Inflammatory Bowel Disease (IBD) presents a daily challenge for those affected, with diet playing a pivotal role in managing its unpredictable symptoms. Whether you're navigating Crohn's disease or ulcerative colitis, understanding the intricate relationship between your eating habits and your gut health is essential. Integrating advice from medical professionals, this article explores how specific dietary adjustments can alleviate symptoms and potentially reduce flare-ups.
Understanding IBD
Inflammatory Bowel Disease, or IBD, is a term used for two specific and separate diseases: Crohn's disease and ulcerative colitis. These diseases cause ongoing inflammation in the digestive system, which can lead to symptoms like stomach pain, diarrhea, and undesired weight loss. Crohn's disease can affect any part of the digestive tract, from the mouth all the way to the anus, and can impact the entire thickness of the bowel wall. Ulcerative colitis, on the other hand, is an inflammatory disease of the colon, or large intestine, which is often accompanied by bloody diarrhea. This inflammation does not go through the entire wall of the intestines and therefore does not result in fistulas.
The pathogenesis of IBD involves genetic and environmental factors. If IBD runs in your family, you're more likely to get it too. Things like what we eat, our lifestyle, and where we live have been linked to IBD. In IBD, the body's defense system, which usually fights off infections, mistakenly attacks the lining of the digestive tract. The balance of bacteria in our gut is important for our health. In people with IBD, this balance is off. Research shows that changes in the gut's bacteria mix are linked to IBD. There are fewer good bacteria, which help make important nutrients, and more bad bacteria that can cause inflammation.
The Role of Diet in IBD Management
Diet significantly impacts the management of Inflammatory Bowel Disease (IBD), influencing both the frequency and severity of flare-ups. No specific food, diet or lifestyle causes, prevents or cures inflammatory bowel disease. Your diet does not cause inflammatory bowel disease, or induce a flare. However, diet is a potentially modifiable environmental risk factor for IBD onset and severity. Diet can promote intestinal inflammation by dysregulating the immune system, altering intestinal permeability and the mucous layer, contributing to microbial dysbiosis, and other mechanisms. Dietary changes therefore might be incorporated into therapeutic strategies for IBD.
General Dietary Recommendations for IBD
Nutritional recommendations are different for each disease and for each individual patient. Information regarding dietary treatments for IBD is often confusing. Many people receive information telling them to avoid entire food groups or specific foods. However, there is no need to avoid foods unless they worsen your symptoms. It is best to restrict as few foods as possible to increase the chances that you are getting a balanced, nutritious diet. No specific diet has been shown to prevent or treat IBD. However, some diet strategies help control symptoms. There are different approaches to diet during flares and in the absence of flares. Regardless of disease, do not overly restrict your diet. Adequate nutrition during illness is important. Try incorporating more omega-3 fatty acids in your diet. These fats may have an anti-inflammatory effect. Patients often find that smaller, more frequent meals are better tolerated.
Read also: The Hoxsey Diet
Dietary Strategies During Flares
During active disease phases, staying hydrated is crucial, with a goal of 64 ounces of fluid per day. Small, frequent meals are preferred over large meals, which might be harder to digest.
Avoid foods that may increase stool output such as fresh fruits and vegetables, prunes and caffeinated beverages. If you have lactose intolerance, follow a lactose-free diet. Lactose intolerance causes gas, bloating, cramping and diarrhea 30 to 90 minutes after eating milk, ice cream or large amounts of dairy. If you have oily and foul-smelling stools, you may have fat malabsorption. Treat fat malabsorption by following a low-fat diet.
Keeping a food diary is a great way to manage flare-ups. Start with a low-fiber or liquid diet until the situation resolves. Eat a low-fiber diet.
Dietary Strategies During Remission
Between flares, eat a wide variety of foods as tolerated. Increase your calorie and protein intake following a flare. Abdominal pain, diarrhea and decreased appetite may have caused poor food intake.
Specific Dietary Approaches
Low-FODMAP Diet
Try a low FODMAP diet. FODMAP stands for fermentable, oligo-, di-, monosaccharides and polyols. This type of diet cuts back on a group of sugars that can be poorly absorbed by your gastrointestinal tract.
Read also: Walnut Keto Guide
Mediterranean Diet
The Mediterranean diet, rich in fruits, vegetables, lean proteins, and healthy fats, is recommended for its anti-inflammatory properties. Unless there is a contraindication, all patients with IBD should be advised to follow a Mediterranean diet rich in a variety of fresh fruits and vegetables, monounsaturated fats, complex carbohydrates, and lean proteins and low in ultra-processed foods, added sugar, and salt for their overall health and general well-being. No diet has consistently been found to decrease the rate of flares in adults with IBD.
Specific Carbohydrate Diet (SCD)
The Specific Carbohydrate Diet (SCD) restricts certain carbohydrates that are difficult to digest, which can help reduce intestinal inflammation.
Enteral Nutrition
In some cases, especially in pediatric IBD, enteral nutrition (a liquid diet) can be used as a primary treatment to induce remission. Exclusive enteral nutrition using liquid nutrition formulations is an effective therapy for induction of clinical remission and endoscopic response in Crohn’s disease, with stronger evidence in children than adults. Enteral nutrition is effective in the treatment of pediatric patients with luminal Crohn's disease, but there have been few studies of the effects of dietary interventions with whole foods-most of these have been studies of exclusion diets in patients with Crohn's disease.
Nutritional Considerations and Potential Deficiencies
IBD patients are at a higher risk of nutritional deficiencies due to reduced food intake, malabsorption, and medication side effects. Be careful with vitamins and mineral supplements. Remember, most of your needed vitamins are obtained by eating a balanced diet. Besides eating a recommended diet, some supplements may be suggested for patients with inflammatory bowel disease. Essential nutrients that may require monitoring include vitamin D, iron, calcium, and B vitamins. People with Crohn's disease may be at increased risk for deficiencies of the following nutrients. A variety of factors affect risk for nutrient deficiency including medications used, portions of the digestive tract removed, degree of inflammation and the patient's ability to take adequate nutrition. Consult your doctor or nutritionist if you have concerns about deficiencies. Vitamin B12, Folate, Vitamins D, E and K, Vitamin A, Magnesium, Calcium, Potassium. People with ulcerative colitis may have increased needs for the following nutrients. Deficiencies depend on medications used and the extent of blood loss and diarrhea. Consult your doctor or nutritionist if you have concerns about deficiencies. Folate, Magnesium, Calcium, Iron, Potassium.
Managing Nutritional Side Effects of Medications
Moderate to severe flares of IBD are often treated with corticosteroids (prednisone), cholestyramine and 5-ASA compounds (sulfasalazine). These medications have nutritional side effects that should be addressed. Prednisone causes decreased absorption of calcium and phosphorus from the small intestine. It also causes increased losses of calcium, zinc, potassium and vitamin C. With continual use of high doses of prednisone, the result may be bone loss and development of bone disease. People on prednisone may need up to 1200 milligrams a day. Sulfasalazine interferes with folate absorption.
Read also: Weight Loss with Low-FODMAP
Post-Surgical Nutritional Needs
Some patients need surgery for severe inflammation, strictures, fistulas and abscesses. In Crohn's disease, the affected portion of the digestive tract is removed. Removal of portions of the intestine can affect nutritional status. When sections of the small or large intestine are removed, surface area for absorption of nutrients is decreased. If you have had or are planning to have surgery to remove intestines, talk to your doctor or registered dietitian about which vitamins and minerals you need to take. In patients with IBD and short bowel syndrome, long-term parenteral nutrition should be transitioned to customized hydration management (ie, intravenous electrolyte support and/or oral rehydration solutions) and oral intake whenever possible to decrease the risk of developing long-term complications.
Specific Considerations for Crohn's Disease and Ulcerative Colitis
Nutritional needs are specific to the individual and differ with disease state, body size and age. A nutritionist can help you estimate your individual needs. Calorie and protein needs are similar for Crohn's disease and ulcerative colitis. In both diseases, needs increase during inflammation and immediately after to restore losses.
- Calories: Calorie needs are only slightly increased, unless weight gain is desired.
- Protein: Protein needs for patients between flares are the number of grams protein equal to your weight in kilograms (1 kilogram equals 2.2 pounds body weight). For example, a 120 lb. female is 54.5 kg. and should therefore eat approximately 55 grams of protein each day. For weight gain and to restore losses after an acute flare, needs may be increased by 50 percent.
- Fluids and electrolytes: It is important to drink adequate amounts of fluid. A good guideline for hydration is to drink half of your body weight in ounces of water (e.g. a 120 lb. person should drink 60 ounces of water). Fluid requirements increase during or after episodes of diarrhea and with exercise. Make sure you replenish losses of electrolytes from diarrhea.
- Vitamins and minerals: A standard multivitamin with minerals can be taken each day. Increased risk for deficiencies of specific nutrients should be treated with an additional amount of those nutrients.
Supplementation Options
During times when solid foods cause irritation or you have a poor appetite, liquid oral supplementation may help provide nutrition.
- Peptamen or Peptamen Junior for kids: Contains protein that has been partially broken down, making it easier to absorb. This may be useful if portions of the digestive tract are inflamed or have been removed. This formula also contains MCT oils that are absorbed more easily, decreasing the undesirable effects of fat malabsorption (diarrhea, gas and bloating). This formula is not highly concentrated, which also may help decrease diarrhea. An 8 ounce ready-to drink can provides 240 calories, 10 grams protein; made by Nestle.
- Peptamen 1.5: Same composition as Peptamen but offers more calories per can.
- Modulen IBD: A mild formulation, which may help control diarrhea. It also contains a growth factor which may decrease inflammation. It contains MCT oil for better absorption of fat.
- EnLive!: Useful for nutrition before surgery, fat malabsorption, lactose intolerance and gluten sensitivity. This is a clear liquid supplement that is a good source of protein and calories. An 8 ounce.
- Lipisorb: High in MCT oil, which is an easily absorbed form of fat -- useful for fat malabsorption.
- Subdue: Partially broken down protein plus MCT oil for better absorption of fat.
- Vivonex: May be indicated for severe problems with absorption. This formula is very low in fat and is "elemental" or contains completely broken down protein, so the intestines can absorb nutrients easily.
- Optimental: This product is also elemental (completely broken down proteins) and contains MCT oils for easier absorption. It is lactose free and contains high levels of antioxidants.
Because people with ulcerative colitis do not have malabsorption concerns, a supplement that contains partially broken down protein is not usually needed. Standard supplements are fine but are more easily tolerated if they are isotonic or low concentration, which helps prevent diarrhea.
Snacking Strategies for IBD
Navigating snacking can be a challenge for individuals with IBD, given the need to avoid trigger foods while ensuring nutritional needs are met. The key to IBD-friendly snacking lies in choosing foods that are easy on the digestive system, nutrient-dense, and high in protein.
- Crackers, Peeled Apples, or Bananas with Nut Butter: These snacks offer a good mix of carbohydrates for energy and protein for muscle maintenance.
- Rice Cakes with Mashed Avocado: This combination provides healthy fats from avocado and a light, easy-to-digest carbohydrate source from rice cakes.
It's essential to stay mindful of portion sizes, as overeating, even healthy snacks, can lead to discomfort and exacerbate IBD symptoms. Monitor added sugars in snack foods, as they can trigger IBD symptoms.
The Importance of Professional Guidance
All patients with IBD warrant regular screening for malnutrition by their provider by means of assessing signs and symptoms, including unintended weight loss, edema and fluid retention, and fat and muscle mass loss. When observed, more complete evaluation for malnutrition by a registered dietitian is indicated. All patients with IBD should be monitored for vitamin D and iron deficiency. All outpatients and inpatients with complicated IBD warrant co-management with a registered dietitian, especially those who have malnutrition, short bowel syndrome, enterocutaneous fistula, and/or are requiring more complex nutrition therapies (eg, parenteral nutrition, enteral nutrition, or exclusive enteral nutrition), or those on a Crohn’s disease exclusion diet.
Additional Considerations
Patients with IBD who have symptomatic intestinal strictures may not tolerate fibrous, plant-based foods (ie, raw fruits and vegetables) due to their texture.
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