Nutrition

What is healthy eating?

A healthy balanced diet that is appropriate for patients with IBD includes a wide variety of foods from each food group. It will provide adequate energy, protein, vitamins, minerals and fluid to maintain optimal health and weight. If your IBD is active and you are unwell or you have lost weight unintentionally, you may need extra energy and protein to boost your nutritional status. A dietitian can help you with this.

A Guide to Healthy Eating

Breads and Cereals

5-6 serves or more per day

• 2 slice bread or roll
• 2-3 dry biscuits
• 1 cup breakfast cereal (small bowl)
• half cup cooked pasta, porridge or rice

Include wholegrain choices, which are higher in fibre and vitamins.

Vegetables and Fruits

At least 5 vegetable & 2 fruit serves daily

• 1 medium piece of fruit, 2-3 small fruits (eg 2 kiwifruit), 1 cup fruit salad or tinned fruit
• half cup cooked vegetables or 1 cup loosely packed salad

Include a variety of different coloured fruits and vegetables each day. Ensure you choose at least one green leafy and one orange vegetable.

Milk and Milk Products

3-4 serves/day

• 1 cup of milk
• 200g tub of yoghurt
• 2 slices of cheese

Unless you are trying to gain weight, low fat choices are recommended. If you are substituting dairy with non-dairy products, ensure they are calcium fortified. Adequate calcium is particularly important for people on long term steroids treatment (eg. Prednisolone), as they put you at increased risk of osteoporosis. In this case you should aim for at least 4 serves per day and is if this amount is not met then calcium supplements are recommended.

Meat and Meat Alternatives

1 – 2 serves a day

• 100 g cooked meat, chicken or fish
• 1 cup cooked lentils or legumes
• 2 eggs or half cup of nuts

Remove the skin and fat, and choose lean cuts over processed or fried foods. In periods of active disease, you may need more protein (up to 3-4 serves/day), especially if you have lost weight unintentionally. These foods are also very important for adequate iron intake; there is a higher availability of iron from meat, particularly red meat, compared to other meat alternatives. Include fish 3 times per week to increase your omega-3 fatty acid intake.

Margarine, Butter and Oils

3 – 4 teaspoons per day

• Limit use of butter, lard, cream, palm oil & coconut oil, as these are saturated fats which raise cholesterol and other body fats
• Choose poly and mono-unsaturated fats (eg: olive oils, margarine, avocado)

NB. If you are trying to gain weight, additional serves from this group can be included, to increase total calorie intake.

Fluid intake

at least 6-8 glasses (1.5-2L per day)

• Choose non-caffeinated drinks such as water and dilute cordial/juice
• Increase your fluid intake if you are losing large amounts of fluid (eg. through diarrhoea, vomiting or excess perspiration during warmer weather)
• Oral rehydration solutions (eg. Gastrolyte®, Repalyte® or Hydralyte®) are the best way to replace losses from severe diarrhoea and vomiting

If these recommendations are followed most people with IBD will not require vitamin or mineral supplementation, except in specific situations:

• During long periods of flare ups and poor food intake
• If found to have a folate, iron or vitamin D deficiency
• With prolonged steroid therapy (recommend 1000-1500mg calcium per day)
• With disease or resection of the terminal ileum, Vitamin B12 injections are required
• Excessive diarrhoea, zinc, potassium and magnesium may be required
• With long term sulphaslazine, folate supplement is recommended

Other general nutrient recommendations for patients with IBD

Fibre

Fibre is important to include in the diet to maintain luminal health of the bowel and normal bowel actions. Dietary fibre is found in plant products, and includes any food material that we are unable to digest completely.

This undigested material passes through the body into the large bowel, and is then fermented by bacteria. The gases produced during this process are beneficial for the bowel lining and environment. Fibre also absorbs fluid, adding bulk to bowel actions, making them soft and easily passed.

There are two main types of dietary fibre (although most foods contain a combination):

• Insoluble fibre is the hard, roughage part of grains such as bran, grains, seeds, skins and the fibrous part of fruits and vegetables
• Soluble fibre is not visibly identifiable in foods. It is soft and absorbs fluid to form a gel. Examples of foods high in soluble fibre include oats, psyllium and legumes (peas, beans, lentils, chick-peas). It is also found in the inner part of many fresh fruits, vegetables and grains

You may be recommended to restrict fibre intake in times of acute flare ups, however this should not be maintained long term.

Other potential beneficial nutrients:

• Omega 3 fatty acids: Thought to assist in decreasing inflammation in the bowel. However studies have not been conclusive and there are no recommendations regarding supplementation
• Probiotics: Thought to play a role in changing the endogenous flora of the bowel. The benefits and use in the treatment of IBD are not known and need further investigation. They have been shown to be effective in the management of pouchitis

General foods that may need to be avoided

During a flare up

Fibre:

• Depending how severe your symptoms are, you may benefit from temporarily reducing the amount of insoluble fibre in your diet.
• This includes grains, seed, nuts, uncooked vegetables, and skins and seeds of fruit and vegetables. This modified fibre diet can help to reduce the discomfort associated with gas, bloating and diarrhoea
• It is not usually recommended in the long term, but only whilst acute pain and diarrhoea are present. There is not a lot of scientific evidence for this however it generally helps with symptom control
• A small group of people who have severe IBD develop scar tissue and strictures within their bowel. In this case, the problem must be diagnosed under medical care, and may be treated in the long term with a low fibre (sometimes called a ‘low residue’) diet. This diet is not nutritionally adequate and therefore it should only be followed with the guidance of a dietitian

Foods that may worsen symptoms and diarrhoea

Foods that may worsen symptoms and diarrhoea include:

• Rich and fatty foods such as fried foods, take-away foods and creamy sauces
• Spicy foods such as hot chillies, peppers, curries and other highly spiced foods
• Large amounts of lactose (which is the sugar in milk). Hard cheese, small amounts of yoghurt and custard are often well tolerated, but try substituting cow’s milk with calcium fortified soy milk or lactose free milk (eg. Liddells®), if you are having ongoing diarrhoea
• FODMAPS – (Fermentable carbohydrates) if you have ongoing symptoms during times of controlled disease, you may require a restriction of fermentable carbohydrate. Discuss this with your dietitian if you are concerned about this

Specific dietary recommendations for ulcerative colitis

• There are no real specific dietary recommendations for patients with ulcerative colitis compared to patients with Crohn’s disease, apart from the fact that patients with ulcerative colitis are not at as higher risk of nutritional deficiencies and malnutrition due to the disease only affecting the large bowel
• It is important to maintain a healthy balanced diet to ensure nutritional deficiencies do not develop
• If as a result of ulcerative colitis you require surgery and the formation of a colostomy there are some dietary guidelines on how to manage your stoma and prevent excessive wind, odour and blockages
• There are no foods that need to be avoided however in some cases food should be manipulated. Soluble fibre can help thicken outputs; these are foods such as white breads, dry biscuits, potatoes and bananas. If wind is a concern avoid gaseous drinks and ‘windy vegetables’ such as cabbage, onion, garlic and legumes
• Always ensure you chew foods well, particularly those that are very hard and fibrous, such as nuts, corn and celery. Your dietitian can provide you extra details on this if required

Specific dietary recommendation s for Crohn’s disease

• Again it is important for all patients with Crohn’s disease to maintain a diet that is healthy and well balanced to prevent deficiencies
• The main difference for patients with Crohn’s disease is that there is the possibility of the disease affecting the whole intestine and therefore there is a greater concern for nutritional status. There may be different dietary recommendations depending on what part of the intestine is affected
• As mentioned earlier, patients with Crohn’s disease are at high risk of malnutrition, secondary to age of onset, site of disease, more severe diarrhoea relating to malabsorption, greater food avoidance and repeated surgery
• Crohn’s is more likely to develop in young children or young adults and during this time of growth, there are greater energy and nutrient needs
• People with chronic inflammation of the small bowel or that require significant small bowel resections, are at higher risk of malabsorbtion of nutrients as the small bowel is responsible for absorbing macronutrients, such as protein, fats and carbohydrates, as well as micronutrients such as vitamins, minerals and electrolytes. This means that intakes often need to be higher and oral or intravenous supplementation is sometimes required. Your dietitian can provide you with more specific guidelines if required
• Appetites of people with Crohn’s disease tend to be poorer and weight loss is more evident. If this is the case try to include higher energy and protein foods to boost your intake
• Recommendations include trying to have 6-8 meals or snack per day, including high protein foods at each meal time, such as full cream dairy product, eggs and meats. Energy intake can be increased by adding oil, margarine and sugar or honey to foods
• In some cases nutritional supplements may be required to boost your intake further. See below for more information

Specific dietary recommendations for people with stomas ulcers

People with stomach ulcers should minimize foods that increase gastric acid secretion. It is recommended to:

• Have small frequent meals
• Chew food well
• Avoid foods high in fat – particularly fried foods, cakes and desserts
• Limit caffeine and alcohol
• Don’t lay flat after eating for at least 60- 90 min

Specific dietary recommendations for males, females, different age groups

• There are different energy, protein and nutrient recommendations for males, females and different age groups within the population. However none of these recommendations are specific to different medical conditions, they are recommendations for the populations to maintain health and growth
• In 2005 the NHMRC published recommendations of Nutrient reference values for Australia and New Zealand. These recommendations include energy, macronutrients, water and vitamin and mineral requirements across all ages and genders. For more information see: http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/n35.pdf

Summary for at risk nutrients for patients with IBD

Energy

• Energy requirements increase from birth and stabilize at the age of about 20 years
• After the age of 30 years they decrease slightly over 20 year periods
• Adult males have 10-20% high energy requirements than females and increased activity
• increases energy requirements
• Times of illness will increase your energy requirements, so it is even more important to eat regularly when you are unwell

Fibre

• Is important to include adequate fibre in your diet to maintain the health of your bowels
• Fibre requirements increase from birth to adulthood and many people find them hard to meet
• To meet daily fibre needs you need to include wholegrain product at least 3-5 times per day and have 5 serves of vegetables and 2 serves of fruit every day
• Children do not need as much fibre as adults and therefore, they do not need as many wholegrain foods and vegetables

Recommended dietary intake for fibre

• For children aim for 15 -20g per day
• Adolescent aim for 20-30g
• Adults aim for 30g per day

Folate

• People with IBD are at higher risk of folate deficiencies due to interactions with medications and malabsorption
• Requirements for folate increase with age and are even greater in pregnancy
• Many people with IBD may require folate supplements if they are deficient
• To maximize your folate intake ensure you include foods high in folate on a daily basis
• These are legumes, green leafy vegetables and fortified wholegrain foods

Recommended dietary intake for folate

Iron

• Iron requirements vary greatly at all ages and between men and women
• See below for details. Iron requirements can be hard to meet especially when you are unwell
• Adolescent females and women of child bearing years are most at risk of deficiencies
• Iron levels should be regularly checked to ensure they are at an adequate level
• Iron containing foods that have high availability of iron include red meat, liver, chicken, fish, eggs and seafood
• Other foods that also contain iron, however they have lower availability of iron, include legumes, green leafy vegetables and wholegrains
• If you are a vegetarian, you can be at greater risk of deficiency and your iron levels should be monitored closely

Recommended dietary intake for iron

Calcium

• Calcium requirements vary between age groups; however they are similar for both sexes. Women after menopause, require increased amounts, which are not often met
• Often people with IBD avoid dairy products as they often cause them symptoms. If you have trouble tolerating cow’s milk or yoghurt, you should substitute it for a lactose free milk or soy milk that is calcium fortified to ensure you get adequate amounts of calcium to avoid osteoporosis
• People with IBD should aim for 3-4 serves of dairy each day to meet their calcium requirements

Recommended dietary intake for calcium

Enteral nutrition to manage inflammatory bowel disease

Enteral nutrition is recommended for the management of IBD. Enteral nutrition refers to food or nutrients via the mouth or gut, which can be swallowed or given via a tube. Supplemental nutrition in the form of nutritional supplements or via a nasogastric tube is recommended where adequate nutrients are not managed from a normal oral diet.

In several studies comparing elemental (predigested), semi-elemental and polymeric diets (standard), there is no significant difference between the formulas in terms of outcome for patients and therefore polymeric (standard) formulas are recommended, as they are the cheapest and most palatable.

There have been several studies on enteral nutrition formulas vs the use of corticosteroids to induce remission in patients with Crohn’s disease and reviews of all these studies favour steroid therapy.

In paediactic studies on Crohn’s disease, there is some evidence that enteral nutrition therapy as a primary treatment is as effective as corticosteroids in inducing remission. Therefore this treatment is sometimes used in paediatrics to prevent the use of steroids in Crohn’s disease.

This diet can be a very daunting task for patients and it requires a specialist dietitian to overseas it. In this case an enteral formula is introduced over 3-4 days to minimize the effects of nausea and osmotic diarrhoea.

Food is replaced with about 8 drinks per day or feeding via a nasogastric tube. This is normally continued for 4-6 weeks to try to achieve remission. Patients generally are hospitalized for the initial few days on this treatment and once a regimen has been established patient can return home. Once the regimen has been completed then foods is gradually reintroduced. Firstly clear fluids, then soft low fibre and low fat protein and vegetable foods and then breads and cereals and finally dairy products.

What supplements are available? What do they taste like?

If you have been eating poorly and have lost weight, you may benefit from high energy/protein drinks, known as nutritional supplements.

The cheapest and most commercially available supplements are in the form of powders, these include Proform®, Sustagen® and Ensure®, they all have added vitamins and minerals, and may be used either as an addition to your normal diet, or instead of a meal when you are feeling too unwell to eat. These are normally quite palatable as at home they can be made up into milkshakes, with your own flavouring added.

These powder supplements can be purchased at all pharmacies, normally in 1kg tins. There are other supplements available and your dietitian can inform you on where they can be purchased. These include Fortisip, Fortijuice, Resource plus, Resource protein, Resource 2.0, Resource fruit beverage, Ensure plus and 2 cal.

These supplements come in many different flavours, they are generally lactose free and some are milk based drinks and others are juice based. Most supplements are fairly sweet, however most people can find one or two that they like.

All of these supplements are used in the hospital system; however it is possible to get access to them at home with the advice of a dietitian.

TPN – what is it? Does it provide relief from symptoms? Can it induce remission? What are the success rates? What is the length of time of this treatment? Do patients need to stay in hospital for this treatment?

Total Parenteral Nutrition (TPN) is a form of nutritional therapy, which is given directly into the vein. It provides all nutrients that are needed in a normal diet, this includes, glucose, amino acids, lipid, electrolytes, vitamins, minerals and trace elements.

This form of nutrition therapy is used to allow bowel rest, which is necessary for patients with very severe disease who are at risk of bowel perforation or if patients have bowel obstructions from stricturing disease.

TPN is also used in severely undernourished patients if they cannot get adequate nutrient intake for oral or enteral nutrition in the lead up to major surgery.

Usually patients would require 1 to 2 weeks of this treatment before and after surgery.

TPN is also used where patients have had several small bowel resections and the length of the bowel is too short to have adequate absorption of nutrients, particularly fluid and electrolytes.

This condition is call short bowel syndrome, and it occurs if there is only approximately 100cm of small bowel remaining.

In fistulizing disease, where there are large outputs from the small bowel fistula, supplemental TPN may be considered to provide adequate nutrient input, to account for extra losses. In these cases TPN often may provide some relief from symptoms and it will assist in improving a patient’s nutritional status.

Patients are generally in hospital for the time that they require TPN, however if a patient requires long term TPN, as a result of short bowel syndrome, they can be trained to do their own TPN at home.

TPN is not and should not be used to try to induce remission.

There is no evidence to suggest that resting the bowel will promote remission of the disease and in fact luminal nutrients have been found to improve the integrity of the bowel and assist with healing.

Elimination diet in the management of IBD

Elimination diets have not been proven to induce or retain remission for people with inflammatory bowel disease. In many studies they have been unable to show induced or improved remission rates for those on elimination diets compared to an unrestricted diets. For this reason it is not recommended for patients to follow elimination diet unless instructed by an Accredited Practising Dietitian, Gastroenterologist or immunologist.

Food intolerances or perceived food intolerances are common amongst people with IBD and many may self impose food restrictions. Although in many studies it has been suggested that food sensitivities are linked to the pathogenesis of IBD it has never been proven. For this reason it is important not to self restrict foods as it may lead to nutritional deficiencies.

If you are concerned that certain foods are linked with you symptoms, discuss it with a dietitian, who can advise you on the appropriate dietary management.

• Avoid high fat take away foods and fried foods – such as fish and chips
• If you are eating take away, try to limit the times you eat it per week and try to choose foods that are lower in fat
• Japanese food is a good choice as it is generally lower in fat and not as spicy as other Asian foods
• If you want to have pizza, then choose toppings that do not contain large amounts of processed meats such as salami and ham
• Don’t over eat, when eating out as this will put more stress on your digestive system
• Try to avoid excessive amounts of alcohol and caffeine as it is a stimulant for the bowel and may increase symptoms
• Avoid foods that often irritate symptoms, to avoid any embarrassment – such as foods high lactose or windy vegetables such as onions, cabbage and legumes and very rich or spicy foods
• Enjoy the time with your friends and family and try not to be overly restrictive with your diet unnecessarily

Useful dietary and nutritional resources

Find an Accredited Practising Dietitian (APD)

• www.daa.asn.au

Australian Crohns & Colitis Association (ACCA)

• www.acca.net.au

Gut Foundation

• www.gut.nsw.edu.au

Digestive Health Foundation

• www.gesa.org.au