Royal Surrey County HospitalNHS Foundation Trust

Patient information leaflet

Nutrition and Dietetics

Diet and Inflammatory Bowel Disease

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Who is this leaflet for?

This leaflet is for people who have a diagnosis of inflammatory bowel disease (IBD).

The information in this leaflet tells you what IBD is, gives advice on what to eat with IBD and how diet can help to manage possible symptoms.

What is IBD?

Crohn’s Disease and Ulcerative Colitis are the most common forms of IBD. Although they can present differently and can have different medical management styles, they share a number of common features. Both involve inflammation of parts of the digestive system (gut) and periods of relapse ‘Flare ups’ and remission.

Crohn’s Disease can involve patchy inflammation of any part of the digestive system from the mouth to the anus, but is most common in the small intestine and colon. It can affect all layers of lining of the bowel. When it involves the small bowel it can impact on the digestion and absorption of nutrients.

Ulcerative Colitis involves inflammation and ulceration of the lining of the large colon and rectum.

Symptoms of IBD can include abdominal pain, bloating, diarrhoea and constipation.

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Is there a diet for IBD?

There are many diets that claim to cure IBD but these often lack enough evidence to support their claims and may be detrimental to health. There is however considerable evidence that certain aspects of nutrition are important in IBD.

You may find that certain foods affect your symptoms or are harder to digest, but a healthy balanced diet is important for everyone, to ensure that you are getting all the nutrients needed for good health. Good nutrition is especially important in IBD for:

■ Maintaining a healthy immune system

■ Maintaining energy levels

■ Aiding recovery from infection and injury

■ Preventing illness and disease

■ Recovery from relapse

■ Recovery from surgery

Some people may find it helpful to alter their diet slightly to manage symptoms, but everyone is individual, and what works for one person may not work for another. Keeping a food and symptom diary may help you to identify foods that are affecting your symptoms.

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What is a healthy, balanced diet?

The department of health have developed the Eat Well Guide which shows the five different food groups and the proportions we should eat them in to ensure a balanced diet.

Crisps

Raisins

Frozenpeas

Lentils

Soyadrink

Cous

Cous

pasta

Whole wheat

Bagels

Porridge

Low fatsoft cheese

Tuna

Plainnuts peas

Chick

Semi

milkskimmed

Choppedtomatoes

lowersaltandsugar

Beans

Whole

graincereal

Potatoes

Spaghetti

Low fatPlain

yoghurt

Leanmince

Lower fatspread

Sauce

OilVeg

Rice

Each serving (150g) contains

of an adult’s reference intakeTypical values (as sold) per 100g: 697kJ/ 167kcal

Check the label on packaged foods

Energy1046kJ250kcal

Fat Saturates Sugars Salt3.0g 1.3g 34g 0.9g

15%38%7%4%13%

Choose foods lower in fat, salt and sugars

Source: Public Health England in association with the Welsh Government, Food Standards Scotland and the Food Standards Agency in Northern Ireland © Crown copyright 2016

Use the Eatwell Guide to help you get a balance of healthier and more sustainable food. It shows how much of what you eat overall should come from each food group.

Eatwell Guide

2000kcal 2500kcal = ALL FOOD + ALL DRINKSPer day

Eat less often andin small amounts

Choose lower fat and

lower sugar options

Eat more beans and pulses, 2 portions of sustainably

sourced fish per week, one of which is oily. Eat less

red and processed meat

Potatoes, bread, rice, pasta and other starchy carbohydrates

Choose wholegrain or higher fibre versions with less added fat, salt and sugar

Frui

t and

vegetables

Oil & spreads

Ea

t at l

east

5 p

ortio

ns o

f a va

riety

of fruit a

nd vegetables every dayLOW LOW HIGH MED

Choose unsaturated oils and use in small amountsDairy and alternativesBeans, pulses, fish, eggs, meat and other proteins

6-8a day

Water, lower fat milk, sugar-free drinks including tea and coffee all count.

Limit fruit juice and/or smoothies to a total of 150ml a day.

Their 8 tips for healthier eating are:

1. Base your meals on starchy foods

2. Eat lots of fruit and veg

3. Eat more fish

4. Cut down on saturated fat and sugar

5. Eat less salt

6. Get active and be a healthy weight

7. Don’t get thirsty

8. Don’t skip breakfast

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With IBD you may find it difficult to eat all five food groups and your diet may change during a flare up. You might find that there are a few foods in each group which are more manageable. It is important not to cut out a particular food unless it consistently causes symptoms. If you feel your diet is missing out a particular food group consider taking a daily A-Z multivitamin tablet available from your pharmacy.

Some people find that spicy foods, very fatty foods (e.g. cream cakes, takeaways), caffeine and alcohol can exacerbate symptoms.

What is a healthy weight?

Body mass index (BMI) is a good indicator of your nutritional status, as it can tell you if you are a healthy weight for your height. It is calculated by dividing your weight in kilograms by your height in metres squared.

BMI range (kg/m2) Weight Category<20 Underweight20-25 Desirable weight25-30 Over weight>30 Obese

If you are underweight you may be at higher risk of nutritional deficiencies, infections, and poor bone health. It may also affect your body’s ability to heal and function.

If you are overweight it puts you at higher risk of diabetes, heart disease, stroke and some cancers.

It is not unusual for people with IBD to have a fluctuating weight due to the symptoms of flare-up’s affecting appetite and absorption of nutrients. It is important to maintain weight during a flare-up to ensure your body is getting enough nutrients and energy to recover.

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Tips for gaining weight if you are underweight or if you have a poor appetite:

■ Avoid diet foods e.g. diet drinks, skimmed milk, low fat yoghurts, low fat crisps and biscuits

■ Have nutritious drinks such as milk, milkshakes, fruit juice, smoothies, hot chocolate, Ovaltine®

■ Eat little and often ■ Have snacks between meals ■ Have puddings ■ Fortify foods ■ Add cheese, cream, sauces, dressings, oil to savoury foods e.g.

soups, salads, potato, meat ■ Add cream, sugar, condensed milk, custard, ice-cream to sweet foods

e.g. fruit and puddings

How do I keep my bones healthy?

Calcium is important for keeping your bones healthy. If you do not get enough from your diet you are at increased risk of getting osteoporosis (weak, fragile bones which are more likely to break). If you have IBD you have higher requirements for calcium. This can be due to:

■ Use of steroid treatment

■ Low body weight and malnutrition

■ Avoidance of dairy products

■ Malabsorption of calcium and vitamin D which can occur in Crohn’s Disease

■ Possibly the inflammatory process itself.

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The daily guideline amount of calcium is 1000mg a day for adults (over 19 years) with IBD, and 1200mg a day for post-menopausal women and men over 55 years with IBD. Calcium is mainly found in dairy foods such as milk, yoghurt, and cheese. It is in milky puddings such as custard, rice pudding, and ice cream. It is also found in foods fortified with calcium such as dairy alternatives (soya milk, oat milk, almond milk, rice milk) and breakfast cereals. Smaller amounts are found in green leafy vegetables such as cabbage and spinach and in bony fish such as sardines.

Vitamin D helps with the absorption of calcium from foods. Most of our vitamin D is made from the reaction of sunlight on the skin. Going outside for 15 minutes 2-3 times a week from April-September without sunscreen should be enough to produce sufficient Vitamin D.

There are some food sources of Vitamin D (e.g. fortified breakfast cereals, margarines, oily fish and eggs) but you cannot get enough Vitamin D from food alone.

Exercise is also important to keep bones healthy. Weight bearing activities are best such as walking, aerobics, running and tennis. Aim for at least 30 minutes of activity five days a week.

If you are unable to meet your daily needs for calcium and Vitamin D, or if you are on steroids, your IBD team may prescribe supplements for you.

Why is Iron Important?

Iron is needed to help carry oxygen around the body. Iron deficiency anaemia can be common in people with IBD. This can be due to blood loss, decreased dietary intake of iron, and malabsorption of iron. Tiredness, reduced appetite and shortness of breath can be symptoms of iron deficiency anaemia.

Good sources of Iron include red meat, offal, liver pâté, green leafy vegetables, beans and pulses and fortified breakfast cereals. Sometimes iron tablets are prescribed if levels are low.

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Should I restrict fibre?

There are 2 types of fibre:Soluble Fibre - Is fully digested by your body and forms a gel. It helps to lower cholesterol and to soften/thicken stools. Sources of soluble fibre include oats, rye, barley and fruit and vegetables without skin, pips, pith, and stalks.

Insoluble Fibre - Cannot be digested fully by your body. It is important for bowel health as it adds bulk to stools and helps them pass through the bowel more easily. It contributes to the health of bacteria in your gut. In some people it can increase feelings of urgency and contribute towards bloating and abdominal pain. It is found in wholegrains, skins/peel on fruit and vegetables, nuts, seeds, pips, and wheat bran.

Some people find that decreasing the amount of insoluble fibre, during a flare-up can help reduce symptoms of diarrhoea, wind, bloating and abdominal pain. However, it is important to slowly reintroduce fibre back into the diet once the flare-up has passed.

Some people with IBD can have a narrowing in their bowels (stricture) which decreases the diameter of the bowel, making it harder for food to move through. If you have a stricture you will need to follow a strict low fibre diet as it is easier for low fibre food to get past the narrowing. If you have a severe stricture you may even need to have a soft or liquid diet. The length of time on a low fibre diet depends on the type of stricture; if it is an inflammatory stricture you should be able to reintroduce higher fibre foods after the inflammation has reduced. If it is a fibrous stricture you will need to follow it long term.

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Ask your team to refer you to a dietitian for more advice on a strict low fibre diet.

Foods low in insoluble fibre Foods high in insoluble fibre ■ Fruits without skins, pips, seeds

e.g. Peeled apples, pears, apricots, plums or bananas, mangos, melon, pineapple

■ Well cooked vegetables: Carrots, parsnips, swede, turnips, butternut squash, cabbage, broccoli, cauliflower (no tough stalks)

■ Peeled and deseeded cucumber, tomatoes, peppers, courgettes

■ Smooth vegetable soup

■ Tinned fruit

■ White bread

■ White rice

■ White pasta

■ Cornflakes®, puffed rice, Special K without berries®

■ Oats

■ Pips, pith, skin, and peel of fruit e.g. Citrus fruits, berries, kiwis, pomegranate

■ Stalks of vegetables

■ Raw vegetables e.g. salad, vegetable sticks

■ Peas and sweetcorn

■ Mushrooms

■ Dried fruit

■ Skins of jacket potatoes

■ Wild rice

■ Wholegrain cereal e.g. Weetabix®, Shredded Wheat®, Bran Flakes®, Fruit and Fibre®

■ Granary bread

■ Nuts and seeds

■ Lentils

■ Beans and pulses

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Can diet be used as a treatment for IBD?

Sometimes an exclusive liquid diet for 6-8 weeks is used as a treatment to help induce remission and promote gut healing in active Crohn’s disease.

Specific nutritional drinks are prescribed in amounts that meet your nutritional requirements. No other food or drink is allowed other than water.

This treatment is more commonly used in children, but can also be used in adults who cannot tolerate steroids, or who have inflammatory strictures. This treatment option would be discussed with your doctor and is followed under the guidance of a dietitian.

People that go on a liquid diet may then go on to a reintroduction diet to gradually reintroduce food back into their diet. Reintroduction diets can be used to identify foods that may trigger symptoms.

Are supplements and herbal remedies recommended in IBD?

There are many different supplements and herbal remedies that claim to treat IBD e.g. turmeric or aloe vera, however, many of these are still being researched. There is no conclusive evidence that they aid symptoms or help with reducing inflammation. It is not known how they work or when. They are often expensive with no proven benefit.

If you do want to take a complementary or alternative product, consult your doctor first and do not stop any prescribed medication without discussion, even if your symptoms improve.

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What is a low FODMAP diet?

The low FODMAP diet (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols) has been widely used to help improve symptoms in people with irritable bowel syndrome. It has been suggested that this diet may help in people with inactive IBD that continue to have symptoms.

FODMAP’s are fermentable carbohydrates which pass into the large bowel undigested where they are broken down by bacteria for energy. These bacteria produce gas as a by-product, which may cause wind, bloating and abdominal pain in some people. The low FODMAP diet aims to reduce fermentable carbohydrates to help reduce symptoms.

It is important that FODMAP foods are gradually reintroduced to help identify food triggers and to increase the variety of the diet.

It is important that this diet is followed with advice from a qualified dietitian as it is complicated, and if it is not followed correctly it can result in nutritional deficiencies.

Probiotics

Probiotics are beneficial bacteria that improve the gut environment.

Currently there is some evidence that suggests that probiotics can help maintain remission in ulcerative colitis. There is not however enough evidence that it helps to induce or maintain remission in Crohn’s disease. More evidence is needed to explore optimal strains and doses.

There is good evidence that the probiotic VSL#3® can help prevent pouchitis (inflammation of an ileo-anal pouch).

If you decide to take a probiotic, guidelines suggest taking it for at least 4 weeks. If there is no improvement in symptoms, try a different bacterial strain.

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Useful websites

https://www.crohnsandcolitis.org.uk/

http://www.nhs.uk/Livewell/goodfood/Pages/the-eatwell-guide.aspx

https://www.bda.uk.com/foodfacts/home

Reference source(s):

Advanced Nutrition and Dietetics in Gastroenterology. Edited by Miranda Lomer. Published 2014 John Wiley and Sons LTD.

British Dietetic Association evidence-based guidelines for the dietary management of Crohn’s Disease in adults. Lee J et al. Journal of Human Nutrition and Dietetics 2014. 27,207–218 doi:10.1111/jhn.12176

British Dietetic Association food fact sheet calcium. https://www.bda.uk.com/foodfacts/Calcium.pdf. 2014

British Society Gastroenterology IBD guidelines. Mowat C, Cole A, Windsor A, et al. Gut 2011.doi:10.1136/gut.2010.224154Craig

Food and IBD, your guide. Crohn’s and Colitis UK. https://www.crohnsandcolitis.org.uk/about-inflammatory-bowel-disease/publications/food-and-ibd. 2015

NICE Guidance Crohn’s disease management. https://www.nice.org.uk/guidance/cg152/resources/crohns-disease-management-35109627942085. 2012

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Notes

© Royal Surrey County Hospital NHS Foundation Trust 2017

PALS and Advocacy contact detailsContact details of independent advocacy services can be provided by our Patient Advice and Liaison Service (PALS) who are located on the right hand side as you enter the main reception area. PALS are also your first point of contact for health related issues, questions or concerns surrounding RSCH patient services.

Telephone: 01483 402757Email: rsc-tr.pals@nhs.netOpening hours: 9.00am–3.00pm, Monday to Friday

If you would like information documents in large print, on tape or in another language or form please contact PALS.

Past review date: N/AFuture review date: MarchAuthor: Louise CooperPIN170202–1227

Contact detailsIf you have any questions about the information in this leafletPlease contact the Dietetic Department at the address below:The Royal Surrey County NHS Foundation Trust Department of Nutrition & Dietetics Egerton Road, Guildford, Surrey, GU2 7XX.Switchboard telephone: 01483 571122 ext 4202 Direct line: 01483 464119 Fax: 01483 464868 Email: rsch.dietitians@nhs.net