Nutrition in Inflammatory Bowel Disease

Maryanne Comrie

Registered Dietician

Inkosi Albert Luthuli Central Hospital

Does diet cause IBD?

Can diet cure IBD? Do I need to cut gluten/milk/wheat

out of my diet?

How do I make sure I am getting the proper nutrition?

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Aims of Todays presentation

Highlight the importance of good nutrition in IBD and the risks of malnutrition.

Give a guideline for how to eat during the active phase/flare up and in remissive phase

Cover common trigger foods that may not be tolerated.

Dispel diet myths about IBD

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IBD and Nutrition

Although diet is not a cause of IBD, it is still very important in the management of IBD and preventing malnutrition.

Malnutrition can worsen the extent of the disease and lower the immune system.

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Causes of malnutrition in IBD

Weight loss

Protein/muscle Loss Vitamin & Mineral

Deficiencies Bone disease

Anaemia

Loss of Appetite

Increased nutrient losses

Increased needs due to

inflammation Poor absorption in gut

Drug-nutrient interactions

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Poor absorption of nutrients in inflamed GUT lining

Protein, vitamin and minerals, blood loss

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Benefits of Good Nutrition

Build up protein stores Heal the gut mucosal lining Replace vitamin and mineral deficiencies Reduce inflammation process Better outcomes in surgeries Maintain a healthy weight

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How can I tell if I am a healthy weight for my height? Weight / (height x height) Between 20 – 25: healthy weight.

BMI

18.5 – 20 Borderline underweight

20 – 25 Normal weight

25 – 30 Overweight

30 – 35 Obese

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Nutritional Aims

Depends on: ◦ Location & extent of the inflammation ◦ Active (flare up) or remissive (no flare

up) phase

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Important to remember

*No specific food or special diet can cause or cure IBD

*Some foods may trigger IBD and some

may ease symptoms

* Diet is individualized, not all foods affect every person with IBD in the

same way.

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Active Phase

If food cannot be tolerated: Clear liquids such as apple/grape juice, jelly, non-fizzy drinks, hot bovril can be taken.

Rehydrate and replace lost electrolytes eg: sugar salt solution, O.R.S, energade, game

Nutritional supplement drinks can help for extra protein.

Aim is to rest the bowel, choose gentle foods that gut can easily digest, cause least discomfort.

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Active Phase

Avoid foods that make symptoms worse. ◦ wheat, ◦ corn, ◦ tomatoes, ◦ citrus fruit ◦ and eggs are common problem foods.

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Active Phase Also avoid milk and milk products

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Active Phase

Slowly introduce food into your diet, starting by adding: ◦ softly cooked vegetables eg: carrots,

butternut, marrows, gem squash ◦ cooked fruit eg: apple sauce, canned fruit

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Active Phase As inflammation and ulceration subsides, a

light diet can be followed.

What is a light diet? Not having high fibre foods, fatty and fried foods or spices/chilli.

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Remissive Phase

Eat balanced mixed meals 3 times daily with healthy snacks in between. ◦ Small, more frequent meals are easier to

digest.

Aim is to eat a variety of foods – leave out the foods that you have a specific problem with.

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Starchy Foods

Include starchy foods. These include foods like rice, phutu, potatoes, butternut and bread.

◦ Starchy foods should be limited to ¼ of the plate, or a fistful on the plate.

◦ Try choose brown, unrefined or high fibre options

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Fibre What is fibre? Fibre forms part of plant

products such as cereal grains, fruit and vegetables & legumes, nuts and seeds. Does not get digested and broken down by our bodies but rather forms part of our stools.

There are 2 types: insoluble or roughage,

and soluble or soft fibre M.K.Comrie IBD Patient Meeting

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Fibre

Insoluble fibre or roughage: ◦ Doesn’t dissolve in water – passes through

the GIT relatively intact/undigested. ◦ Adds bulk to the diet ◦ Helps feed the good bacteria in the gut for

immune function

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Fibre

Soluble or Soft fibre: ◦ Gentle fibre that attracts water forming a gel. ◦ Can help can improve diarrhoea ◦ Helps regulate blood sugar levels ◦ Can lower “bad” (LDL) cholesterol

• It may help to have less insoluble / rough fibre in the diet and include more soluble fibre in the diet

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Fibre Roughage Soluble or soft fibre Wheat bran (bran flakes, bran muffins, digestive bran) Wholewheat bread Brown rice

Oats, oat bran Brown bread White rice

Stringy or fibrous vegetables and fruit eg: celery, spinach Pips, seeds, peels of vegetables

Peeled fruits and vegetables Dried fruit (not raisons/prunes)

Beans, lentils with skins Popcorn kernels Flax seeds

Beans, peas and lentils without husks, barley, tiger soup mix, chickpea flour, split peas

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Fibre

No evidence showing benefits in

following a completely fibre-free diet in IBD – unless in a flare up or when you

have a stricture/ blockage in the bowel

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Protein Foods

Chicken, fish, low fat dairy or eggs may

be eaten every day: ◦ good source of iron & protein and help with wound

healing. Always choose low fat/lean. ◦ Red meat < 3 / week, fish and chicken more often. ◦ Beans/lentils/soya healthy alternative to animal

protein

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Protein Foods Oily fish eg: mackerel, tuna, salmon, sardines

contain omega 3 fatty acids, good for reducing inflammation and blood pressure. Vegetarian sources of omega 3

Dairy products also good source of protein and calcium. No need to cut out dairy although some patients with IBD do not tolerate them well [Shah et al 2015].

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Vegetables and Fruit Eat plenty of vegetables and fruit, good source

of vitamins, minerals and antioxidants. Vitamin C containing fruit and vegetable helps absorption of iron.

Choose variety of colours ◦ Red ◦ Orange/yellow ◦ Green

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Fluids, Physical Activity Drink plenty of fluid, especially water (at

least 6-8 glasses daily), works with fibre in the body, prevents dehydration.

Physical Activity 30 minutes daily ~ builds muscle and bone strength, good for overall immune system

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Foods and beverages that may worsen symptoms Excess fruit and fruit juices Sorbitol (artificial sweetener) containing

foods eg: diet cooldrinks and gums Fizzy drinks Skins and pips of vegetables Gas forming vegetables ◦ eg broccoli, brussels sprouts, cauliflower, cabbage,

cucumber, corn, leeks, onions, peas, green peppers, radishes & turnips

High roughage foods eg: popcorn, wheat bran.

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Foods and beverages that may worsen symptoms

Concentrated carbohydrates eg sugar, chocolates, sweets, cakes and desserts.

Fatty foods. Limit oil when cooking. Limit fatty foods eg: vet koeks, processed meats (sausages, polony), organ meat, full cream dairy products, mayonnaise, pies. Limit fatty takeaways eg: chinese, fried chicken/chips

Empty calories!

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Foods and beverages that may worsen symptoms

Spices, chilli, seasoning and spicy food Caffeine eg tea, coffee, coke, diet coke, pepsi

etc Smoking and drinking alcohol – increases

inflammation These all irritate the gut!

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Food allergies and intolerances

Lactose intolerance: similar symptoms to IBD. Bloating, stomach cramps or diarrhea 30 -90 min after taking a dairy containing food eg: milk. Cheese, yoghurts & maas better tolerated.

Fat malabsorption: called steatthorea: pale, grey, foul smelling stools avoid fatty foods.

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Food allergies and intolerances

Gluten or wheat intolerance eg: coeliac disease ~ not common, needs to be tested. Speak to your doctor if you suspect

Limited data on gluten-free diets being beneficial for IBD [Shah et al 2015]

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Supplements Vitamin and mineral supplements ◦ Iron, Vitamin B12, Folic acid (anaemia) ◦ Zinc (wound healing) ◦ Calcium & vitamin D (bone health) ◦ Vits ADEK, if malabsorption of fat ◦ Antioxidants (vit A,C,E) & omega 3 – may reduce

inflammation.

Always separate iron and calcium supplementation

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Supplements

Probiotics Live “friendly” bacteria, which are beneficial to the

gut and immune system. The balance of good and bad bacteria can be

disrupted with antibiotic use, or during frequent diarrhoea.

Probiotics are found naturally in certain fermented foods, eg: live yoghurt and maas, or taken in tablet form.

Have shown to be beneficial in patients with UC, with pouchitis. No evidence in Crohns [Shah et al 2015]

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Supplements

Nutritional Supplements ◦ In active phase ◦ For poor appetite ◦ To help with weight and muscle gain ◦ High protein and added nutrients (eg:

prebiotics, vits&minerals) ◦ If not tolerating milk, choose one you can

mix with water ◦ Specialized supplements on the market –

Modulen IBD & Peptamen M.K.Comrie IBD Patient Meeting

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Conclusion

Healthy eating is important in preventing malnutrition as well as vitamin and mineral deficiencies.

Focus on a balanced diet – it is one of the building blocks to health along with medication and following a healthy lifestyle.

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Conclusion

Try not to eliminate any food groups unnecessarily and take a nutritional supplement if you are struggling to gain weight.

Always consult a doctor before starting any alternative therapy as it could interact with medication.

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Conclusion

Don’t be shy to see a dietician as she can give you a diet plan for your individual needs

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References

Crohns and Collitis Foundation of America www.ccfa.org HealingWell Crohn’s Disease Resource Center

www.healingwell.com/IBD National Association for Colitis and Crohn’s Disease

www.nacc.org.uk/content/home.asp

Mahan L & Escott-Stump S (2008). Krause’s Food and Nutrition therapy (pg: 689–694)

ESPEN Guidelines on Enteral Nutrition: Gastroenterology (2006) 25, 260 – 274

Nutritional Therapy for Active Crohn’s Disease: World J. Gastroenterology 2008 July 21; 14(27): 4420 - 4423 Paul A Smith

Oral Diets and Nutrition Support for Inflammatory Bowel Disease: What is the Evidence? 2015 Shah ND, Parian AM, Mullin GE, Limketkai BN. Nutrition in Clinical Practice

Food and IBD, Information Booklet - Crohns and Colitis UK

Useful Websites

Questions?

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