Transcript Inflammatory Bowel Disease Your Diet Your Nutritional Choices

Nutrition & IBD: Choices for
Adults and Kids
Content
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Overview of adult and pediatric IBD
Impact of IBD on nutrition
Overview of diets often used by IBD patients
Eating well with IBD
Choosing supplements with IBD
Is Food the Friend or Enemy?
• Many people with IBD cannot tolerate
certain foods when feeling well and
during flares
• Although associations have been and are
being investigated, no conclusive
evidence that diet can cause or cure IBD
• Nutrition and diet are important to IBD
management
What You Eat is Important
• Diet is the actual food that is consumed (“What you
eat”)
• Nutrition refers to properly absorbing food and staying
healthy (“How you eat”)
• IBD is not related to food allergies (immune response)
but symptoms may be worsened by food intolerance
(non-immune response)
• Diet may affect the symptoms of IBD, but not the
inflammation
• Proper diet and nutrition may improve symptoms of
IBD and overall wellness
Overview of IBD
Chronic autoimmune diseases with a genetic component
that affect the gastrointestinal (GI) tract
CROHN’S DISEASE
• Patchy, full-thickness
inflammation
• Anywhere from mouth to anus
• Mostly affects small intestine
• Extraintestinal
Indeterminate
manifestations
Colitis
10%-15%
ULCERATIVE COLITIS
• Continuous, superficial
inflammation
• Colon and/or rectum
• Extraintestinal
manifestations
The Effect of IBD on Digestion
• Crohn’s disease (CD)
• Ulcerative colitis (UC)
– If small intestine is
affected, digestion and
absorption of nutrients
may be affected
– Poor absorption and
inflammation in colon
may also cause diarrhea
– Small intestine works
normally
– Inflamed colon causes
urgency and does not
reabsorb water properly,
resulting in diarrhea
The Effect of IBD on Nutrition
IBD patients are at an increased risk for:
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Nutritional deficiencies
Weight loss
Iron deficiency
Folic acid deficiency
Vitamin B12 deficiency
Heller A. Eating Right with IBD. 2004.
• Mineral/electrolyte
deficiencies
• Dehydration
• Osteoporosis
• Growth retardation
in children
The Effect of IBD on Growth
• Growth often affected in children with IBD
– More common in CD than in UC
– Seen both before and after disease is
diagnosed
• Decreased rate of growth and height
– Adult height compromised
– CD: 32-88%
– UC: 9-34%
• Growth is a good marker for disease
activity
The Effect of IBD on Growth
The Effect of IBD on Growth
• Causes of poor growth
– Intestinal inflammation
– Steroids
– Poor nutrition
• Disease location
• Early treatment after
diagnosis is crucial
Bone Health in Children to Adults
• Decreased bone mineral density (amount of mineral
in bone) is common in people with IBD due to:
– Poor calcium absorption/intake (i.e., limited dairy and
dark leafy vegetable intake)
– Vitamin D deficiency
– Decreased physical activity
– Inflammation
• Peak bone mass occurs by age 30-32
• Steroid use (repeated, and or prolonged more than 6
weeks) increases short- and long-term risk
Heller A.
Nutrition Screening and IBD
Nutritional evaluation may include:
• Patient history
• Physical exam and laboratory studies:
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Height and weight
Blood count (CBC)
Biochemical profile, magnesium
Inflammatory markers (CRP, ESR)
Serum iron studies, including ferritin
Albumin and pre-albumin
Folic acid/Vitamin B12
25 OH vitamin D
Bone density testing (DEXA) – if concerned about low
bone density
Heller A. Eating Right with IBD. 2004.
Adult IBD Nutritional Goals
• Maintaining an adequate intake of
protein, carbohydrates, and fat, as well
as vitamins and minerals, is necessary
for good health
• Communicating regularly with your
healthcare team is important!
– Identify deficiencies or problems in advance
– After surgery, there may be different needs
– People with j-pouches and ostomies may have
different needs
Principles of Good Nutrition
Maintaining good nutrition is key to:
– Medications being more effective
– Healing, immunity, and energy levels
– Preventing or minimizing GI symptoms and
normalizing bowel function
Is There a Special Diet for
Patients With IBD?
NO, THERE AREN’T ANY SPECIAL DIETS FOR
IBD
• Some diets may be used to help identify trigger
foods or relieve symptoms
• Several diets advertised specifically for managing
IBD inflammation
– Many claims are supported by a small number of
subjects
– Most have not been proven scientifically
– Benefits have not been confirmed in formal studies
Diets That May be Prescribed
Diet
Description
Elimination Diet
Keeping a food and symptoms diary over
several weeks to help match symptoms to
“problem foods.”
Low-fiber with
Low-residue Diet
Minimizes the intake of foods that add bulk
residue to stool (e.g., raw fruits, vegetables,
seeds, nuts).
Often used in patients with strictures or during
flares.
May be restricted in certain vitamins, minerals,
and antioxidants. Needs monitoring.
Total Bowel Rest
Period of complete bowel rest during which
patients are nourished with fluids delivered
intravenously. May be useful short term with
medication.
May be used to treat short bowel syndrome.
Other Diets
Diet
Description
Gluten-free Diet
Excludes grains that contain the protein gluten. Used
primarily in patients with celiac disease.
Decreases complex carbohydrates which may affect bowel
function.
Clear Liquid Diet
Period of bowel rest during which patients get
nourishment from clear liquids. Considered nutritionally
inadequate even with clear liquid supplements.
Elemental Diet
Consists of nutrients in their simplest form. High in
carbohydrates, low in fats. Used in Europe as primary
treatment for CD, but not considered as good as other
treatments.
FODMAPs
Acronym for Fermentable, Oligo-, Di- and Monosaccharides, and Polyols. Diet minimizes consumption of
these fermentable carbohydrates to manage GI symptoms,
including diarrhea, gas, and bloating. More commonly
used for IBS.
Heller A; Scarlata K. Today’s Dietitian. 2010.
Popular Diets
Diet
Description
The Specific
Carbohydrate Diet™
Reducing poorly digestible carbohydrates to
lessen symptoms of gas, cramps, and diarrhea.
Consists mainly of meats, vegetables, oils, honey.
South Beach Diet™
and Atkins Diet™
Both South Beach and Atkins diets restrict
carbohydrates. Very strict diet at beginning
followed by long-term eating plan.
Decreases complex carbohydrates which may
affect bowel function.
The Maker’s Diet
Focuses on four components of total healthphysical, mental, spiritual, and emotional.
Consists of a phased approach.
Recommended foods are unprocessed, unrefined,
and untreated with pesticides or hormones.
*Note: none of these diets have been studied with scientific or clinical rigor to
prove they have a direct benefit for IBD patients.
Enteral Nutrition
Provides support for deficiencies in calories and/or
macro- and micronutrients in the form of a liquid
supplement.
• Administered through
- Nasogastric tube (NG tube) from nose to stomach
- Gastrostomy tube (G-tube) from abdominal wall to stomach
• Helpful for children with IBD to ensure adequate nutrition
when:
- Appetite is poor
- Concerns about growth
- Complications in gaining weight
• Tube feedings can be given at night
• Oral supplements (e.g., Ensure®) can be
useful but do not require tube feedings
Parenteral Nutrition
Delivered through catheter placed into a
large blood vessel
• More complications than enteral nutrition
• Requires specialized training to
administer
• Rarely necessary
Diet Research
• Research studies on the relationship between diet,
nutrition, and IBD are limited
• Most studies are small, resulting in
anecdotal outcomes
• Diet may have impact on disease,
but research has been inadequate to
show how
– Different mechanisms proposed:
effect on immune system, gut bacteria
Hou JK, et al. Am J Gastroenterol . 2011; Korzenik J; Lewis J.
Diet Research: Associations
2011 review article showed associations between dietary
intake and risk of IBD
Fats and Meats
• High dietary intakes associated with an increased risk of IBD
Fiber and Fruits
• High dietary intakes were associated with decreased risk of CD
Vegetables
• High dietary intake was associated with decreased risk of UC
 Take-home points
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Limitations with review (different studies, majority were retrospective)
No particular foods, but component common to many foods may have a
role
Studies did not explore role of diet on current disease activity
Albenberg LG, et al. Curr Opin Gastroenterol. 2012; Korzenik J; Lewis J.
Key Messages
Diet Has Not Been
Shown to:
Diet Can
Diet Should be
• Cause IBD
• Help symptoms
while disease is
being treated in
other ways
• Individualized based
on:
1. Which disease
you have (CD vs.
UC)
2. What part of
intestine is
affected
3. Disease activity
(remission vs.
flare)
4. Individual caloric
and nutritional
needs
• Prevent IBD
• Provide sustainable
disease control alone
without the help of
maintenance therapy
• Improve nutritional
status and overall
wellness
Eating Well with IBD
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People with IBD should maintain as diverse and
nutrient-rich diet as they can
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When experiencing a flare, you may need to avoid
foods that worsen symptoms
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Be flexible and focus on what you can eat
– Follow your experience, and keep track of
foods that trigger symptoms
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USDA site (www.choosemyplate.gov)
has general recommendations on
healthy eating, and sample meal plans
Heller A. Eating Right with IBD. 2004; Bonci L. American Dietetic Association Guide to Better
Digestion. 2003.
Nutrition Basics
Macronutrients
– Carbohydrates
• Provide energy
• Simple: digested quickly (e.g., sugar, honey, lactose)
• Complex: longer to digest (e.g., starches, fiber in
vegetables, legumes, grains)
– Protein
• Provide “building blocks” for bones, muscles, cartilage,
skin, and blood, as well as enzymes and hormones
• May need more when experiencing inflammation or
recovering from inflammation
– Fat
• Often viewed as bad, but has important role in providing
energy and essential fatty acids; needed to absorb some
vitamins
• Saturated, monounsaturated, polyunsaturated
Kane S. IBD Self-Management. 2010; Roscher B. How to Cook for Crohn’s and Colitis. 2007; USDA. choosemyplate.gov.
Nutrition Basics
Micronutrients
– Vitamins
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Substances that the body cannot manufacture
Necessary for a variety of biochemical processes
Body must obtain them, mostly from animal sources
Fat-soluble (A,D,E,K) and water-soluble (B vitamins, folic
acid, vitamin C)
– Minerals
• Elements that do not form chains
• Necessary for a variety of biochemical processes
• Include sodium, potassium, iron, magnesium, calcium,
zinc
Stein SH, Rood RP, eds. Inflammatory Bowel Disease: A Guide for Patients and Their
Families. 1999.
Water: The Forgotten Nutrient
• Fluid intake essential for people with IBD
• Average person should ingest 64 oz of water per day
or 8 (8 oz) glasses per day
– Does not include alcohol or caffeine
• Diarrhea can cause dehydration
Other options for keeping hydrated
• Oral rehydration solution (e.g., Pedialyte®)
• Water-diluted sports drinks or juices
– Dilution prevents excessive sugar intake
• Water with electrolytes
Avoid caffeinated or carbonated beverages
Dalessandro T. What To Eat With IBD. 2006; Roscher B. How to Cook for Crohn’s and Colitis. 2007.
Tips for Healthy Eating with IBD
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When feeling well, people with IBD can eat
a normal, balanced diet
When experiencing symptoms, may need
to adjust diet:
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Eat more small, frequent meals
Eat in a relaxed atmosphere
Avoid high fat or greasy foods
Limit spicy or highly seasoned foods
Avoid trigger foods
Limit high-fiber foods
Consider nutritional supplements
Heller A. Eating Right with IBD. 2004; Bonci L. American Dietetic Association Guide to Better
Digestion. 2003.
Types of Fiber
Soluble Fiber
Insoluble Fiber
Soluble – dissolves in water
Insoluble – not soluble in water
Absorbs water in GI tract, forms
smooth, gel-like consistency in
bowel
Draws water into GI tract, increases
bulk
Beneficial for diarrhea sufferers
Food moves more quickly through
bowel
Slows food and increases
absorption
Increases movement of food,
decreasing absorption
Examples – Pectins (e.g., citrus,
carrots, jelly)
Gums (e.g., seaweed, agar)
Mucilages (e.g., oats)
Examples – Cellulose (e.g., Brussels
sprouts, cabbage, kale, wheat bran)
Lignin (e.g., celery, flaxseed, sesame
seeds)
Kane S. IBD Self-Management. 2010; Dalessandro T. What To Eat With IBD. 2006; Roscher B. How to Cook for Crohn’s
and Colitis. 2007.
Fiber Needs
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Either type of fiber may cause bloating and gas
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Recommended daily intake: 25 grams for
women, 38 grams for men (best obtained from
food sources)
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Children should consume the number of grams
equal to their age +5
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If you reduced your fiber intake during a flare,
slowly increase when you are feeling better (only
a few grams per week)
Kane S. IBD Self-Management. 2010; Slavin JL, J Am Diet Assoc. 2008.
Control IBD Symptoms
Avoid “trigger” foods
Not all IBD patients are affected by the same foods
Common foods that may cause GI discomfort:
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High-fiber foods (e.g., nuts, raw, leafy vegetables)
High-fat foods (e.g., greasy, fried foods)
Caffeine (e.g., coffee, tea, soda, chocolate)
Alcohol
Carbonated beverages
Dairy (lactose)
Sugar alcohols in sugar-free foods (e.g., sorbitol)
Spicy foods
Use food diary to help identify “trigger” foods
Vegetables
When experiencing a flare:
• Cooked, pureed, or peeled vegetables
may be better tolerated
• Select vegetables that are easier to
digest (e.g., asparagus, potatoes)
• Avoid vegetables that are gas-producing
or have a tough skin (e.g., broccoli, Brussels
sprouts)
• Add vegetable stock to rice or pasta for
additional nutrients
Heller A. Eating Right with IBD. 2004; Dalessandro T. What To Eat With IBD. 2006.
Fruits
When experiencing a flare:
• Cooked, pureed, canned, or peeled fruit
may be better tolerated
• Select fruits that are easier to
digest and have less insoluble fiber
(e.g., applesauce or melon)
• Avoid fruits with high fiber content
(e.g., oranges, dried fruit such as raisins)
Heller A. Eating Right with IBD. 2004; Dalessandro T. What To Eat With IBD. 2006.; Bonci L.
American Dietetic Association Guide to Better Digestion. 2003
Carbohydrates
When experiencing a flare:
• Carbohydrates that are more refined
with less insoluble fiber may be
better tolerated
– Examples: oatmeal, potato,
sourdough, and French breads
• Avoid carbohydrates with more insoluble
fiber, such as grains with seeds and nuts
Dalessandro T. What To Eat With IBD. 2006; Roscher B. How to Cook for Crohn’s and Colitis. 2007.
Protein
• Protein needs may be greater during inflammation
When experiencing a flare:
• Lean sources of protein may be better tolerated
– Excess fat can lead to poor absorption and may make
symptoms worse
– Examples: fish (salmon, halibut, flounder, swordfish),
chicken, eggs, and tofu
• Try smooth nut butters (peanut, almond, cashew)
• Avoid fatty, fried, or highly processed meats, as
well as nuts and seeds
Heller A. Eating Right with IBD. 2004; Dalessandro T. What To Eat With IBD. 2006; Roscher B. How
to Cook for Crohn’s and Colitis. 2007; Kane S. IBD Self-Management. 2010; USDA.
choosemyplate.gov.
Tips for Eating Out
There is No “IBD-safe” Menu
• Don’t go out feeling too hungry
• Don’t be afraid to make special requests
• Call ahead or review menu online
• Eat smaller portions
• When in doubt, keep it simple
– Go for boiled, grilled, broiled,
steamed, poached, or sautéed options
– Limit sauces and spices
Crohn’s & Colitis Foundation of America. Take Charge. 2006.
Promoting Growth and Bone Health
• Control inflammation through treatment
– Induce remission
– Maintain remission
• Ensure adequate caloric intake
– For some, high calorie supplements or tube
feedings may be needed
• Avoid long-term or repetitive steroid use
• Ensure adequate calcium and vitamin D
Heller A. Eating Right with IBD. 2004.
Importance of Calcium
Calcium consumption important for IBD patients due to:
• Increased risk of osteoporosis
• Poor intake of dairy due to avoidance, allergies, lactose intolerance,
etc.
• Medications such as corticosteroids
1200-1500 mg per day is recommended (400-500 mg at a time)
How to get 1200-1500 mg per day:
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Consume three servings of calcium-rich foods daily,
such as milk (regular, lactose-free, fortified
almond or soy), yogurt, cheese, tofu,
dark leafy vegetables, or canned fish with bones
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Add a calcium citrate supplement if needed
Heller A. Eating Right with IBD. 2004; Dalessandro T. What To Eat With IBD. 2006; Scarlata K. Today’s
Dietitian. 2010.
Supplements for IBD
Multivitamin/multimineral formula
• Absorbability: liquid or powder-filled options may be
better tolerated, metabolized faster
• Look for United States Pharmacopeial Convention (USP)
symbol: guarantees it has met quality standards of
organization
Supplements that are often recommended:
Highly absorbable calcium supplement
• 1200-1500 mg as calcium citrate (split into 3 doses)
Vitamin D – Helps absorption of calcium
• Supplement with 1000 IU daily
Dalessandro T. What To Eat With IBD. 2006; Kane S. IBD Self-Management. 2010.
Supplements to Discuss with
Healthcare Team
Folic Acid
• 800 mcg to 1 mg per day
Vitamin B12
• Monthly intramuscular injection may be given to patients with ileitis or with
significant ileal resection
Iron, when necessary
• Must be determined by deficiency present, excess iron can be toxic
• Usual dose is 8 to 27 mg, taken one to three times a day
Zinc, when necessary
• Deficiency may be due to diarrhea, fistulas, inflammation
• Recommended supplement typically 15 mg/day
Probiotics
• “Good” bacteria that restores balance to the
intestines
• May help for maintenance of UC, pouchitis
• Found in fermented foods such as yogurt, kefir, kimchee
Omega-3 fatty acids (fish oils)
• Large, well-controlled trials showed no benefit in CD
Heller A. Eating Right with
IBD. 2004; Dalessandro T.
What To Eat With IBD. 2006;
Kane S. IBD SelfManagement. 2010.
Supplements That May Worsen Symptoms
• Angel’s trumpet: decreases motility
(anticholinergic hyoscyamine, scopolamine)
• Alder buckthorn: increases motility
(anthraquinone laxative)
• Aloe latex (anthraquinone laxative)
• Cascara (anthraquinone laxative)
• Castor oil (ricinoleic acid laxative)
• European buckthorn (anthraquinone laxative)
• Fo – ti (anthraquinone laxative, potential
hepatotoxin)
• Rhubarb (anthraquinone laxative)
• Senna (anthraquinone laxative)
Heller A. Eating Right with IBD. 2004; Natural Medicines Comprehensive Database. 2004.
Summary
• Every case of IBD is different
• Generally, people with IBD should eat a well-balanced,
nutrient-rich diet when feeling well and should not feel
limited by their disease
• When experiencing a flare or complication (such as a
stricture), may need to adjust diet
– Make sure you are meeting your calorie and
nutrient needs
Summary
Take things day-by-day and plan meals
• Prepare a shopping list to ensure caloric and
nutrient intake is achieved
• Read food labels
• Keep a food diary
– CCFA-prepared food diary is available at:
www.ccfacommunity.org, click on Resource Center
tab
→ Work
with healthcare team to make
sure nutrition needs are met!
EXAMPLE OF AN IBD MEAL PLAN
Breakfast:
1 cup plain low-fat Greek yogurt
½ cup Cheerios®
½ cup sliced peaches
Snack:
1 hard boiled egg
¾ cup honeydew melon
Lunch:
¼ lb cooked lean ground turkey meat divided on
2 corn or flour tortillas, topped with slices of avocado,
shredded Bibb lettuce, and mild salsa (as tolerated)
Snack:
1 small banana spread with 1 tbsp creamy all-natural
nut butter
Dinner:
1 cup cooked penne pasta with 1-2 tbsp olive oil, fresh herbs,
well-cooked broccoli florets, and cooked shrimp
Nutrition and Diet Resources
• American Society of Parenteral & Enteral Nutrition –
www.nutritioncare.org
• Academy of Nutrition & Dietetics – www.eatright.org
• Find a registered dietitian – www.eatright.org/programs/rdfinder
• The American Association of Nutritional Consultants –
www.aanc.net
• USDA foods for wellness information – www.choosemyplate.gov
• CCFA Community Forum – Diet Forum – www.ccfacommunity.org
• CCFA “I’ll Be Determined” – Diet Module– www.ibdetermined.org
• CCFA Website – www.ccfa.org
Questions and Answers
Contributors
Beth K. Arnold, MA, RD, LD, CCFA AL/NW FL Chapter Board President
Tracie Dalessandro, MS, RD, CDN, Registered Dietitian, Private Clinical Practice, Briarcliff Manor, New
York
Arthur D. Heller, MD, Private Practice, New York, NY
Michael Kappelman, MD, University of North Carolina, Division of Pediatric Gastroenterology, Co-Chair,
Professional Education Committee, CCFA National Scientific Advisory Committee
Sandra Kim, MD, University of North Carolina, Division of Pediatric Gastroenterology, Co-Chair,
Pediatric Affairs Committee, CCFA National Scientific Advisory Committee
Joshua Korzenik, MD, Brigham and Women's Hospital
James Lewis, MD, PhD, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Raymond and Ruth Perelman School of Medicine , Chair, CCFA National Scientific Advisory
Committee
Richard Rood, MD, Medical Director, Inflammatory Bowel Disease Program, Digestive Disease Division,
University of Cincinnati College of Medicine
David T. Rubin, MD, Associate Professor of Medicine, Co-Director, Inflammatory Bowel Disease Center,
Program Director, Fellowship in Gastroenterology, Hepatology and Nutrition, University of Chicago
Medical Center
Laura Walls, MPH, RD, Research Coordinator, University of North Carolina, Division of Pediatric
Gastroenterology
Colleen Webb, MS, RD, CDN, Registered Dietitian, Weill Cornell Medical Center
References
Albenberg LG, Lewis JD, Wu GD. Food and the gut microbiota in inflammatory bowel diseases: a critical
connection. Curr Opin Gastroenterol. 2012;28(4):314-320.
Bonci L. American Dietetic Association Guide to Better Digestion. Hoboken, NJ: John Wiley &Sons, Inc,
2003.
Crohn’s & Colitis Foundation of America. No reservations: how to take the worry out of eating out. Take
Charge. 2006:13-14.
Dalessandro T. What To Eat With IBD: A Comprehensive Nutrition and Recipe Guide for Crohn’s Disease
and Ulcerative Colitis. New York, NY: CMG Publishing; 2006.
Heller A. Eating Right with IBD. In: Patient Education Symposium 2004; New York, NY: Crohn’s & Colitis
Foundation of America, Greater New York Chapter.
Hou JK, Abraham B, El-Serag H. Dietary intake and risk of developing inflammatory bowel disease: a
systematic review of the literature. Am J Gastroenterol. 2011;106(4):563-573.
James A. Inflammatory bowel disease and nutrition. About Kids Health Web site.
http://research.aboutkidsheath.ca/ofhc/news/CLMNABD/5522.asp. Published October 5, 2006.
Updated February 2, 2010.
References (cont).
Kane S. IBD Self-Management: The AGA Guide to Crohn's Disease and Ulcerative Colitis. Bethesda, MD:
AGA Press; 2010:143-175.
Lucendo AJ, De Rezende LC. Importance of nutrition in inflammatory bowel disease. World J
Gastroenterol. 2009;15(17):2081-2088.
Roscher B. How to Cook for Crohn’s and Colitis. Nashville, TN: Cumberland House; 2007.
Scarlata K. The FODMAPs approach — minimize consumption of fermentable carbs to manage functional
gut disorder symptoms. Today’s Dietitian. 2010;12(8):30.
Slavin JL, American Dietetics Association Positions Committee Workgroup. Position of the American
Dietetic Association: Health Implications of Dietary Fiber. J Am Diet Assoc. 2008;108:1716-1731.
Stein SH, Rood RP, eds. Inflammatory Bowel Disease: A Guide for Patients and Their Families. 2nd
edition. Philadelphia: Lippincott-Raven, 1999.
United States Department of Agriculture. choosemyplate.gov. www.choosemyplate.gov. Accessed June
29, 2012.