods; fast foods; biscuits; crisps; cereals; icing etc

DiarrhoeaFlatus

Reduced Fat

Low cholestero

l

Low saturated

fat

During a Flare-UpNeed to try to give the gut ‘easily digestible’ food - simple building blocks for repair

General Approach: High Protein (esp. animal); Low fat; Low carbohydrate; Low fibre - ideally for 4-6 weeks until symptoms resolving.

✴Small frequent meals✴Maintain hydration✴Increase protein from animal sources - esp. minced/ tenderised✴Reduce intake of complex carbohydrates (thus decrease bloating)✴Reduce lactose intake - natural yogurt; hard cheeses; lactose free milk; soya✴Limit caffeine & alcohol intake (esp. lager; beer; fizzy drinks)✴Avoid artificial sweeteners & processed foods✴Food preparation important

Once improving....As pain, diarrhoea, bleeding & bloating improve:

Phased re-introduction of normal dietIntroduce foods slowly one at a time every few daysMonitor symptom responseAvoid rapid increase in fibre & carbohydrate intake

Food preparation important role:

Modern techniques - fast food: impact on gut health

Especially during flare-up try to stick with casseroles; roasted meat; steaming; poaching; boiling. Avoid ready meals; sauces; spices etc

Other Types of Nutrition Support

Parenteral Nutrition

Enteral Nutrition

Elemental DietPolymeric Diet

Short gut

Fistulas - bypass gut

Preparation pre-op

Mucosal healing

Fluids; electrolytes; or complete nutrition

Nutrition in simplest form

First line treatment in children with SB Crohns

As effective as Steroids in trials for remission

Require 6 weeks - compliance; palatability

Supplemental/ complete

Overnight ‘top ups’

Useful in stricturing crohns

? May promote healing

Questions?

Special Considerations

“You will need to start a Low residue diet”

Decreases bulk and volume of stoolHelps reduce ‘obstructive symptoms’, pain & bloating

Foods to EatWhite breadRice crispies, cornflakes etcWhite rice or pastaWell cooked vegetablesCooked or tinned fruit (no skin or seeds) Fruit or vegetable juices

Foods to Reduce/AvoidWholegrain/wholemeal cereals, bread or pastaBrown riceLentils, chick peas, beans & pulses Nuts & seedsPotato skinsRaw vegetables and salads Vegetable stalksSkin, pith, seeds etc on fruit Dried fruit