Diet, Nutrition, And Inflammatory Bowel Disease

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Diet, Nutrition,and InflammatoryBowel Diseasea

What’s InsideAbout Crohn’s & Colitis2Impact of IBD on MaintainingHealthy Nutrition4Healthy Diet andNutritional Choices8Tips for Managing IBDwith a Healthy Diet15Vitamin and MineralSupplementation25Guide to Dietary Supplements30Nutritional Support Therapy32Impact of Surgery onDiet and Nutrition34Managing Diet & NutritionDuring a Flare35Final Words About Diet,Nutrition and IBD39Diet Research40Enclosed Resources41Credits42Glossary43About CCFAInside Back CoverInformation contained within this brochure is up-todate as of the print date. Due to rapid advances andnew findings, there may be changes to this informationover time. You should always check with your doctorto get the most current information. This informationshould not replace the recommendations and adviceof your doctor.b

Food choices can becomemore complicated sincecertain foods may worsensymptoms.When you are first diagnosed with Crohn’sdisease or ulcerative colitis, there are manychoices you will need to make. For many peoplewith Crohn’s disease or ulcerative colitis,collectively called inflammatory bowel disease(IBD), the simple act of eating can no longerbe taken for granted. Because IBD affects thedigestive system, diet and nutrition are impacted in a variety of ways. Food choices canbecome more complicated since certain foodsmay worsen symptoms. Attention must bepaid to avoiding foods that worsen or triggerdisease symptoms. In addition, it is importantto learn how to make healthy food choices,replace nutritional deficiencies and maintain awell-balanced nutrient-rich diet. This brochureexplains the impact of IBD on diet and nutritionand provides practical information to help youeat well, stay healthy, learn to minimize dietrelated problems and enjoy what you eat.1

About Crohn’s &ColitisCrohn’s disease and ulcerativecolitis belong to a group ofconditions known as inflammatory bowel diseases (IBD).These disorders cause chronic inflammation inthe gastrointestinal (GI) tract, the area of thebody where digestion and absorption of nutrients take place. Inflammation is the body’s response to tissue injury. Normally, inflammationhelps protect the body from harmful germs,damaged cells or irritants, but in IBD, the immune system reacts inappropriately, leading toinflammation. Inflammation impairs the abilityof affected GI organs to function properly. Ongoing inflammation leads to symptoms such asabdominal pain and cramping, diarrhea, rectalbleeding, weight loss and fatigue.To learn more about these diseases, view: Living with Crohn’s Disease at:online.ccfa.org/crohnsdisease Living with Ulcerative Colitis at:online.ccfa.org/ulcerativecolitis2

THE GASTROINTESTINAL(GI) TRACT12345671Oral Cavity2Esophagus3Liver4Stomach5Large Intestine/Colon6Small Intestine7Rectum8Anus8Figure 1The Gastrointestinal SystemTo understand the relationship between diet,nutrition and IBD, it is helpful to know how thegastrointestinal tract processes the food weeat. The GI tract consists of a series of mostlyhollow organs beginning at the mouth, followed by the esophagus, stomach, small intestine, colon, rectum and anus (see Figure 1).The roles of the gastrointestinal system are: Digestion—the breakdown of food Absorption of nutrients and water Elimination of wasteThe Effect of IBD on DigestionIn people with IBD, inflammation in the organsof the digestive tract can affect the process ofdigestion. Inflammation in the small intestineof a person with Crohn’s disease can interferewith the digestion and absorption of nutrients.Incompletely digested food that travels throughthe colon may cause diarrhea and abdominalpain. In a person with ulcerative colitis, thesmall intestine works normally, but the inflamed colon does not absorb water properly,3

resulting in diarrhea, increased urgency to havea bowel movement and increased frequency ofbowel movements.Impact of IBD onMaintaining HealthyNutritionPeople with IBD may havedifficulty maintaining healthynutrition for a variety ofreasons, including diseasesymptoms, complicationsand medication.IBD SymptomsDuring times of disease flares, diarrhea, urgency to have a bowel movement, abdominal pain,nausea, vomiting, blood in the stool, constipation, loss of appetite, fatigue and weight losscan negatively impact nutrition.Severe diarrhea can cause dehydration, robbing the body of fluids, nutrients and electrolytes (sodium, potassium, magnesium andphosphorus). People with Crohn’s disease andulcerative colitis often have a reduced appetiteas a result of nausea, abdominal pain or alteredtaste sensation. This can make it difficult toconsume enough calories and obtain sufficientnutrients. Additionally, the need to have numerous bowel movements in a day may cause a person with IBD to shy away from eating too muchto avoid symptoms. Eating too little puts peopleat risk for being malnourished.4

Another possible symptom of IBD is rectalbleeding resulting from sores (ulceration) thatform in the inner lining of the intestinal tract,leading to blood loss. Chronic blood loss caneventually lead to anemia, which if left unchecked, may cause fatigue.Weight loss may occur as a result of diarrheaand loss of appetite due to abdominal pain,nausea, vomiting or worsening diarrhea. Inaddition, the inflammatory process in Crohn’sdisease and ulcerative colitis can result inincreased consumption of stored energy and abreakdown of the body’s tissues, often resultingin weight loss despite adequate caloric intake.IBD ComplicationsMalabsorption of nutrientsInflammation in the small intestine of a personwith Crohn’s disease can interfere with theabsorption of nutrients. This is called malabsorption. Amino acids (from proteins), fattyacids (from fats), sugars (from carbohydrates),vitamins and minerals are mostly absorbedfrom the last two sections of the small intestine(jejunum and ileum).The degree of malabsorption depends onhow much of the small intestine is affected byCrohn’s disease, whether the disease is activeand if any portion of the intestine has beensurgically removed. Generally, the malabsorption and nutrient deficiencies tend to be moresignificant if larger sections of the small intestine are inflamed or removed. If a significantportion of the ileum is inflamed or removed, theabsorption of fat-soluble vitamins (A, D, E andK) and vitamin B12 will likely be affected.Bile acids or bile salts (responsible for aiding inabsorbing fats and making the stool brown incolor) can also be malabsorbed if the ileum isinflamed or removed. This can result in excessbile salts being transported to the colon wherethey cause increased fluid secretion in thecolon and watery diarrhea. If a larger section5

of the ileum is affected, malabsorption of fattyacids may occur, resulting in abdominal cramping, diarrhea, malabsorption of fat-solublevitamins and weight loss.Patients with ulcerative colitis may have lesssignificant nutrient deficiencies; however,weight loss and anemia can be prominent dueto severe diarrhea and blood loss.Growth delaysSome children with IBD fail to grow at a normalrate. Possible causes of poor growth includethe impact of intestinal inflammation on nutrition (as described above in “IBD Symptoms”),long-term use of corticosteroid medications(which have a negative impact on bone growth)and general poor nutrition.To minimize the negative effects of IBD ongrowth, good eating habits, adequate caloricintake and control of the underlying diseaseare essential for children. It is also importantfor children to be monitored carefully for properweight gain and growth. If your child is notstaying on their typical growth curve, it may benecessary to consult your physician or a registered dietitian for help with evaluating caloricand nutrient intake.6

Decreased bone mineral densityDecreased bone mineral density (low bonemass) is common in children, adolescents andadults with IBD. Severe forms of decreasedbone mineral density (osteoporosis) increasesthe risk for bone fracture. This may be due toinsufficient calcium intake, poor absorption ofcalcium, vitamin D deficiency, decreased physical activity, inflammation and/or long-term useof medications such as corticosteroids (as previously discussed). Calcium helps to form andmaintain healthy bones and teeth, and vitaminD is needed to help the body use calcium.StricturesIn some people with Crohn’s disease, chronicinflammation in the intestine can cause thewalls of the intestine to narrow and also formscar tissue. The scar tissue can cause narrowing of the passageway, making it difficultfor digested food to pass easily through theintestine. Narrowing of the intestine is called astricture. Dietary modifications such as a lowfiber or liquid diet along with medication maybe necessary if the stricture is mostly inflammatory. If the narrowing is mostly scar tissue,surgery may be needed to widen the narrowedsection or remove it. A low-fiber or liquid diet isoften prescribed until surgery is performed.IBD MedicationsMedications tend to be more effective in peoplewith good nutritional status. Certain medications used in IBD may also have adverseeffects on nutrition. Corticosteroids may affectnutrition in many ways by increasing appetite,increasing serum glucose levels, increasingthe risk for diabetes and affecting electrolyte(mineral) levels.Although effective for reducing inflammation,steroids have potential adverse effects whenused for long periods of time. For example, theycan slow the process of new bone formationand accelerate the breakdown of old bone.7

Steroids also interfere with calcium absorptionand may also decrease bone mineral density aspreviously discussed. Most bone loss occursin the first six months of corticosteroid use.Supplementation with calcium and vitamin Dcan help protect bone health, especially whilepatients are treated with steroids.Patients on sulfasalazine and methotrexateshould receive supplemental folic acid. Cholestyramine, which is used sometimes to treatbile acid diarrhea, may decrease the absorptionof fat-soluble vitamins. Check with your doctoror pharmacist to find out if any of your medications could interfere with your nutrition.Healthy Diet andNutritional ChoicesDiet and nutrition are importantaspects of IBD management.“Diet” refers to the foods we eat. “Nutrition” isa term that refers to properly absorbing foodand staying healthy. A well-balanced diet withadequate intake of protein, carbohydrates andfat, as well as vitamins and minerals, is necessary for nutrition. This can be achieved by eating a variety of foods from all the food groups(See Figure 2). Meat, fish, poultry and dairyproducts are sources of protein. Bread, cereal,starches, fruits and vegetables are sources ofcarbohydrates. Butter, margarine and oils aresources of fat.8

Figure 2The United States Department of Agriculture(USDA) has general recommendations onhealthy eating, such as how much of each foodgroup is needed and the health benefits of thefood in each group. This information is on theUSDA website (www.choosemyplate.gov).Having a chronic, active disease, such asCrohn’s disease or ulcerative colitis, tends toincrease the body’s requirements for calories,nutrients and energy. During disease flares, itmay be difficult to maintain adequate nutrition.However, maintaining good nutrition helpsimprove overall wellness, promotes healingand immunity, increases energy levels and mayalleviate some gastrointestinal symptoms.Is there an IBD Diet?There is no evidence to suggest that any particular food or diet causes, prevents or cures IBD.There is no one special IBD diet. A few dietsare advertised specifically for managing IBD,including the Specific Carbohydrate Diet andThe Maker’s Diet (see page 44).It is important to note that people may reportsuccess with these and other diets in alleviating symptoms, but there has been no scientificevidence supporting these diets. Additionally,the diets may be very restrictive and difficultto follow. The Crohn’s & Colitis Foundation ofAmerica (CCFA) does not promote any one diet.9

Researchers are continuing to study the interaction between diet and IBD. More informationon diet research can be found on page 40. Fornow, dietary recommendations are generallyaimed at easing symptoms during flares andensuring an overall adequate intake and absorption of nutrients, vitamins and minerals.Is there a place for fast or “junk” food?Individuals with IBD face special challenges,and eating nutritiously is high on the list ofissues to consider. Some fast foods provide avaluable supply of nutrients as well as calories. Take pizza, for instance. The cheese offerscalcium, protein and vitamin D; the tomatosauce provides vitamins A and C; and thecrust supplies B vitamins. The same is true forother popular favorites such as hamburgersor cheeseburgers, although all of these foodsalso contain more fat and salt than should beconsumed on a regular basis. Milkshakes andice cream also offer a good source of calcium,proteins and calories. If lactose intolerance isa problem, sometimes it can be overcome bytaking commercially available lactase in tabletform or using lactose free products. Junk foodshould be eaten in moderation.Developing an Individual DietMany people with IBD can consume a normaldiet during times of disease remission but mayneed to alter their diet during flares. Otherpeople with IBD, such as patients with intesti10

nal strictures, will need to stay on a modifieddiet until the stricture is successfully treatedmedically or surgically.The individual diet should be based on: Symptoms (diarrhea, constipation,abdominal pain, etc.) Whether the person is in remissionor experiencing a flare Location of disease Presence of narrowing of the small intestine(strictures) Any prior surgeries Whether there are any specific nutritionaldeficiencies (such as iron deficiency)Impact of Certain FoodsDuring flares, certain foods or beverages may irritate the digestive tract and aggravate symptoms.Not all people with IBD are affected by the samefoods, and it may be necessary to experiment todiscover which foods affect symptoms the most.Keeping a food journal (see “Resources” section)may help you to track how your diet relates toyour symptoms and identify trigger foods.Possible Trigger Foods and FoodIntolerancesFood allergies and intolerancesNeither Crohn’s disease nor ulcerative colitisis caused by a food allergy. Yet some peoplewith IBD may also have food allergies. The mostcommon foods causing an allergic reaction aremilk, eggs, peanuts, tree nuts (e.g., walnuts,almonds, cashews, pistachios and pecans),wheat, soy, fish and shellfish.It is important to distinguish between anactual food allergy and food intolerance. Afood allergy is associated with an immune11

system response and can cause a severe andlife-threatening reaction, while a food intolerance can cause GI symptoms. Many peoplehave food intolerances—far more than havetrue food allergies.Elimination diets (avoiding trigger foods)are used to determine which foods must beavoided or minimized. This involves systematically removing foods or ingredients that maybe causing symptoms. It is important to dothis under the supervision of your doctor and adietitian to be sure it is done correctly without causing poor nutrition. When eliminatingfoods, it is important to substitute other foods,that provide the same nutrients. For example,when eliminating dairy products, be sure to obtain calcium and vitamin D from other sources.FiberDietary fiber is found in plant foods, such asfruits, vegetables, nuts and grains. It is essentialfor health and for digestion. For many people with IBD, consuming fiber during times ofdisease flares or strictures can cause abdominalcramping, bloating and worsening diarrhea. Butnot all sources of fiber cause these problems,and some sources of fiber may help with IBDsymptoms.Soluble (ability to dissolve in water) fiber helpsabsorb water in the gut, slowing down the transit time of food that is stored there. It can helpto reduce diarrhea by forming a gel-like consistency and delaying emptying of the intestine.Insoluble fiber does not dissolve in water. It ismore difficult to digest because it pulls waterinto the gut and makes food move more quicklythrough the gut. It is a harder more course fiberfound in the skins of foods such as apples andseeds. Consuming insoluble fiber can aggravate IBD symptoms by causing more bloating,diarrhea, gas and pain. When there is severeinflammation or narrowing, consuming insoluble fiber can lead to worsening symptoms anda blockage in the intestinal tract.12

Most foods contain a combination of fibers,so cooking, peeling and removing seeds are important for patients who are in a flare and needto reduce their intake of insoluble fiber.LactoseLactose intolerance is a condition in whichthe body does not properly digest lactose, thesugar present in milk and milk products. Somepeople with IBD may be lactose intolerant. Inaddition, some people with IBD may only haveproblems with lactose digestion during a flareor after surgical removal of a segment of thesmall intestine.Poor lactose digestion may lead to cramping,abdominal pain, gas, diarrhea and bloating.Because the symptoms of lactose intolerancemay mimic those of IBD, it can be difficult torecognize lactose intolerance. Your doctor canperform a simple test called a lactose breathtest to diagnose this condition. Not all peoplewith IBD are lactose intolerant.The severity of symptoms will depend on howmuch lactose an individual can tolerate. Somepeople may be able to consume small amountsof milk, while others may need to avoid it altogether. Lactase is the enzyme responsible forbreaking down the lactose in dairy products.Lactase supplements can be taken along withmilk to help digest it and specialty milk products that do not contain lactose are also available. Dairy products that contain yogurt andkefir may be more easily tolerated as well. Hardcheeses are generally well tolerated because oftheir minimal lactose content.Milk and dairy products are important sourcesof nutrients, particularly calcium. Therefore,people who limit or eliminate milk and dairyproducts from their diet must be mindful aboutobtaining calcium from other food sources orfrom supplements.13

High-fat foodsHigh-fat foods, such as butter, margarine andcream, may cause diarrhea and gas if fat absorption is incomplete. These symptoms tendto occur more in people who have inflammationin the small intestine or who have had largesections of the small intestine removed.GlutenGluten is a protein found in grains includingwheat, rye and barley products.Some people with IBD may be sensitive togluten and have gluten intolerance. Thesepeople may also have symptoms of abdominalbloating and diarrhea after eating gluten-containing food, and they may benefit from avoidingfoods with gluten as well. A food diary can helpdetermine the effect of gluten-containing foodon symptoms. In addition, if you suspect youhave symptoms to gluten, ask your doctor for aceliac disease test. Celiac disease is a inflammatory reaction to gluten and different from glutenintolerance.Nonabsorbable sugars (sorbitol, mannitol)Sugar alcohols, such as sorbitol and mannitol,cause diarrhea, bloating and gas in some people. These ingredients are often found in sugarless gums and candies. Sorbitol is also found inice cream and in several types of fruits, such asapples, pears, peaches and prunes, as well asthe juices of these fruits.FODMAP (Fermentable Oligo-Di-Monosaccharides and Polyols)FODMAPs are sugars that are found in certaincarbohydrates and sugar alcohols. If someonehas intolerance to foods high in FODMAPs itcould result in excessive gas, bloating, diarrheaand cramping.Foods that are high in FODMAPs include: Fructose—fruits, honey, high fructosecorn syrup14

Lactose from dairy products Oligosaccharides are carbohydrates witha small number of simple

Diet and nutrition are important aspects of IBD management. “Diet” refers to the foods we eat. “Nutrition” is a term that refers to properly absorbing food and staying healthy. A well-balanced diet with adequate intake of protein, carbohydrates and fat, as well as vitamins and minerals, is nec-essary

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