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Nutrition in Inflammatory Bowel Disease
Maryanne Comrie
Registered Dietician
Inkosi Albert Luthuli Central Hospital
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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?
M.K.Comrie IBD Patient Meeting
SAGES '15
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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
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Questions?
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