Transcript Nutrition Support

“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: [email protected]
Objectives
•
Basic Facts
•
Brief overview of IBD
•
Basic overview: protein; carbohydrates; fibre; fats
•
Dietary options during a flare up
•
Nutrition Support in the acute setting
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
Overview of IBD
What causes weight loss in IBD?
Increased USE or
LOSS of nutrients
Active inflammation
Malabsorption
Profuse Diarrhoea
Recurrent Vomiting
Abdominal Pain
Bloating
Cramping
Wind
Fear of causing
diarrhoea
Nausea
Vomiting
Decreased INTAKE
due to Symptoms
Food Terminology
Fibre
Protein
animal
plant
soluble
insoluble
saturated
Fat
trans-fats
Carbohydrate
unsaturated
complex
hydrogenated
simple
Protein
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
Should make up approximately 15% calorie intake
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
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
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
SIMPLE - Sugars
Potatoes
Root vegetables
Cereals
Legumes - peas, beans, lentils
Rice
Pasta
Bread
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
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
Abdominal
Pain
Bloating
Flatus ++
Normal intestinal bacteria then digests (by fermentation) CHO
producing gas (carbon dioxide, hydrogen, & methane)
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
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
Peeled fruit & veg (no skin/seeds)
White rice
White pasta
Processed cereals: porridge;
cornflakes; puffed rice
INSOLUBLE
“High fibre diet”
Abdominal
Generally good for health butPain
not
Bloating
in IBD with colonic inflammation
Flatus ++
Not digestible by gutDiarrhoea
but intestinal
Undigeste
bacteria partially digest
d food in
stool
Remainder passes through
colon
causes irritation if already inflamed
Wheat bran; wholemeal bread
Cabbage
Broccoli
Sweetcorn
Legumes
Skins & seeds of fruit & veg
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
TIPS
UNSATURATED
Vegetable sources & oily fish
Diarrhoea
Flatus
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
Low
Low
Reduced Fat
saturated fat
Trans-Fats - Margarine; snack foods; fast cholesterol
foods; biscuits; crisps;
cereals; icing etc
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
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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
Other Types of Nutrition Support
Elemental Diet
Polymeric Diet
Nutrition in simplest form
Parenteral
Nutrition
Short gut
Fistulas - bypass gut
Preparation pre-op
Mucosal healing
Fluids; electrolytes; or
complete nutrition
First line treatment in children
with SB Crohns
As effective as Steroids in
trials for remission
Require 6 weeks compliance; palatability
Enteral
Nutrition
Supplemental/ complete
Overnight ‘top ups’
Useful in stricturing crohns
? May promote healing
Questions?
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
Foods to Reduce/Avoid
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
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