Which of the following diets would be most appropriate to patients with ulcerative colitis?

Inflammatory Bowel Disease (IBD) is a term used for two specific and separate diseases: Crohn's disease and ulcerative colitis. Nutritional recommendations are different for each disease and for each individual patient. It is important to discuss the treatments that are right for you with a registered dietitian and with your doctor.

Disease Definitions

• Crohn's disease Crohn's disease is a chronic inflammatory disease of unknown cause that can involve any portion of the digestive tract. Inflammation can extend entirely through the intestinal wall, often resulting in diarrhea, strictures (narrowing), fistulas (abnormal opening), malabsorption and the need for surgical resections of portions of the digestive tract.
• Ulcerative colitis Ulcerative colitis 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. However, extensive inflammation may eventually require surgery for removal of the affected area.

FAQ: Dietary Management of IBD

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. This is important for maintaining the function of your digestive tract and your overall health.

Can diet control IBD?

No specific diet has been shown to prevent or treat IBD. However, some diet strategies help control symptoms. See information below for diet strategies that may be appropriate for you.

How can I identify problem foods?

Keeping a record of foods eaten and then taking note of when symptoms worsen may help you identify patterns that indicate problem foods.

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What are dietary strategies for managing symptoms and when are they appropriate?

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. See below for specific recommendations.

Diet Recommendations for Ulcerative Colitis Flare

• Follow a low residue diet to relieve abdominal pain and diarrhea.
• Avoid foods that may increase stool output such as fresh fruits and vegetables, prunes and caffeinated beverages.
• Decrease concentrated sweets in your diet, such as juices, candy and soda, to help decrease amounts of water pulled into your intestine, which may contribute to watery stools.
• Decrease alcohol consumption.
• Try incorporating more omega-3 fatty acids in your diet. These fats may have an anti-inflammatory effect. They are found in fish, including salmon, mackerel, herring and sardines.
• Patients often find that smaller, more frequent meals are better tolerated. This eating pattern can help increase the amount of nutrition you receive in a day.
• Consider taking nutritional supplements if appetite is poor and solid foods are not tolerated well (see section on recommended liquid supplements).

Diet Recommendations for Crohn's Disease Flare

• Follow a low residue diet to relieve abdominal pain and diarrhea.
• If you have strictures, it is especially important to avoid nuts, seeds, beans and kernels.
• Avoid foods that may increase stool output such as fresh fruits and vegetables, prunes and caffeinated beverages. Cold foods may help reduce diarrhea.
• 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. A breath hydrogen test may confirm suspicions of lactose intolerance.
• If you have oily and foul-smelling stools, you may have fat malabsorption. Treat fat malabsorption by following a low-fat diet. Discuss these symptoms with your doctor or nutritionist.
• Smaller, more frequent meals are better tolerated and can maximize nutritional intake.
• If your appetite is decreased and solid foods not tolerated well, consider taking nutritional supplements (see section on recommended liquid supplements).

Diet Progression Following Flares for Ulcerative Colitis and Crohn's Disease

• Continue to follow a low residue diet and slowly add back a variety of foods.
• Begin with well-tolerated liquids and advance to soft solids, then solids (see below for liquid and solid food suggestions).
• Introduce one or two items every few days and avoid any foods that cause symptoms.
• Add fiber to diet as tolerated. Well-tolerated fiber sources include tender cooked vegetables, canned or cooked fruits, and starches like cooked cereals and whole wheat noodles and tortillas.
• Between flares, eat a wide variety of foods as tolerated. This includes fruits, vegetables, whole grains, lean protein, and low-fat and nonfat dairy products.
• Increase your calorie and protein intake following a flare. Abdominal pain, diarrhea and decreased appetite may have caused poor food intake. Steroids used to treat flares also can increase protein needs.

Suggestions for first foods after a flare include:

• Diluted juices
• Applesauce
• Canned fruit
• Oatmeal
• Plain chicken, turkey or fish
• Cooked eggs or egg substitutes
• Mashed potatoes, rice or noodles
• Bread – sourdough or white

FAQ: Treatments and Nutritional Side Effects

Do any medications have nutritional side effects?

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. If you use any of these medications, talk to your doctor or registered dietitian for treatment advice.

• 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. Protein needs also are increased for people taking prednisone because it increases protein breakdown in the body.
• Cholestyramine decreases absorption of fat-soluble vitamins (A,D, E and K), as well as folate, vitamin B-12, calcium and iron.
• Sulfasalazine interferes with folate absorption. People taking this drug also should take a 1 milligram folate supplement each day.

Can surgery affect nutritional status?

Some patients need surgery for severe inflammation, strictures, fistulas and abscesses. In Crohn's disease, the affected portion of the digestive tract is removed. In ulcerative colitis, the colon is often removed and the ileum (bottom of the small intestine) may be attached to the anus.

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. The following diagram illustrates where nutrients are absorbed. If certain portions of the intestine are severely inflamed, or have been removed, absorption of nutrients may be affected. Malnutrition and nutrient deficiencies can result.

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.

What side effects of IBD can cause malnutrition?

There are several reasons why people with IBD may be at risk for malnutrition. The following list includes some side effects that contribute to malnutrition.

• Inadequate food/fluid intake may by caused by nausea, abdominal pain, loss of appetite or altered taste sensation
• Increased losses – intestinal inflammation during acute flares results in increased protein losses, losses from fistula fluids, diarrhea and bleeding
• Increased nutritional needs – inflammation or infection increases metabolic requirements
• Malabsorption with Crohn's disease may be caused by severe intestinal inflammation, resection of small intestine and medications, such as prednisone and sulfasalazine

Are nutritional needs different for people with IBD? What are the specific nutritional needs for people with 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. The following are general statements about nutritional needs that may apply to you.

• Calories Calorie needs are only slightly increased, unless weight gain is desired. Weight loss can occur due to episodes of inflammation, poor appetite and decreased intake.
• 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. Needs also are increased if you are taking corticosteroids (prednisone).
• 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. Sodium, chloride and potassium can be replenished by drinking sports drinks, such as Gatorade and Powerade.
• 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. Discuss vitamin and mineral needs with your nutritionist or doctor.
  • People with Crohn's disease are at greater risk for deficiencies of several vitamins and minerals due to extensive inflammation or removal of large portions of the digestive tract.
  • People with ulcerative colitis have less risk for vitamin and mineral deficiencies but are more prone to iron, fluid and electrolyte loss with bleeding, diarrhea and/or removal of the large intestine.

What can I do for periods of poor appetite and weight loss to prevent malnutrition?

At times, there are very few foods that are tolerated well. During these times it is important to eat high calorie foods in tolerable amounts as frequently as possible. During times when solid foods cause irritation or you have a poor appetite, liquid oral supplementation may help provide nutrition. The following list includes liquid supplements for Crohn's Disease and ulcerative colitis.

Liquid Supplements for Crohn's Disease

• 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. Recommend adding flavor packets to improve palatability.
• Peptamen 1.5 Same composition as Peptamen but offers more calories per can. An 8 ounce ready-to-drink can provides 360 calories, 16 grams protein; made by Nestle.
• 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. An 8 ounce serving made from powder provides 240 calories, 9 grams protein; made by Nestle.
• 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. ready-to drink box provides 300 calories, 10 grams protein; made by Ross.
• Lipisorb High in MCT oil, which is an easily absorbed form of fat -- useful for fat malabsorption. An 8 ounce ready-to drink can provides 325 calories, 14 grams protein; made by Mead Johnson.
• Subdue Partially broken down protein plus MCT oil for better absorption of fat. An 8 ounce ready-to drink can provides 240 calories, 12 grams protein; made by Mead Johnson.
• 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. An 8 ounce ready-to drink can provides 240 calories, 11 grams protein; made by Novartis
• 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. An 8 ounce ready-to drink can provides 237 calories, 12 grams protein; made by Ross.

Liquid Supplements for Ulcerative Colitis

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. Some formulas that may be helpful include Modulen IBD or Enlive (see above).

Nutrient Deficiencies and Treatment

Ulcerative Colitis

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. Correct with supplements and nutrient-rich foods.

• Folate Increased risk with Sulfasalazine use
• Magnesium Increased risk with chronic diarrhea
• Calcium Increased risk with prednisone use
• Iron Increased risk with blood loss from ulceration of colon and/or clinical signs and symptoms of deficiency (anemia)
• Potassium Increased risk with chronic vomiting and diarrhea, prednisone use and/ or low blood levels of potassium

Crohn's Disease

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. Nutrient deficiencies are treated with supplements and nutrient-rich foods.

• Vitamin B12 Increased risk with extensive inflammation in the ileum (lower small intestine) or removal of the ileum.
• Folate Increased risk with Sulfasalazine use; extensive inflammation in the jejunum (middle portion of the small intestine) or removal of the jejunum.
• Vitamins D, E and K Increased risk with fat malabsorption; inflammation of large portions of the jejunum and/or ileum or removal of portions of the jejunum and ileum.
• Vitamin A Increased risk with fat malabsorption; disease involvement of the duodenum (upper small intestine) and/or upper jejunum.
• Magnesium Increased risk with extensive inflammation and/or removal of large portions of the jejunum and ileum, fistula losses and chronic diarrhea.
• Zinc Increased risk with extensive inflammation and/or removal of the jejunum, diarrhea, fistula losses, prednisone use or measured low blood levels of zinc.
• Calcium Increased risk with avoidance of dairy foods for lactose intolerance, fat malabsorption, prednisone use, extensive inflammation or surgery throughout the entire small intestine.
• Potassium Increased risk with chronic vomiting and diarrhea, prednisone use.

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