Nutrition and Inflammatory Bowel Disease
Both Ulcerative Colitis and Crohn’s Disease have direct involvement on the gastrointestinal tract and may have a profound affect on nutritional status. Dietary management involves a combination of increasing intakes of nutrients to replenish losses and prevent malnutrition while also restricting those foods that may worsen symptoms in order to facilitate healing.Frequently asked Questions
Can diet control IBD?
Research has not shown that any specific diet will prevent or treat IBD, but there are some ways to help control certain symptoms. More details are described below.
How can I identify problem foods?
It is very helpful to keep a food diary of the foods that are eaten and noting when you have worsened symptoms. This will help you identify problem foods.
What are ways that I can manage symptoms through diet?
The most important thing to remember is to not overly restrict your diet because adequate nutrition is very important. There are approaches to managing symptoms during flare-ups and the absence of flare-ups. The recommendations for these are listed below.
Ulcerative Colitis Flare
- Foods that cause increased stool output should be avoided such as caffeine, vegetables, fresh fruits, bran, and prunes.
- Limit the amount of sugary foods you eat such as candy, pop, fruit juice, etc, as these foods may pull more water into your gut leading to watery stools.
- Try eating more foods that contain omega-3 fatty acids because of their anti-inflammatory effect. You can find omega-3 fatty acids in fish such as salmon, mackerel, herring, and sardines. Ask your doctor before starting a supplement.
- Consider taking a liquid nutrition supplement such as BoostTM or EnsureTM if you are unable to tolerate food due to poor appetite or if you are losing a significant amount of weight.
- Try eating smaller, more frequent meals.
- Limit alcohol consumption.
- Follow a Low Residue Diet to help decrease abdominal pain and diarrhea. Slowly add foods back into diet as tolerated.
- Foods that cause increased stool output should be avoided such as caffeine, vegetables, fresh fruits, bran, and prunes.
- If you are lactose intolerant than follow a lactose-free diet. A breath hydrogen test is used to confirm lactose intolerance. Lactose intolerance leads to gas, cramping, bloating and diarrhea soon after the consumption of milk, ice cream or large amounts of dairy.
- You may be experiencing fat malabsorption if you notice that you have foul-smelling stools that appear oily. If this is the case, follow a low-fat diet and discuss this with your doctor.
- Try eating smaller, more frequent meals.
- Consider taking a liquid nutrition supplement such as BoostTM or EnsureTM if you are unable to tolerate food due to poor appetite or if you are losing a significant amount of weight.
- Follow a Low Residue Diet (see below) and slowly add foods back into your diet as tolerated.
- Start with liquids and advance to softer solids, then regular solids.
- Introduce 1-2 new items every few days. Avoid any foods that cause worsened symptoms.
- Add fibrous foods back into your diet gradually: Well-tolerated fiber sources include canned or cooked fruits, tender, cooked vegetables, cooked cereals, whole wheat pastas and tortillas.
- During a flare up it is important to increase your intake of calories and protein since you may have a decreased appetite during this time due to diarrhea and abdominal pain.
A low residue diet is designed to reduce the frequency and volume of stools while prolonging intestinal transit time. It restricts foods that increase bowel activity such as milk and milk products and prune juice. A low residue diet typically contains less than 10-15 grams of fiber per day. This is a diet that is meant to be followed only during flare-ups and is not meant to be followed long-term as it restricts many healthy foods that contain essential nutrients.
Foods allowed:
- White bread, refined pasta and cereals, and white rice
- Limited servings of canned or well-cooked vegetables that do not include skins
- Moderate fresh fruits without peels or seeds, certain canned or well-cooked fruits
- Tender, ground, and well cooked meat, fish, eggs, and poultry
- Milk and yogurt (usually limited to 2 cups per day), mild cheese, ricotta, cottage cheese
- Butter, mayonnaise, vegetable oils, margarine, plain gravies and dressings
- Broth and strained soups from allowed foods
- Pulp free, strained, or clear juices
Foods to Avoid:
- Whole grain breads and pastas, corn bread or muffins, products made with whole grain products, or bran
- Strong cheeses, yogurt containing fruit skins or seeds
- Raw vegetables, except lettuce and other leaves
- Tough meat, meat with gristle
- Crunchy peanut butter
- Millet, buckwheat, flax, oatmeal
- Dried beans, peas, and legumes
- Dried fruits, berries, other fruits with skin or seeds
- Chocolate with Cocoa Powder (white chocolate has no fiber)
- Food containing whole coconut
- Juices with pulp
- Highly spiced food and dressings, pepper, hot sauces
- Caffeine
- Popcorn
- Nuts and Seeds
Suggested “First Foods” after a flare:
- Applesauce or canned fruit
- Diluted juice (half water, half juice)
- Bread (white)
- Oatmeal
- Mashed potatoes, white rice, noodles
- Plain chicken, turkey, fish or eggs
Are there any drug-nutrient interactions I need to be concerned about?
IBD flare-ups are often treated with corticosteroids (prednisone), cholestyramine, and 5-ASA compounds (Sulfasalazine).
- Corticosteroids: Prednisone (DeltasoneTM), methylprednisolone (MedrolTM), hydrocortisone, budesinide (EntocortTM). Decrease the absorption of calcium and phosphorus and increases the loss of calcium, zinc, vitamin C and potassium. Prolonged use of high doses can result in bone loss and may benefit from calcium supplementation.
- Cholestyramine: Decreases absorption of folate, vitamin B-12, calcium, and iron and the fat-soluble vitamins A, D, K and E.
- Sulfasalazine: People taking this medication should take a 1 milligram folate supplement daily due to the drugs affect on folate absorption.
How does surgery affect nutritional status?
Surgery is sometimes needed for patients with severe inflammation, fistulas, strictures and abscesses. In ulcerative colitis the colon is removed and the ileum is then attached to the anus. In Crohn’s the part that is removed depends on the location of the digestive tract that is affected.
When parts of the small or large intestine are removed or inflamed it results in decreased absorption of essential nutrients. Therefore, it is not uncommon for people to become malnourished or have nutrient deficiencies during severe inflammation or after surgery. It is important to talk to your doctor or Registered Dietitian about which vitamins and mineral supplements you may need to take.
What are some factors that may affect nutritional status in IBD patients?
Decreased food and beverage intake due to poor appetite and fear of eating
- Nausea, vomiting, or abdominal pain,
- Restrictive diets
- Side effects of medications
- Oral ulcers
- Protein losses from an inflamed, ulcerated intestine
- Increased nutritional needs for healing
- Surgical resections leading to malabsorption of nutrients
- Blood loss
Everyone is different and therefore have different nutritional needs based on body size, gender, age, activity level and disease state. Here are some general guidelines.
- Calories – Calorie needs may be increased, especially if a person is losing significant weight. Therefore, if weight gain is desired a person should try to consume 500 extra calories per day in addition to what they are already eating.
- Protein – Between flares a person should get about the number the grams of protein equal to their weight in kilograms. (1 kg = 2.2 lb.). Example: A 150 lb. person weighs 68.2 kg and should therefore aim for 68 gm of protein per day. During flare-ups protein needs are increased by as much as 50% to help restore losses and prevent muscle breakdown. Protein needs are also increased after surgery for healing.
- Fluids and electrolytes – Drinking sufficient fluid is necessary to prevent dehydration. Fluid needs are increased during exercise and during and after bouts of diarrhea. Sports drinks such as Gatorade and PowerAde may be used to help replenish electrolytes lost from diarrhea.
Are there specific nutrient deficiencies to be concerned about?
People with IBD may have deficiencies in certain vitamins or minerals based on medications and the extent of diarrhea and blood loss. With Crohn’s, nutrient deficiencies may be related to the portion of the intestine that is affected. Talk to your doctor or a dietitian if you have concerns about deficiencies. Increase your intake of nutrient-rich foods or use supplements to meet nutritional needs.
Ulcerative Colitis
- Folate – Increased risk of deficiency with 5-ASA use.
- Calcium – Increased of deficiency risk with steroid use.
- Iron – Increased risk of deficiency with loss of blood from ulcerated colon.
- Magnesium – Increased risk of deficiency with chronic diarrhea.
- Potassium – Increased needs with diarrhea and steroid use.
- Vitamin B12 – Increased risk of deficiency with inflammation of the ileum
- Folate – Increased risk of deficiency with 5-ASA use and also due to inflammation of the jejunum.
- Vitamins A, D, E, K – Increased risk of deficiency with people who experience fat malabsorption.
- Zinc – Increased risk of deficiency with inflammation/removal of jejunum and due to losses from fistula, diarrhea. Prednisone use also increases zinc needs.
- Calcium – Increased risk of deficiency with steroid use as well as from inflammation of small intestine and fat malabsorption. Also increased risk of deficiency for those who avoid dairy products.
- Potassium – Increased needs related to chronic diarrhea, vomiting, and with steroid use.
