Inflammatory Bowel Disease

and Diet-Question and Answers

By Nicola AttwoodGastro Dietitian-Colchester Hospital

Crohn’s and Colitis Meeting May 2013

What is Inflammatory Bowel Disease?

Ulcerative Colitis Crohn’s Disease

ChronicNo medical cure

ChronicNo cure

Inflammatory Bowel Disease

Indeterminate Colitis 10%

What is Difference between UC and CD?

Ulcerative Colitis

•Starts in the rectum•Extends to beginning of large bowel (caecum)•Inflammation limited to lining of the colon

Crohn’s Disease

•Can effect any part of the bowel•Can be patchy •Can extend through the bowel wall

Why is malnutrition common in IBD?Effect Cause

Reduced food intake

MalabsorptionIncreased intestinal losses

Drugs

Poor appetite ,pain, nausea, dietary restrictionReduced absorption caused by damaged from inflammation and surgery

Altered absorption and utilisation.

What vitamin and mineral deficiencies need to be treated?• Deficiencies in vitamins and minerals in IBD is

common• Supplement with Folic acid, vitamin D, vitamin B

complex and vitamin C may be good idea if you are symptomatic.

• May need calcium if on steroids• Supplement with iron if anaemic• Supplement with zinc if there is long-term

diarrhoea.

How is malnutrition treated?

• Provide extra energy and protein in diet by fortifying foods

• Aim for small frequent meals• May need prescription supplements such as

Fresubin Energy®, Fortisip ®, Ensure Plus ®, Modulen ® or Elemental 028 ®

Is There a special diet for those with IBD?

• Diet for IBD needs to be individualised• Depends of type of disease and part of bowel

affected• Depends on previous surgery• An elimination diet can help identify food

intolerances• A low residue diet may be needed if there is a

stricture or in a flare-up• Dietitian is the best guide in selection of most

appropriate diet

What to eat if IBD is active?

• Best diet should include foods from all the food groups

• Choose low fibre starchy foods, fruit and vegetables

• Avoid some foods if intolerance is identified• Smaller meals are better tolerated

What is a low fibre or low residue diet?

• These diets help to reduce the amount of “roughage” or residue in the stool

• Restriction of raw fruits and vegetables, their skins

• Restriction of seeds, nuts and sweet corn• Restrict high fibre carbohydrates such as bran,

wholemeal, and potato skins• These diets are used when there is significant

diarrhoea, high output stomas or strictures.

High fibre foods to avoid

Recommended foods and those to avoidFood GroupsRecommend Avoid

Grains Bread and cereals made from refined flours: Wholegrain/meal bread and cereals:(four or more white bread, Cornflakes, Rice krispies, wholewheat/meal bread, granary bread,servings daily) Cheerios, Puffed wheat, Special K, porridge seeded bread, cereals containing bran,

Weetabix, Shredded Wheat, muesli orother cereas/snack bars containing bran, dried fruit/coconut or nuts

white rice wholegrain/brown rice, fried ricewhite pasta wholegrain/wheat pasta

wholegrain/wheat biscuits/crackerswhite flour and foods made with this flour wholemeal/wheat flour

Pulses None Dried beans including baked beans, lentils, dried peas

Nuts and seeds None All nuts and seeds and foods containing them including nut butters, coconut

Potatoes Potatoes boiled, mashed, baked without Potato skin, fried potatoes including chips(2 medicum size/day) skin roasted, crisps, potato salad

Vegetables Well cooked vegetables as follows: Salads and other raw vegetables

(2 cups/day) green beans, spinach, pumpkin

Food GroupsRecommend Avoid

Vegetables asparagus tips, beetroot, carrots, seedless brussel sprouts no pips, seeds, husks,strained vegetable soup/vegetable juices, skins or stalks, sweetcorn, cabbage, Vegetables can be pureed if necessary sauerkraut, mushrooms, turnip, onions,

leeks, peppers

Fruit squash, tinned fruit, Fruit juices with pulp, prune juice, fizzy ( 2 medium size ripe banana, melon, tomato no skin or seeds, drinks, tinned pineapple, fresh fruit

pieces/day) ripe avocado. Jelly jam, shredless preserves,lemon curd. dried fruit, cakes/biscuits containing driedFruit can be pureed if necessary fruit, jam, marmalade with seeds, skins,

pips. Mincemeat. Fruit pie/tart/flan. Skin, stalks, seeds, stones

Milk and milk Whole milk up to 300ml (1/2 pint)/day, semi- Full fat cheese, milk puddings made products skimmed up to 450ml (3/4 pint), skimmed with wholegrain ingredients

milk up to 600ml (1pt), low fat products quiche, pizzaeg plain yogurt or with allowed fruit fromagefrais or milk puddings or custard or cream oricecream without nuts or pieces of fruit,creamy soup with sieved vegetables, plaincottage cheese or low fat cheese, milk substitudes eg soya milk and plain soya desserts

Fats and oils Oil (1 tablespoon/person), low fat margarine, Full fat margarine, coconut cream, lard,butter (scraping), low fat cream sauces suet

Food GroupsRecommend Avoid

Meat and poultry Tender lean meat and poultry, lean Tough/course meats with gristle,(100g/4oz) processed meats eg ham/chicken/turkeyluncheon meats, sausages, hotdogs,

or bacon cold cuts, meat pies, pasties, pates,fried meat/poultry, meat prepared with wholegrain ingredients/seeds/nutsmeat burgers

Fish (up to 160g or Fish (white/oily) steamed, poached, boiled, Fried fish and shellfish6oz) tinned in water or oil (discard)

Eggs (up to 4/wk) Boiled, poached, scrambled, omelette Fried

Miscellaneous Sugar, honey, syrup, boiled sweets, mints Popcorn, pickles, horseradish, relish, caramel, marshmallow, jelly, pepper, salt, herbs, spices, curries, chilli, alcohol, gravy made with water, tomato sauce, soy, mustard, lemon juice, vinegar, garlicsauce, low fat white sauce, chocolates, carbonated drinks. Scones,

pastries

What to eat when IBD is in Remission?

• Important to eat foods from all the main foods groups

• Can slowly introduce fibre rich foods • Add one new food at a time and start with small

portions-gradually increasing• Keep a food and symptom diary to identify food

intolerances• Gradually build up to a

normal diet.

Can food make IBD inflammation worse?

• No• certain foods in any individual may aggravate

symptoms of these diseases• no evidence that the inflammation of the bowel is

directly affected.• Avoid food out of date or contaminated as food

poisoning will aggravate IBD

Identifying “problem foods”

• Keeping a food and symptom diary is very important

• Common foods less well tolerated are:o alcohol (mixed drinks, beer, wine) , Fizzy drinks, caffeine drinks

and fruit juiceo Skins, husk and stalks of fruit and vegetableso dairy products (if lactose intolerant) o fatty foods (fried foods) o foods high in fibre such as whole grains and brano gas-producing foods (lentils, beans, legumes, cabbage,

broccoli, onions) o nuts and seeds (peanut butter, other nut butters) o raw fruits and raw vegetables o spicy foods

Should someone with active IBD drink more fluid?

• Yes!• chronic diarrhoea increases the risk of

dehydration• dehydration and salt loss create a feeling of

weakness.• people with IBD should drink plenty of fluids,

especially in warm weather when skin losses of salt and water may be high

Diet tips for IBD-summary

• Keep a food and symptom diary to identify problem foods that may aggravate symptoms

• Follow a low residue diet or low fibre diet if having a flare up

• Small frequent meals are often better tolerated• If losing weight let us know-you may need

supplements• No special diet for IBD – everyone is difference.

Aim for a balance of all the main foods groups

Thank You