1. “Supporting Nutrition in Inflammatory Bowel Disease when Patients are ill” Managing diet & symptoms NACC Spring Meeting 2012 Dr Nicola Burch MBChB MRCP(UK)(Gastro) MSc(hons) Consultant Gastroenterologist & Clinical Nutrition Lead University Hospitals Coventry and Warwickshire NHS Trust Tel: 024 7696 6092 (sec) email: nicola.burch@uhcw.nhs.uknicola.burch@uhcw.nhs.uk

2. Basic Facts Brief overview of IBD Basic overview: protein; carbohydrates; fibre; fats Dietary options during a flare up Nutrition Support in the acute setting Objectives

3. Some basic facts.... There is no food that causes inflammatory bowel disease (IBD) Diet manipulation cannot cure IBD - but can be useful for symptom control Certain types of food can exacerbate symptoms during a ‘flare-up’ Diet & Bowels are not “One Size Fits All” Tolerance to certain food types will vary according to degree active inflammation Understanding some of the basics about nutrition and IBD can help you to manage your symptoms BUT.... Beware... Over-zealous dietary restriction will result in weight loss and illness

4. Overview of IBD

5. What causes weight loss in IBD? Increased USE or LOSS of nutrients Decreased INTAKE due to Symptoms Abdominal Pain Bloating Cramping Wind Fear of causing diarrhoea Nausea Vomiting Active inflammation Malabsorption Profuse Diarrhoea Recurrent Vomiting

6. Food Terminology Protein animal plant Fibre soluble insoluble Carbohydrate complex simple Fat saturated unsaturated trans-fats hydrogenated

7. Protein Animal Protein (“Complete’): Meat, Fish, Eggs, Dairy Plant Protein: Cereals, Nuts, & Pulses. Low amounts of the 10 essential aa. Harder to digest due to fibre content Should make up approximately 15% calorie intake Made up of amino acids Body uses amino acids to make proteins and for repair and growth of body tissue Hormones, Enzymes, & Antibodies are types of proteins Insufficient protein intake decrease immunity and affects ability to heal More protein required during illness/ after surgery for the body to regenerate tissue, heal wounds, and rebuild damaged tissue

8. Protein & IBD Increased protein loss due to inflammation & malabsorption Recommended protein intake: 0.75g/kg body weight. In IBD better to aim for 1.2g/kg Tips: - Ideally more from animal sources - Lean cuts of meat - Plant protein: not well absorbed - especially in small bowel. Leads to increased ‘bloating’ Dairy Products Excellent source of protein, ‘milk sugar’ (lactose), calcium, vitamins May contribute to bloating & abdominal pain esp in SB inflammation, lactose intolerance Temporary lactose intolerance during ‘flare-ups’ Not wise to avoid dairy completely (unless good medical reason) - instead consider lactose free dairy products or lactase enzyme supplements NB: lactose found in ready meals, margarine, mayonnaise as well as dairy products milk & ice-cream

9. Carbohydrate Converted to glucose by digestion Cells utilise glucose to make energy - thus ‘fuels the body’ Contain starch and sugars which may be difficult to digest COMPLEX - eg Starch & Fibre Potatoes Root vegetables Cereals Legumes - peas, beans, lentils Rice Pasta Bread SIMPLE - Sugars Natural: Milk; Fruits; Vegetables Refined: Cakes; Biscuits; Pastries Raffinose - esp. in vegetables such as beans; cabbage; brussel sprouts; broccoli & asparagus Fructose - esp. in onions; artichokes; wheat; most fruits Lactose - Natural milk sugar

10. Carbohydrate Small bowel inflammation or rapid transit through SB (eg. post operatively) decreases ability to digest CHO Results in increased delivery of CHO to colon Normal intestinal bacteria then digests (by fermentation) CHO producing gas (carbon dioxide, hydrogen, & methane) Abdominal Pain Bloating Flatus ++ TIPS White rice - entirely digested in SB. Thus not gas producing Difficult to digest CHO Wholemeal bread; brown rice; wholemeal pasta Peas; beans; lentils; corn; wholegrain cereals; seeds; nuts The Cabbage Family: broccoli; cabbage; cauliflower; brussel sprouts Onion; garlic; chives Grapes; melons; dried fruits Even more difficult to digest if Fatty - eg chips; crisps; fried veg; chocolate; bicuits; cake etc

11. Fibre Carbohydrate from Plant-Based foods Not absorbable - thus no nutritional value SOLUBLE (dissolves in H20) Completely broken down by gut bacteria in colon Less gas forming Less likely to irritate colon Thus...Better for patients with colonic inflammation INSOLUBLE “High fibre diet” Generally good for health but not in IBD with colonic inflammation Not digestible by gut but intestinal bacteria partially digest Remainder passes through colon causes irritation if already inflamed Peeled fruit & veg (no skin/seeds) White rice White pasta Processed cereals: porridge; cornflakes; puffed rice Wheat bran; wholemeal bread Cabbage Broccoli Sweetcorn Legumes Skins & seeds of fruit & veg Abdominal Pain Bloating Flatus ++ Diarrhoea Undigested food in stool

12. Fat Good source of energy - but more complicated to digest Should not constitute >1/3 of our energy intake in diet Important for brain, nervous system, immune system, hormone metabolism, healthy hair, nails & skin Vitamin absorption: A, D, E, K Thermal regulation SATURATED Animal & dairy products UNSATURATED Vegetable sources & oily fish TIPS Patients with IBD need easy to digest food - thus low fat High fat foods Unsaturated fats healthier than saturated Hydrogenated Fats - modified fats used in food industry to prolong shelf-life; flavour; stability. Creates trans-fats that are harmful to health Trans-Fats - Margarine; snack foods; fast foods; biscuits; crisps; cereals; icing etc Diarrhoea Flatus Reduced Fat Low cholesterol Low saturated fat

13. During a Flare-Up Need to try to give the gut ‘easily digestible’ food - simple building blocks for repair General Approach: High Protein (esp. animal); Low fat; Low carbohydrate; Low fibre - ideally for 4-6 weeks until symptoms resolving. ✴ Small frequent meals ✴ Maintain hydration ✴ Increase protein from animal sources - esp. minced/ tenderised ✴ Reduce intake of complex carbohydrates (thus decrease bloating) ✴ Reduce lactose intake - natural yogurt; hard cheeses; lactose free milk; soya ✴ Limit caffeine & alcohol intake (esp. lager; beer; fizzy drinks) ✴ Avoid artificial sweeteners & processed foods ✴ Food preparation important

14. Once improving.... As pain, diarrhoea, bleeding & bloating improve: Phased re-introduction of normal diet Introduce foods slowly one at a time every few days Monitor symptom response Avoid rapid increase in fibre & carbohydrate intake Food preparation important role: Modern techniques - fast food: impact on gut health Especially during flare-up try to stick with casseroles; roasted meat; steaming; poaching; boiling. Avoid ready meals; sauces; spices etc

16. Other Types of Nutrition Support Parenteral Nutrition Enteral Nutrition Elemental Diet Polymeric Diet Short gut Fistulas - bypass gut Preparation pre-op Mucosal healing Fluids; electrolytes; or complete nutrition Nutrition in simplest form First line treatment in children with SB Crohns As effective as Steroids in trials for remission Require 6 weeks - compliance; palatability Supplemental/ complete Overnight ‘top ups’ Useful in stricturing crohns ? May promote healing

17. Questions?

19. Special Considerations “You will need to start a Low residue diet” Decreases bulk and volume of stool Helps reduce ‘obstructive symptoms’, pain & bloating Foods to Eat White bread Rice crispies, cornflakes etc White rice or pasta Well cooked vegetables Cooked or tinned fruit (no skin or seeds) Fruit or vegetable juices Foods to Reduce/Avoid Wholegrain/wholemeal cereals, bread or pasta Brown rice Lentils, chick peas, beans & pulses Nuts & seeds Potato skins Raw vegetables and salads Vegetable stalks Skin, pith, seeds etc on fruit Dried fruit