Inflammatory Bowel Disease and Diet-Question and Answers In the small bowel digestive juices from both the liver (termed bile) and the pancreas mix with food. After digested food is broken down into small molecules, it is absorbed through the surface of the small intestine and distributed to the rest of the body by the blood stream. Watery food residue and secretions that are not digested in the small bowel pass on into the large bowel(the colon). The colon reabsorbs much of the water added to food in the small intestine. Solid, undigested food residue is then passed from the large bowel as a bowel movement. When the small bowel is inflamed—as it often is with Crohn’s disease—the bowel becomes less able to digest and absorb food nutrients fully. Such nutrients, as well as unabsorbed bile salts, can escape into the colon to varying degrees, depending on how extensively and how severely the small bowel has been injured by inflammation. This is one reason why people with Crohn’s disease become malnourished, in addition to just not having much appetite. Furthermore, incompletely digested foods that travel through the colon interfere with water absorption , even if the colon itself is not damaged. Thus, when Crohn’s disease affects the small bowel , it may cause diarrhoea as well as malnutrition. Should the colon also be inflamed, the diarrhoea is likely to be worse. In ulcerative colitis, only the colon is inflamed; the small bowel works normally. Because the inflamed colon does not recycle water properly, diarrhoea can be severe. By Nicola Attwood Gastro Dietitian-Colchester Hospital Crohn’s and Colitis Meeting May 2013

What is Inflammatory Bowel Disease? Ulcerative Colitis Crohn’s Disease Introduction We do not know the exact cause of IBD but we do know it is related to the immune system in the gut not “switching off”. Although UC and CD are seen as 2 distinct conditions, it is possible that these conditions exist in a continuum of diseases with UC and CD at opposite ends. There is a theory that 10% of patients has something in-between the two and that is indeterminate colitis. Most people are diagnosed from 15-30 years old, although it can occur at any age. About 10% of people are diagnosed with it as a child. (<18 year) Indeterminate Colitis 10% Chronic No medical cure Chronic No cure

What is Difference between UC and CD? Ulcerative Colitis Starts in the rectum Extends to beginning of large bowel (caecum) Inflammation limited to lining of the colon Crohn’s Disease Can effect any part of the bowel Can be patchy Can extend through the bowel wall There are distinct differences between UC and CD and they can be treated differently.

Why is malnutrition common in IBD? Effect Cause Reduced food intake Malabsorption Increased intestinal losses Drugs Poor appetite ,pain, nausea, dietary restriction Reduced absorption caused by damaged from inflammation and surgery Altered absorption and utilisation. Table above explains why malnutrition is common in IBD. IBD patients, especially people with Crohn’s disease, are prone to becoming malnourished for many reasons. The appetite is often reduced leading to poor dietary intake. Active IBD or a flare up may increase the energy (calorie) needs of the body. IBD, particularly Crohn’s disease is often associated with malabsorption of nutrients. There can also be increased intestinal losses from damage to the bowel and previous surgery. Some medications can also affect nutrition such as steroids which can affect calcium. Therefore, the tendency to become malnourished must be addressed. maintenance of good nutrition is a key principle in the management of IBD

What vitamin and mineral deficiencies need to be treated? Deficiencies in vitamins and minerals in IBD is common Supplement with Folic acid, vitamin D, vitamin B complex and vitamin C may be good idea if you are symptomatic. May need calcium if on steroids Supplement with iron if anaemic Supplement with zinc if there is long-term diarrhoea. Patients with IBD should routinely take folic acid, 1 mg/day because it also helps protect against bowel cancer. Due to high level of deficiencies , supplementation with vitamin B complex and vitamin C should be recommended. May need vitamin D and E supplements if there is malabsorption. Vitamin D supplementation should be in the range of 800 U/day, especially in the non-sunny areas of the country, and calcium intake should be encouraged, Steroid use and Crohn’s disease itself are linked to bone thinning and osteoporosis, so screening with bone density studies is suggested for those at risk. Vitamin B-12 is absorbed in the lower ileum. Therefore, persons with ileitis (Crohn’s disease that affects the ileum) may require injections of vitamin B-12, because they cannot absorb enough from their diet. In most IBD patients, there is no obvious lack of minerals. However, calcium, phosphorus, and magnesium supplements may prove necessary in people who have extensive small intestinal disease or who have had substantial lengths of intestine removed through surgery. Iron therapy is helpful to correct anaemia. Oral iron turns the stools black, which can sometimes simulate intestinal bleeding Good idea to supplement with zinc if you have diarrhoea. IBD is often treated with steroids which increase the risk of osteoporosis, so supplement with calcium as well.

How is malnutrition treated? Provide extra energy and protein in diet by fortifying foods Aim for small frequent meals May need prescription supplements such as Fresubin Energy®, Fortisip ®, Ensure Plus ®, Modulen ® or Elemental 028 ® Supplements? May need nutritional supplements to help treat weight loss.e.g. Fresubin Energy®. These needs to be presccribed. Can get Complan ® or Buildup Shakes ® over the counter.

Is There a special diet for those with IBD? Diet for IBD needs to be individualised Depends of type of disease and part of bowel affected Depends on previous surgery An elimination diet can help identify food intolerances A low residue diet may be needed if there is a stricture or in a flare-up Dietitian is the best guide in selection of most appropriate diet Dietary recommendations for people with IBD must be individualised: They depend on which disease you have and what part of your intestine is affected. Many people have food intolerances— far more than really have true food allergies. One of the more common intolerances, lactose intolerance, is the inability to digest lactose (milk sugar), which is related to genetic tendencies and to small bowel function. Elimination tests are better at diagnosing which foods must be avoided or modified than the standard allergy skin or blood testing. Speak to your dietitian about an “elimination diet,” which involves keeping a food and symptom diary over several weeks. About two thirds of people with small bowel Crohn’s disease develop a marked narrowing (or stricture) of the lower small intestine, the ileum. For these patients, a low-fibre with low residue diet (see below) or a special liquid diet may be beneficial in minimising abdominal pain and other symptoms. Often, these dietary modifications are temporary. Keeping a foods and symptom dairy along with the advice of a registered dietitian, remains the single most useful guide to selection of foods for any person with IBD

What to eat if IBD is active? Best diet should include foods from all the food groups Choose low fibre starchy foods, fruit and vegetables Avoid some foods if intolerance is identified Smaller meals are better tolerated An appropriate diet should contain a variety of foods from all food groups. Meat, fish, poultry, and dairy products, if tolerated, are sources of protein; bread, cereal, starches, fruits, and vegetables are sources of carbohydrate; margarine and oils are sources of fat. Generally, if the colon is inflamed, avoiding scrappy foods such as nuts, corn hulls, and raw vegetables is advised until some healing has occurred.

What is a low fibre or low residue diet? These diets help to reduce the amount of “roughage” or residue in the stool Restriction of raw fruits and vegetables, their skins Restriction of seeds, nuts and sweet corn Restrict high fibre carbohydrates such as bran, wholemeal, and potato skins These diets are used when there is significant diarrhoea, high output stomas or strictures. This diet minimises the consumption of foods that add residue to the stool. These include raw fruits, vegetables, and seeds, as well as nuts and corn hulls. These diets are used when there is significant diarrhoea or stoma output.

High fibre foods to avoid

Recommended foods and those to avoid Food Groups Recommend Avoid Grains Bread and cereals made from refined flours: Wholegrain/meal bread and cereals: (four or more white bread, Cornflakes, Rice krispies, wholewheat/meal bread, granary bread, servings daily) Cheerios, Puffed wheat, Special K, porridge seeded bread, cereals containing bran, Weetabix, Shredded Wheat, muesli or other cereas/snack bars containing bran, dried fruit/coconut or nuts white rice wholegrain/brown rice, fried rice white pasta wholegrain/wheat pasta wholegrain/wheat biscuits/crackers white flour and foods made with this flour wholemeal/wheat flour Pulses None Dried beans including baked beans, lentils, dried peas Nuts and seeds None All nuts and seeds and foods containing them including nut butters, coconut Potatoes Potatoes boiled, mashed, baked without Potato skin, fried potatoes including chips (2 medicum size/day) skin roasted, crisps, potato salad Vegetables Well cooked vegetables as follows: Salads and other raw vegetables (2 cups/day) green beans, spinach, pumpkin

Food Groups Recommend Avoid Vegetables asparagus tips, beetroot, carrots, seedless brussel sprouts no pips, seeds, husks, strained vegetable soup/vegetable juices, skins or stalks, sweetcorn, cabbage, Vegetables can be pureed if necessary sauerkraut, mushrooms, turnip, onions, leeks, peppers Fruit squash, tinned fruit, Fruit juices with pulp, prune juice, fizzy ( 2 medium size ripe banana, melon, tomato no skin or seeds, drinks, tinned pineapple, fresh fruit pieces/day) ripe avocado. Jelly jam, shredless preserves,lemon curd. dried fruit, cakes/biscuits containing dried Fruit can be pureed if necessary fruit, jam, marmalade with seeds, skins, pips. Mincemeat. Fruit pie/tart/flan. Skin, stalks, seeds, stones Milk and milk Whole milk up to 300ml (1/2 pint)/day, semi- Full fat cheese, milk puddings made products skimmed up to 450ml (3/4 pint), skimmed with wholegrain ingredients milk up to 600ml (1pt), low fat products quiche, pizza eg plain yogurt or with allowed fruit fromage frais or milk puddings or custard or cream or icecream without nuts or pieces of fruit, creamy soup with sieved vegetables, plain cottage cheese or low fat cheese, milk substitudes eg soya milk and plain soya desserts Fats and oils Oil (1 tablespoon/person), low fat margarine, Full fat margarine, coconut cream, lard, butter (scraping), low fat cream sauces suet

Food Groups Recommend Avoid Meat and poultry Tender lean meat and poultry, lean Tough/course meats with gristle, (100g/4oz) processed meats eg ham/chicken/turkey luncheon meats, sausages, hotdogs, or bacon cold cuts, meat pies, pasties, pates, fried meat/poultry, meat prepared with wholegrain ingredients/seeds/nuts meat burgers Fish (up to 160g or Fish (white/oily) steamed, poached, boiled, Fried fish and shellfish 6oz) tinned in water or oil (discard) Eggs (up to 4/wk) Boiled, poached, scrambled, omelette Fried Miscellaneous Sugar, honey, syrup, boiled sweets, mints Popcorn, pickles, horseradish, relish, caramel, marshmallow, jelly, pepper, salt, herbs, spices, curries, chilli, alcohol, gravy made with water, tomato sauce, soy, mustard, lemon juice, vinegar, garlic sauce, low fat white sauce, chocolates, carbonated drinks. Scones, pastries

What to eat when IBD is in Remission? Important to eat foods from all the main foods groups Can slowly introduce fibre rich foods Add one new food at a time and start with small portions-gradually increasing Keep a food and symptom diary to identify food intolerances Gradually build up to a normal diet.

Can food make IBD inflammation worse? No certain foods in any individual may aggravate symptoms of these diseases no evidence that the inflammation of the bowel is directly affected. Avoid food out of date or contaminated as food poisoning will aggravate IBD No. While certain foods in any individual may aggravate symptoms of these diseases, there is no evidence that the inflammation of the gut is directly affected. Any contaminated food that leads to food poisoning will aggravate IBD.

Identifying “problem foods” Keeping a food and symptom diary is very important Common foods less well tolerated are: alcohol (mixed drinks, beer, wine) , Fizzy drinks, caffeine drinks and fruit juice Skins, husk and stalks of fruit and vegetables dairy products (if lactose intolerant) fatty foods (fried foods) foods high in fibre such as whole grains and bran gas-producing foods (lentils, beans, legumes, cabbage, broccoli, onions) nuts and seeds (peanut butter, other nut butters) raw fruits and raw vegetables spicy foods

Should someone with active IBD drink more fluid? Yes! chronic diarrhoea increases the risk of dehydration dehydration and salt loss create a feeling of weakness. people with IBD should drink plenty of fluids, especially in warm weather when skin losses of salt and water may be high Yes. In a condition with chronic diarrhoea, there may be a risk of dehydration. If fluid intake does not keep up with diarrhoea, kidney function may be affected. Patients with Crohn’s and other diarrheal diseases have an increased incidence of kidney stones, which is related to this problem. Furthermore, dehydration and salt loss create a feeling of weakness. For these reasons, people with IBD should drink plenty of fluids, especially in warm weather when skin losses of salt and water may be high.

Diet tips for IBD-summary Keep a food and symptom diary to identify problem foods that may aggravate symptoms Follow a low residue diet or low fibre diet if having a flare up Small frequent meals are often better tolerated If losing weight let us know-you may need supplements No special diet for IBD – everyone is difference. Aim for a balance of all the main foods groups Thank You