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IBD and Your Diet

Ellen J. Scherl, MD

Introduction

Inflammatory Bowel Disease (IBD) is an umbrella term for two chronic gastrointestinal diseases: ulcerative colitis (UC) and Crohn's disease (CD). Because IBD affects the digestive tract it is very easy to associate food with the diseases and be concerned that your eating habits caused your IBD. Your disease was not caused by your diet, nor can your diet cure your disease. However, what you eat can affect your symptoms.

While no single special diet or eating plan works for everyone with IBD, you can develop a plan that may help you control your symptoms. You may want to start by reading about how IBD affects digestion. Or, you can skip to the sections that will help you pinpoint the foods that cause your symptoms to flare up or get the vitamins and minerals you need. Keep in mind that IBD can change over time, and you may need to revise your plan accordingly.

How Does IBD Affect Digestion?

When you think about how your body digests food, you probably picture your stomach. In reality, the majority of digestion actually happens in your small intestine, where food travels after it leaves your stomach. That's where digestive juices and churning help to break down what you eat. It's also where nutrients are absorbed into your bloodstream for distribution to the rest of your body. Anything left unabsorbed passes into your large intestine, where water is reabsorbed into your body. The remaining solid food residue leaves your body as a bowel movement.

When you have ulcerative colitis, your small intestine is usually healthy, but your large intestine is inflamed, which makes it difficult to reabsorb water properly and results in diarrhea. When you have Crohn's disease, usually your small intestine is inflamed although your entire digestive tract may become involved, making it less able to digest and absorb nutrients in the foods you eat. These unabsorbed nutrients pass along to your large intestine, where they interfere with water reabsorption, potentially causing both malnutrition and diarrhea.

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What Can You Do to Decrease Discomfort and Malnutrition?

Avoid foods that trigger flare-ups.

Many patients report that the following foods and beverages tend to cause problems:

• Dairy Foods

  Your body may not produce enough lactase, the enzyme needed to digest the lactose in dairy foods like milk or cheese. This can cause abdominal pain, gas, and diarrhea, so you may find it helpful to limit these foods. Since not all dairy products contain the same amount of lactose, you may be able to tolerate some better than others. For example, hard cheeses tend to be lower in lactose, as does yogurt, which also contains lactase. Also try looking for lactose-reduced or lactose-free products in the dairy case where you shop. Finally, taking lactase enzyme tablets before a meal or adding lactase enzyme drops to milk will decrease the amount of lactose your body has to digest.

  Be sure to watch out for lactose in nondairy foods too. It is often added to foods like cereal, instant soups, salad dressings, and baking mixes. Remember to check ingredient lists for words like milk, lactose, whey, milk byproducts, nonfat dry milk, buttermilk, and dry milk solids.

  Dairy products are an important source of calcium, so if you cut back on milk and cheese, make sure that you get calcium from other sources. Try broccoli, leafy greens, canned salmon, some types of tofu and soy milk (check the label), and calcium-fortified breads and juices. You may also want to consider taking a calcium supplement. A registered dietitian can help you make sure that you get enough calcium.

• High-fiber foods

  The fiber in raw fruits and vegetables, especially those in the cabbage family (including broccoli and cauliflower), may cause a flare-up in your IBD symptoms. Try steaming, baking, or stewing fruits and vegetables. You may also find that your body cannot tolerate the fiber in nuts, seeds, and popcorn, so you may also want to avoid those foods.

  Your physician may suggest that you try a low-residue/low-fiber diet. This means that, in addition to limiting high-fiber foods, you should also limit high-residue foods (like milk and fruit juice), which may be low in fiber, but are also sometimes difficult to digest.

• High-fat foods

  High-fat foods can be problematic for two reasons: The first is that fat speeds up the movement of food through your intestines. If you are prone to diarrhea, a high-fat meal could make the problem worse. The second reason is that your body might have difficulty absorbing fat. This could be the case if you have Crohn's disease involving your ileum (the lower part of your small intestine) or if you have had part of your small intestine removed. If your body doesn't properly absorb fat, a form of diarrhea called steatorrhea may develop. Reducing the amount of fat in your diet may help control these problems. Key sources of fat are butter, margarine, vegetable oils, mayonnaise, peanut butter, sauces and gravies, cream, ice cream, chocolate, and fried foods.

• Caffeine-containing foods and beverages

  Like fat, caffeine also speeds up the movement of food through your intestines and can promote diarrhea in patients with IBD. It can also irritate your intestinal lining. Coffee is a major source of caffeine, but significant amounts are also found in tea, chocolate, and some soft drinks. Herbal teas contain no caffeine and may help soothe your digestive track.

• Alcohol

  There are several reasons why drinking alcohol may cause difficulty if you have IBD. Most importantly, alcohol may interact with some medications to cause dangerous side effects, so always be sure to check with your physician first before drinking wine, beer, or liquor. Also, since alcohol is an irritant to the digestive tract, many people find that it triggers diarrhea and indigestion. Others find that drinking alcohol is not a problem if they limit the amount and consume it along with a meal. Finally, alcohol intake can inhibit the absorption of important nutrients, increasing the risk of malnutrition.

• Foods containing artificial fats and sweeteners

  Artificial fats (like Olestra) and sweeteners (like Sorbitol and Aspartame) often cause diarrhea. When it comes to fat, you might find you are better off choosing low-fat options (like baked chips, instead of the fat-free options). With sugar, try smaller amounts of the real thing instead of sugar substitutes.

• Spicy foods

  Many people with IBD find that spicy foods cause flare-ups. Like fat and caffeine, spicy foods can speed up the movement of food through your digestive system and may cause diarrhea. Specific spices to watch out for are black and red pepper, chili peppers and powders, nutmeg, and mustard. Herbs, cinnamon, paprika, allspice, and cloves are typically less problematic.1

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Get the Vitamins and Minerals you need

You may sometimes feel like you are walking a tightrope between avoiding the foods that worsen your symptoms and eating enough food to stay well-nourished. IBD, especially Crohn's disease, can make you prone to malnutrition for several reasons:

• Your body is less able to absorb dietary protein, fat, carbohydrates, water, and many vitamins and minerals.
• You may not have much of an appetite, due to frequent bouts of nausea and abdominal pain.
• Your disease may increase your caloric needs, especially during flare-ups.
• You may lose nutrients through bleeding and diarrhea.
• You may have had part of your small intestine removed, leaving less area for nutrient absorption.
• Your medications may interfere with nutrient absorption.

To compensate for any of the challenges listed above, your physician may recommend that you supplement the foods you eat with a general multivitamin and/or specific vitamins, minerals, and other essential nutrients. The following list reviews some of the supplements that you may need. Before taking any supplement, be sure to check with your physician.

• Folic acid (also called folate or folacin)

  Your daily diet should include about 400 micrograms of folic acid. Many foods, like cereals and breads, are fortified with folic acid. Orange juice, broccoli, spinach, liver (beef and chicken), eggs, bananas, and cantaloupes are also good sources. Folic acid supplements can be taken orally or injected. They are often necessary if you are taking sulfasalazine, which may interfere with your body's ability to absorb folic acid.

• Vitamin B₁₂

  Your daily diet should include about 2.4 micrograms of vitamin B₁₂, which is found in meat, chicken, fish, and eggs. B₁₂ supplements can be taken orally as a regular pill or as a dissolving tablet under the tongue, and as an injection or as a nasal spray.

• Vitamin E

  Your daily diet should include about 22 international units (IU) of vitamin E, which is found in leafy green vegetables and vegetable oils. Vitamin E supplements are taken orally, in the form of an oil-filled capsule.

• Magnesium

  Your daily diet should include about 310 mg of magnesium if you are a woman and 420 mg of magnesium if you are a man. Magnesium is found in bananas, avocados, peanut butter, sesame seed butter (tahini), and potatoes. Supplements are taken orally. However, large doses of magnesium can have a laxative effect, so magnesium is best obtained through food and supplementation should be undertaken with care and only under the supervision of your doctor.

• Iron

  Your daily diet should include from 8 to 18 mg of iron, depending on your sex and age. Iron is found in fish, chicken, beef, and eggs. Supplements are taken orally and may cause constipation and nausea, so try taking them with meals and a lot of fluids. If you are also taking calcium supplements, the two should be taken at different times of the day, since iron interferes with calcium absorption. Iron can also be a gastrointestinal irritant so you may need to find a formulation you can tolerate. Ferrous sulfate is the most common iron supplement, but it is also available as ferrous fumarate, ferrous succinate, ferrous gluconate, ferrous lactate, ferrous glutamate, and ferrous glycine.

• Calcium

  Your daily diet should include from 1,000 to 1,200 mg of calcium, depending on your sex and age. Calcium is found in dairy foods, like milk, cheese, and yogurt, as well as in canned salmon and sardines. Also look for foods that are fortified with calcium, like some orange juice, grapefruit juice, and cereals. Supplements are taken orally and may especially be required if you are taking corticosteroids, like prednisone, which increase calcium loss. If you are also taking iron supplements, the two should be taken at different times of the day, since iron interferes with calcium absorption.

• Vitamin D

  Your daily diet should include about 200 international units (IU) of vitamin D, which helps your body absorb calcium. Your body makes vitamin D when sunlight hits your skin. Fifteen minutes of exposure to the sun each day is typically all you need. Vitamin D is also added to most fluid milk. Supplements are taken orally and may be needed if you are older, housebound, live in a northern climate, or don't drink milk.

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Get Enough Calories

You may not always feel like eating, but it's important to be sure to get the calories your body needs to stay as healthy as possible. There are simple ways to increase calories without adding a lot of additional food to your diet. For example, add a hard-boiled egg to vegetables and sandwiches; add instant breakfast mix to your milk; eat presweetened cereal; and choose higher calorie fruite juices (cranberry, grape, pineapple, or apricot).

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Eat small meals

Eating smaller meals at more frequent intervals may help reduce abdominal pain. For example, instead of three meals per day, try eating smaller meals every three to four hours.

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Drink plenty of liquids

Chronic diarrhea increases your risk of dehydration, so focus on getting enough fluids each day, especially in warm weather. Each day, try drinking one-half ounce for every pound you weigh. That means if you weigh 130 pounds, you should try to drink 65 ounces (about 8 cups) per day. Water is the best choice. Make sure you sip instead of gulp, to cut down on discomfort caused by increased air in your digestive track.

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Proceed with caution

You may have read about some new approaches to nutritional therapy for IBD. Most are in their infancy and haven't been rigorously studied, so it's important to first discuss them with your physician and then proceed with caution. The National Center for Complementary and Alternative Medicine has developed a Web site (http://nccam.nih.gov) to help you learn more about nontraditional therapies.

• Herbs

  Herbal therapy is the most common type of alternative treatment used by people with IBD2. Herbs used range from traditional Chinese remedies to aloe vera gel, frankincense, and curcumin (the yellow pigment in turmeric). Just because herbs are "natural," does not mean they are always safe. For more information about herbal therapy, see the "Treatment of IBD" newsletter by Dr. Kornbluth.

• The Specific Carbohydrate Diet

  The Specific Carbohydrate Diet is a strict grain-free, lactose-free, and sucrose-free meal plan. The diet is very difficult to follow, since it prohibits

  • all grains, pasta, breads, and starchy foods (including those made with wheat, corn, barley, oats, rye, buckwheat, soy, and others).
  • all milk, high-lactose cheeses, commercial yogurt, cream, buttermilk, and sour cream.
  • all sugar (including sucrose, fructose, high-fructose corn syrup, or any processed sugar).
  • canned and most processed meats.

  The diet's premise is that, if you have IBD, carbohydrates in your diet promote overgrowth of bacteria and yeast in your intestines. This causes an imbalance that prevents digestive enzymes from functioning properly. The result is that carbohydrates remain undigested and unabsorbed, continuing the cycle of bacteria and yeast overgrowth.

  Although some IBD patients are fans of the Specific Carbohydrate Diet, many have found that it provides no relief. To date there have been no well-designed clinical trials testing the diet's effectiveness, so the jury is still out.

• Probiotics

  Your intestines are home to more than 400 different types of bacteria, and IBD can disrupt the delicate balance among them. Probiotic therapy for IBD is based on the idea that supplementing your diet with certain bacteria (usually lactobacillus or acidophilus in capsule form) can help normalize intestinal function by restoring a healthier balance. To date, studies of probiotics have focused on patients with specific types of IBD. As is the case with the Specific Carbohydrate Diet, clinical trials are needed to better understand their potential.

• Short-chain fatty acid supplements

  Dietary carbohydrates are broken down into short-chain fatty acids by bacteria in the large intestine. These fatty acids contribute to the health of the intestinal lining. Several clinical trials focusing on patients with ulcerative colitis have found that using an enema to boost the amount of short-chain fatty acids in the large intestine decreases disease symptoms and increases the effectiveness of mesalamine (5-ASA). Other studies have not been able to repeat these findings, so more research is needed.

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Understand the role of nutritional support.

If you become significantly malnourished, there are several different types of nutrition support available. Commercially available, nonprescription formulations, like Ensure and Sustacal can be used to increase the caloric and nutrient content of your diet. These ready-made drinks provide complete nutrition and are easily absorbed in the small intestine.

If you find ready-made drinks difficult to digest or unpalatable, your physician may prescribe an elemental diet, which is even more readily absorbed. Elemental diets can be delivered through a nasogastric tube (through the nose to the stomach) or through a gastronomy tube (directly into the stomach through a surgical opening in the abdominal wall). This is called enteral nutrition. Both types of tubes are typically used during sleep and removed in the morning; however gastronomy tubes can also be used intermittently during the day.

Sometimes severe relapses of IBD require interventions to bypass the digestive tract while ensuring that patients receive the nutrition they need. Should this happen to you, to give your intestines a complete rest, your physician may prescribe a therapy called total parenteral nutrition (TPN), which means that a solution of nutrients is delivered through a catheter or needle placed in a vein in your upper arm or chest. Patients typically start TPN treatment in the hospital. Once stabilized, they can then continue receiving TPN at home. TPN may result in more complications than enteral nutrition. For example, a small number of patients develop liver damage, blood-borne bacterial infections, or clotting within the major vein. It is also significantly more expensive than other types of nutritional support and requires a higher level of training to use.

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Summary

Remember, your diet did not cause and cannot cure your disease, but what you eat can have a significant impact on reducing your IBD symptoms, promoting healing, and helping you feel in charge. Avoiding the foods that cause flare-ups and getting adequate calories and nutrients can sometimes feel like a challenge, but there is a healthcare team to help you along the way. Work with your physician and a registered dietitian to develop the best plan for you.

This information has been reviewed and approved by CCFA's National Scientific Advisory Committee.

1. Steiner-Grossman, P, Banks, PA, Present, DH, Eds. The New People Not Patients. New York: Crohns and Colitis Foundation of America;1992:29,117.
2. Langmead, L, Rampton, DS. Review article: complementary and alternative therapies for inflammatory bowel disease. Aliment Pharmacol Ther. 2006;23:341-349.

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