IBD And Nutrition

The importance of nutrition in maintaining or returning you to good health is a well-recognized concept of our time.

Meeting nutritional needs is necessary for everyone, but is especially important for people with inflammatory bowel disease.

Medications are often more effective when your nutritional state is not depleted. In addition, when intestinal losses of proteins and other nutrients occur in IBD, they must be compensated for by increasing the amount of food taken in. The slowing of growth which occurs in some children and teenagers with IBD often responds dramatically to increases in the intake of protein and calories.
Weight loss can also affect the body's hormones: in women and girls, this can result in irregular periods or the temporary cessation of the menstrual cycle. Being able to eat sufficient quantities of food is often very difficult when gastrointestinal symptoms are active.

Several approaches that may be helpful in maximising food intake in IBD.

Nutritional requirements for an individual with IBD will vary with age, sex, physical activity level and any excessive losses caused by intestinal inflammation and diarrhoea. The first step in individual counselling is for a dietician or nutritionist to analyse your nutrient intake. This is usually accomplished by completing a "food diary" over a period of days or weeks. If you are eating less than the recommended amount for a healthy person of your age, size, etc., (based upon Recommended Daily Allowances or RDA), then you will need to find ways to increase your intake of food.

If you are having trouble gaining or maintaining your weight, you may need even more calories than the RDAs require. It is important to recognise that the amounts of some nutrients (calories, protein, vitamins and minerals) that are needed by the body increase from childhood through adolescence and then decrease during adulthood.

Recommendations for nutrient intake must be increased further if there is evidence of excessive losses of fat, protein, iron, calcium, or zinc, or if chronic undernutrition has resulted in depleted body stores of these nutrients.

Usually, the nutritional needs of the person with IBD can be met by food alone, together with a well-formulated multivitamin and, if needed, additional supplemental iron. It is important to recognise that it is the total daily intake of calories, protein and other nutrients, not the amount eaten at mealtimes, that determines whether you are eating enough. Therefore, if you feel full at mealtimes, frequent smaller meals with snacks may meet your nutritional needs.

Parents sometimes consider the "fast foods" enjoyed by their children or teenagers unhealthy "junk foods." However, some of these foods have substantial nutritional value. A slice of pizza provides protein, calcium and vitamin D from the cheese, vitamins A and C from the tomato sauce, and B vitamins from the crust. Similarly, hamburgers and cheeseburgers provide plenty of protein in addition to calories. While these foods contain more fat and salt than is wise on a long-term basis, the calories and protein they provide during the growing period can help to maintain normal gains in height and weight for young people with IBD.
Milk products like cheese, milk shakes and ice cream are excellent sources of calcium, calories and protein and should not be avoided simply because a child or adult has IBD.

In people with low intestinal levels of the enzyme lactase, milk sugar (lactose) may cause bloating or diarrhoea (lactose intolerance). Discomfort is temporary, however, and can usually be alleviated with the use of a commercially prepared enzyme (see below). There is no evidence to suggest that these products will irritate IBD.

Some people with IBD limit their intake of food during daytime hours to prevent cramping, trips to the bathroom, or accidents at work or school. Unfortunately, this practice can greatly reduce the number of calories consumed each day. If the physician is made aware of this situation, specific medications can be prescribed and arrangements made with teachers or employers.

At times, the symptoms of IBD can prevent you from eating enough to satisfy nutritional requirements. This can happen when there is a narrowing of the bowel or continuous diarrhoea. Eating is often difficult under these circumstances, so liquid formula supplements may be used to provide additional nutrients. Many products are now available in a range of flavours and prices. Your doctor may prescribe an elemental formula when a more digested protein or lower residue diet is necessary.

How to Decrease Intestinal Cramping Associated with Eating

When IBD is active, it is not unusual for eating to cause cramping and intestinal discomfort. This is especially true when the small intestine is inflamed. Since there are several reasons why this occurs (as described below), it is important to observe any association between specific foods or types of foods and the onset of gastrointestinal symptoms. Any the following foods can cause discomfort:

Milk and milk products.

Lactase is an enzyme in the small intestine which breaks down lactose, the sugar found in dairy products. If lactase levels are low, symptoms of bloating, gas and/or diarrhoea usually occur 30 to 90 minutes after drinking milk or eating large amounts of cheese or ice cream. Some dairy products with small amounts of lactose, like butter, yoghurt and hard cheeses (Swiss, muenster, cheddar) cause few problems. Using non-dairy (milk substitute) products, taking commercially available lactase in capsules, or adding it to milk for 24 to 48 hours before drinking, will help alleviate these symptoms. Recently, enzymatically-treated (pre-digested) milk and non-dairy frozen desserts have become available in grocery stores.

High fibre foods.

This category includes foods such as seeds, nuts, popcorn, corn, and certain Chinese vegetables. These foods may produce cramping if there is narrowing of the bowel. When this occurs early in the course of the disease, it is often a temporary problem caused by edema or swelling of the bowel wall. Later in the course of the illness, these symptoms may indicate scarring (stenosis) of the intestine. High fibre foods also contribute to diarrhoea (greater stool volume) because they are incompletely digested by the small intestine. Once fibre enters the large intestine, it stimulates contractions, especially when the colon is inflamed with either Crohn's colitis or ulcerative colitis. This is the reason for using "low residue" foods such as broth, gelatine, poultry without skin, potatoes without skin, rolls, noodles, rice, eggs and fish. High fibre foods may also contribute to diarrhoea by causing mechanical irritation if the colon is severely inflamed.

Fried or greasy foods.

This category includes pork products, butter, margarine, cream sauces, etc. These foods may cause gas and diarrhoea if fat absorption is incomplete. Usually this occurs after removal of large amounts of small bowel, especially ileum. One way to overcome these symptoms is to decrease the amount of fat in the diet. Another way is to use an easily absorbable fat, such as medium-chain triglyceride (MCT) oil, in cooking and salad dressings.

Large meals.

Many people with IBD find that frequent (perhaps five) small meals produce fewer symptoms than the customary three large meals per day. From a nutritional point of view, what matters most is the total number of calories, protein and calcium consumed daily. Despite attention to all of these factors, intestinal discomfort may continue to recur with eating. If this happens, an adjustment in medication may help alleviate the symptoms.

Corticosteroid medications such as prednisone may significantly decrease intestinal inflammation and allow the bowel to function more normally. Other medications (such as antispasmodics and anti diarrhoea medications) decrease cramping and stool liquidity and frequency. When taken 15 to 20 minutes before eating, these medications decrease symptoms that interrupt meals, thus encouraging greater intake of food. They are most helpful in mild disease but must be used with caution, if at all, in severely active disease because of the possibility of causing excessive dilatation of the bowel (megacolon).
Sometimes, despite repeated attempts at eating, nutritional status deteriorates in IBD. Weight loss may persist and body stores of muscle, fat and protein diminish. In children and teenagers, the growth rate may slow to below normal. Faced with problems such as these, the physician may adjust the medication schedule or reconsider the option of surgery.

FOOD/DRUG INTERACTIONS

Some drugs that are used to treat Crohn's disease and ulcerative colitis can interfere with the body's absorption of specific nutrients. To prevent deficiencies, it's important to be aware of these drug-nutrient interactions. Your doctor or nutritionist may recommend that you increase your intake of foods rich in these nutrients, or that you take supplements.

Sulfasalazine interferes with the absorption of folic acid, a water-soluble vitamin.
Corticosteroids, when taken daily in high doses, can decrease intestinal absorption of calcium and phosphorus, increase urinary losses of vitamin C, calcium, potassium, zinc, and nitrogen, and cause excessive breakdown of protein. They also can cause fluid retention, an effect that can be counteracted by a low-salt diet.
Cholestyramine (Questran®) may cause poor absorption of the fat-soluble vitamins (A, D, E, and K), as well as folic acid, vitamin B-12, calcium, and iron.

It has also been suggested that some people with IBD also have food sensitivities. Food sensitivity is different than a true food allergy, so it may not be detected in allergy tests. Some of the more common offenders have been identified as:

Sorbitol (a sugar substitute)
Fructose (found in fruit juice and dried fruit)
Lactose (found in milk)
Wheat bran

Lactose intolerance is a common condition that is the result of the body's inability to digest lactose, or milk sugar. Symptoms include gas, bloating, and sometimes-even pain. If lactose intolerance is suspected, avoidance of milk and milk products (cheese, ice cream, and butter) should reduce symptoms. When milk products are reduced, care must be taken that enough calcium is added to the diet through either foods high in calcium, or a calcium supplement.

Lactobacillus acidophilus, the so-called "friendly bacteria" may be helpful in digestion. Acidophilus helps maintain the 'good' bacteria in the gut. It is readily found in yogurt that contains live cultures. Yogurt contains calcium, and is by and large better tolerated than other milk products due to the active cultures.
A food diary may help with identifying the offending foods. Any food sensitivity should be investigated with the help of a nutritionist or a doctor. Sensitivities may be overlooked without the help of a trained professional.

Discovering what foods will help your IBD can be a challenge. At times it will be difficult to follow a strict diet, especially if other people are not sensitive to your needs (you know them - they tell you "it's all in your head"). It may be hard for you and the people around you to accept, but it may be even worse to deal with an IBD attack caused by trigger foods or heavy meals.

There are certain foods which are believed to help maintain remission in Crohns Disease

Foods Important for Protection

Protein.
Proteins are very important for the repair of cells. Diarrhoea can cause protein deficiency and so IBD patients may need more protein than the general population.
Patients might consider choosing fish and soy as primary protein sources. One study reported that a soy protein diet was particularly useful for patients who were intolerant to milk products.
Oily fish, such as salmon and tuna, may be particularly beneficial in Crohn's disease;
Other options are poultry and lean meats.
Dried beans and legumes also provide protein.

Updated July 2003