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____________________________________________________________
The informed patient
Diet and Nutrition in
Crohns Disease and
Ulcerative Colitis
20 Questions 20 Answers
Completelyrevisededition 2008
-------------------------------------------------------- ^
www.falkfoundation.com
2008 Falk Foundation e.V.
All rights reserved.
17th edition 2008
-------------------------------------------------------- ^
Diet and Nutrition in
Crohns Disease and
Ulcerative Colitis
20 Questions 20 Answers
Prof. Dr. Dr. J. Stein
In association with
Dipl. oec. troph. C. Bott
-------------------------------------------------------- ^ page 1
Authors:
Prof. Dr. Dr. J. Stein
Zentrum fur Viszeral- und Ernahrungsmedizin ZAFES
Krankenhaus Sachsenhausen IfS
Stresemann Allee 3
D-60596 Frankfurt am Main
Germany
Dipl. oec. troph. C. Bott
Medizinische Klinik I ZAFES
Klinikum der Johann Wolfgang Goethe-Universitat
Theodor-Stern-Kai 7
D-60590 Frankfurt am Main
Germany
-------------------------------------------------------- ^ page 2
The informed patient
Contents
What is the importance of diet and nutrition
in the therapy concept in patients with
inflammatory bowel diseases (IBD)? 5
1. How do Crohns disease and
ulcerative colitis affect the digestion? 6
1.1 Crohns disease 6
1.2 Ulcerative colitis 8
2. Can the wrong diet trigger IBD? 9
3. Nutritional deficiencies in IBD:
How do they occur and what can I do? 10
4. What nutrients are especially critical and
what foods contain them? 13
5. How can I adapt my diet to the different
disease phases? 20
5.1 Diet during an acute inflammatory flare 20
5.2 Diet as the acute flare resolves 21
5.3 Diet during the inactive phase 25
6. Are there dietary factors that might
prolong the inactive phase in IBD? 28
6.1 Prebiotics, probiotics and synbiotics 29
6.2 Low-sulfur foods 31
6.3 Formula supplements 32
6.4 Fish oil and omega-3 fatty acids 32
7. Are there things I must consider in terms
of nutrition if I have been diagnosed with
bowel stenosis (narrowing)? 33
8. What can I do about fatty stools and
diarrhea related to bile acids? 34
9. How does lactose intolerance develop
and how should I change my diet? 35
-------------------------------------------------------- ^ page 3
10. When is artificial nutrition necessary and
what do I need to know? 36
11. What must I do after surgery involving the
bowel? 41
11.1 Special dietary factors to be considered
after creation of an ileostomy,
jejunostomy or ileoanal pouch 43
11.2 Special dietary factors to be considered
after creation of a colostomy 45
11.3 Special dietary factors in patients with
increased oxalic acid excretion 47
12. How helpful is dietary fiber? 48
13. Are there any ingredients in foods that I
should avoid? 50
14. Do sweets, sugar and refined carbohydrates
worsen the course of the illness? 50
15. Can I drink alcohol? 51
16. What type of nutrition is essential for my baby? 52
17. What changes can I make in my diet to
prevent development of osteoporosis? 52
18. What dietary supplements are recommended? 56
19. Are there special recommendations in
pregnancy? 57
20. What must I consider while traveling? 57
Summary 59
-------------------------------------------------------- ^ page 4
The informed patient
What is the importance of diet and
nutrition in the therapy concept in
patients with inflammatory bowel
diseases (IBD)?
Crohns disease and ulcerative colitis represent a special
challenge for both the patient concerned with the choice
of foods and for the practitioners of nutrition therapy
seeking how to best advise them. Typical symptoms,
such as digestive complaints, stool irregularities, diarrhea,
abdominal pain, nausea and weight loss, have
often been blamed on dietary factors, since they often
occur after eating. As a result, both patients and their
families are uncertain what they should eat and drink in
order to both avoid an increase in symptoms and prevent
nutritional deficiencies. A poor nutritional status has
an unfavorable effect on the activity of the disease.
A comprehensive nutritional counseling and therapy program
can go a long way to improving the quality of life in
patients with Crohns disease and ulcerative colitis. The
belief that there is a generally applicable nutrition concept
for patients with inflammatory bowel diseases, however,
is incorrect. To be effective, nutrition therapy must
first consider the individual requirements of the individual
patient. Here, several important questions must be
asked, and decisions made, prior to beginning therapy:
Which inflammatory bowel disease is present:
Crohns disease or ulcerative colitis?
What is the patients current disease phase
(acute flare or symptom-free interval)?
Which segments of the digestive tract are affected?
Has the digestive function been significantly impacted?
What medications does the patient take?
Does the patient report any individual nutritional
intolerances?
Have there been any disease complications?
-------------------------------------------------------- ^ page 5
Thus, each patient requires his or her own individualized
nutrition plan. And, as the requirements in terms of nutrition
and nutrition therapy evolve in response to changes
in the persons illness, the nutrition plan will at times require
revision to take these changes into consideration.
The goal of nutrition therapy is both to react quickly to
problems caused by incorrect or deficient nutrition and
to help prevent disease-related symptoms.
1. How do Crohns disease and ulcerative colitis
affect the digestion?
1.1 Crohns
disease
Crohns disease can affect any segment of the digestive
tract from the mouth to the anus. The most common
site of inflammation in this disorder, however, is the final
segment of the small bowel (the terminal ileum) and the
immediately following first part of the colon, or large intestine.
The inflammatory changes in Crohns disease affect
all layers of the bowel wall. This explains the frequent
formation of fistulae (figure 1).
Disease affecting the small bowel in patients with Crohns
disease may result in the inadequate absorption of nutrients.
The consequences include weight loss or deficiencies
of individual or many nutrients. Patients, especially
those who have undergone surgery on the terminal
ileum, may require regular, life-long replacement injections
of vitamin B12, usually at intervals of two to three
months. If vitamin B12 deficiency persists, patients develop
pernicious anemia, a dangerous condition in which
the number of red blood cells is reduced.
-------------------------------------------------------- ^ page 6
Esophagus
Stomach
Duodenum
35%
Anorectal disease
3040% Involvement
of the rectum
1126%
Esophagus
Stomach
Duodenum
35%
Anorectal disease
3040% Involvement
of the rectum
1126%
Esophagus
Stomach
Duodenum
35%
Anorectal disease
3040% Involvement
of the rectum
1126%
Esophagus
Stomach
Duodenum
35%
Anorectal disease
3040% Involvement
of the rectum
1126%
(Sub-)
total
colitis
1520%
(Sub-) Partial
total
colitis
colitis 3050%
1520%
Partial
colitis
3050%
Rare:
Non-continuous
disease spread
(Rectum spared)
Rare:
Non-continuous
disease spread
Figure 1: Localization and frequency of inflammation in Crohns
(Rectum spared)
Proctitis
3050%
Back-
wash
ileitis
Proctitis
3050%
Back-
wash
ileitis
disease and ulcerative colitis
Small
intestine
and
colon
4055%
Small
intestine
and
colon
4055%
The informed patient
Only small
intestine
2530%
Only small
intestine
Only
2530%
colon
2025%
Only
colon
2025%
-------------------------------------------------------- ^ page 7
> 2 bowel
movements
per day
> 2 bowel
movements
per day
Ulcerative
colitis
Crohns
disease
Diarrhea > 4 weeks
?
?
?
?
?
Liquid/
porridge-like
stool
Abdominal
pain
1.2 Ulcerative
colitis
In ulcerative colitis, inflammation is restricted exclusively
to the colon, or large bowel. During an acute disease
flare the capacity of the colon to absorb water is usually
severely reduced, which serves to further worsen the diarrhea.
Because in ulcerative colitis only the colon is affected
by the inflammatory process, nutritional deficiencies
and associated symptoms are less common than
with Crohns disease. Also, unlike Crohns disease, the
inflammation in ulcerative colitis is limited to the mucosal
layer. A common symptom is the occurrence of bloody
diarrhea with admixtures of mucus (figure 2).
Blood in stool
Figure 2: Symptoms that suggest inflammatory bowel diseases
-------------------------------------------------------- ^ page 8
The informed patient
2. Can the wrong diet trigger IBD?
Patients often ask whether individual nutritional or dietary
factors are responsible for the development of inflammatory
bowel diseases (IBD). The suspicion of a correlation
is supported by the reported increase in the rate of IBD
since the 1950s in Western industrialized nations. Factors
that have been discussed in relation to this increased
frequency of IBD since the end of World War II
include the increased consumption of refined carbohydrates
and chemically processed fats (trans fatty acids),
the reduced consumption of dietary fiber, allergic reactions
to bakers yeast, the replacement of human milk in
Ulcerative
colitis
Crohns
disease
Margarine
Sugar
Low-fiber
diet
Cows milk
Fats
?
?
?
?
?
Figure 3: Inflammatory bowel diseases and nutrition: unsubstantiated
correlations
-------------------------------------------------------- ^ page 9
the diet of infants and exposure to Mycobacterium avium
paratuberculosis in inadequately pasteurized cows milk.
Current investigations are focusing on whether foods
containing sulfur or sulfurated additives are responsible
for the inflammatory changed in ulcerative colitis. Convincing
evidence for a possible role for nutritional or dietary
factors in the development of either Crohns disease
or ulcerative colitis, despite the increasing number
of cases and changed style of life and nutrition in modern
industrial nations, has yet to be discovered (figure 3).
Only in the case of breast-feeding has there been clear
evidence that this may protect against the development
of IBD.
3. Nutritional deficiencies in IBD:
How do they occur and what can I do?
During the course of their illness, a large number of patients
with IBD experience either a general malnutrition
or deficiencies of individual nutrients (table 1). Many IBD
patients, especially those with Crohns disease, are underweight
and/or suffer from anemia. Low body weight
and malnutrion, however, are associated with an increased
risk for inflammatory flares and everything
should be done to prevent them. Attention should be
paid to a balanced diet and, when necessary, to nutrition
therapy. Malnutrition and nutrient deficiencies in patients
with IBD can be due to a wide range of causes. Potential
causes for the development of malnutrition in inflammatory
bowel diseases include:
Reduced dietary intake
Reduced absorption of nutrients in the small bowel
(malabsorption) due to functional disturbances
Increased bowel movements in cases of diarrhea
with associated nutrient loss
-------------------------------------------------------- ^ page 10
The informed patient
Interactions between pharmaceutical agents and
nutrients
Increased nutritional requirements during phases of
active inflammation
Table 1: Frequency (in %) of nutrient deficiency or nutrient deficiencyassociated
findings in in- and outpatients with IBD
NutrientCrohns diseaseUlcerative colitisInpatientOutpatientInpatientOutpatientWeigh t loss657554186243Hypalbuminemia
(Albumin deficiency)258002550n. s.
Anemia (various types)60805466n. s.
Iron2550375381n. s.
Folate (folic acid)5662103041n. s.
Vitamin B1248345n. s.
Vitamin A1150n. s.93n. s.
Vitamin D2375n. s.35n. s.
Calcium13n. s.n. s.n. s.
Magnesium1433n. s.n. s.n. s.
Potassium620n. s.n. s.n. s.
Zinc401n. s.n. s.
n. s. = not studied
Often responsible for nutritional deficiencies is a reduction
in dietary intake. Patients often are reluctant to eat
because the onset of symptoms, such as colic, has in
the past been associated with eating. This is especially
true in patients with disease affecting the terminal ileum.
A further cause may be dietary intolerances, such as lactose
intolerance, especially during the active inflammatory
phase. This may result in a narrow and unbalanced
choice of foods.
11
-------------------------------------------------------- ^ page 11
A second factor to consider is the fact that, during an
acute inflammatory flare, the bowels capacity to absorb
nutrients, especially the trace elements, such as iron and
zinc, is disturbed or reduced (malabsorption).
In addition, during an acute inflammatory flare, proteins
may be lost through the inflamed intestinal mucosal
membrane into the bowel. This can result in a deficiency
of various proteins in the blood, such as albumin (an important
serum protein) and immunoglobulins (protein
substances that contribute to the immunity). The consequences
of albumin deficiency include edema, which is
the accumulation of water in the legs. Furthermore, loss
of blood occurring during an acute flare can result in
anemia and depletion of the bodys iron stores.
Patients with persistent diarrhea are especially at risk for
excessive loss and deficiency of potassium, magnesium
and zinc. Patients with steatorrhea, that is, excessive
loss of fats with the stool, also lose the fat soluble
vitamins A, D, E and K, and also vitamin B12, which is
particularly pronounced in patients with inflammation of
the terminal ileum or those who have undergone surgical
removal of this bowel segment. This is compounded by
the fact that each inflammatory flare, because of fever,
infections and increased cell loss in the intestinal mucosal
membrane, represents a stress situation for the body
with significant increases in its needs for energy and nutrients.
Patients with active fistula formation are exposed
to an additional loss of zinc and magnesium in the fistular
secretion.
Medications used in the treatment of inflammatory bowel
diseases may also contribute to deficiencies of individual
nutrients. For example, cortisone may contribute to the
development of calcium and magnesium deficiencies
and may have a negative effect on protein metabolism,
resulting in a reduction in muscle mass. Sulfasalazine
reduces the absorption of folate. The absorption of
fat-soluble vitamins may be reduced by colestyramine,
-------------------------------------------------------- ^ page 12
The informed patient
which is used to bind bile acids. Therapy with antibiotics
may have a negative effect on the vitamin K status.
4. What nutrients are especially critical and what
foods contain them?
This section discusses the micro-nutrients that are especially
critical for patients with IBD, their related deficiency
symptoms and the foods which are rich in these
nutrients. In addition, the options for targeting these deficiencies
with special nutritional supplements are explained.
Vitamin A is especially crucial for vision (light/dark adaptation)
as well as for wound healing and immune defenses
in the skin, mucosal membrane, the lungs and
the gastrointestinal tract. A frequent cause of vitamin A
deficiency is a disturbance of lipid (fat) absorption. Foods
rich in vitamin A include liver, butter, margarine, cheese,
eel and tuna. Its precursor .-carotin is found in yellow
and red fruits and vegetables, such as carrots, tomatoes,
apricots etc. Supplementation with appropriate nutritional
preparations, however, should always be monitored
by a physician and should not be started in pregnant
women or those with liver disease.
Vitamin B12 plays an important role in cell growth and
division, and in the formation of red blood cells. Typical
deficiency symptoms include anemia and psychic
changes. Long-standing vitamin B12 deficiency can
cause permanent damage to the nervous system. Deficits
in this vitamin are particularly common after surgical
removal of segments of the distal small bowel, since it is
only here that vitamin B12 can be absorbed. Bacterial
overgrowth in the bowel and the formation of fistulae can
also contribute to vitamin B12 deficiency. Sufficient
-------------------------------------------------------- ^ page 13
amounts of vitamin B12 are found in foods derived from
animals, including fish, milk and other dairy products,
and in pickled vegetables, such as sauerkraut. Resection
or permanent damage (e.g. due to inflammation) to
the segments of the gastrointestinal tract responsible for
vitamin B12 absorption (stomach, terminal ileum) makes
it impossible to remedy this deficiency using oral nutritional
supplements. In these cases, regular injections of
vitamin B12 by the treating physician are necessary.
Vitamin D plays a central role in bone metabolism. Disturbances
of bone metabolism are associated with pain
and demineralization of the bones and with muscle
pains. Typical syndromes associated with vitamin D deficiency
include rickets in children, osteomalacia (softening
of the bones) in adults, and osteoporosis. In patients
with IBD, vitamin D deficiency can be caused by reduced
lipid absorption. Vitamin D is contained in fatty fish (herring,
mackerel), liver, vitamin-D fortified margarines and
egg yolk. The body itself produces vitamin D in response
to sunlight. Because excessive amounts of supplemented
vitamin D can be dangerous, supplementation with
appropriate nutrient preparations should always be monitored
by a physician.
Vitamin K is well known to be required for coagulation
(clotting) of the blood; it is also essential for normal bone
metabolism. Vitamin K deficiency leads to abnormal coagulation,
mucosal bleeding and disturbances of bone
formation with an increased risk for fracture (osteoporosis).
Because vitamin K is produced in large quantities
by the intestinal flora, deficiency of this vitamin can be
caused by treatment with antibiotics. Foods containing
vitamin K include green vegetables, milk and dairy products,
red meat, eggs, grains and fruit. It is degraded by
exposure to light. The type and dose of dietary supplementation
with vitamin K is dependent on the cause and
-------------------------------------------------------- ^ page 14
The informed patient
severity of the deficiency. It should be ordered by the
treating physician.
Folate is essential for the formation of red blood cells
and for normal cell division and reproduction. It is closely
associated with vitamin B12 and iron. Symptoms of folate
deficiency thus include anemia (megaloblastic anemia),
bleeding in the mucous membranes, reduced immunity,
danger of fetal malformations (neural tube defects), and
risk of colon cancer. The long-term use of certain medications,
such as sulfasalazine, can cause folate deficiency.
The risk of folate deficiency is also associated with
increased consumption of alcohol. Folate is contained
in wheat germ, soybeans, certain vegetables, such as
tomatoes, cabbage, spinach and cucumbers, certain
fruits, such as oranges and grapes, as well as in breads
and other products backed with whole wheat flour and
in potatoes, meat, liver, milk and dairy products, and in
eggs. Because high doses of folate can mask a vitamin
B12 deficiency, the regular intake of folate in dietary preparations
should be restricted to a folate equivalent of
1000 .g per day or less and be discussed with your
treating physician.
Iron is a component of hemoglobin, the red pigment of
red blood cells that is responsible for the transport of
oxygen in the blood, and is also essential for the proper
function of the immune system. Symptoms of iron deficiency
include anemia, increased susceptibility to infection
and reduced physical performance. In IBD, iron
deficits may develop as a result of reduced absorption
in the bowel, as a result of the inflammatory activity itself,
and secondary to intestinal bleeding. The body normally
obtains iron from a balanced diet including meat, fish
and poultry. The iron contained in foods of animal origin
is more easily absorbed than in those derived from
plants. The bowels ability to absorb iron is promoted by
-------------------------------------------------------- ^ page 15
the simultaneous intake of vitamin C and foods rich in
this vitamin, such as citrus fruits. Certain medications
may reduce iron absorption, including salicylates, antacids
and ion exchangers. Iron absorption is also inhibited
by phytates (substances contained in whole grain products
and legumes), oxalic acid (contained in rhubarb,
beets, spinach, cocoa, chocolate), as well as calcium
and dairy products.
Because of the potential side effects, such as diarrhea,
abdominal pain, vomiting, constipation and black stools,
it is a general rule that oral iron preparations should not
be used in patients with inflammatory bowel diseases.
Only the intravenous administration of iron by a physician
is adequate for replacement of significant losses
and for effective filling of the bodys depleted iron stores.
Magnesium is required for energy and electrolyte metabolism
and for muscle contraction. In magnesium deficiency,
potassium ions pour from the cells as through a
sieve and are lost with the urine. The consequences include
disturbances in the excitability of cardiac and skeletal
muscle, which often first manifest in the form of
cramps in the calves at night. Magnesium deficiency
symptoms are frequency seen in patients with diarrhea
(especially if it is chronic) and fistulae. In addition, cortisone
preparations (e.g. prednisone) and diuretics (medications
that promote urine formation), when used for a
long period, may cause magnesium deficiency due to an
increased urinary excretion of magnesium. Whole grain
cereal products, long-grain rice, milk and dairy products,
green vegetables, liver, poultry, fish, soybeans, berries,
oranges and bananas are good sources of dietary magnesium.
Dietary supplementation with magnesium preparations
up to 350 mg is considered safe.
Calcium is required for bone metabolism, for the normal
functioning of the heart, kidneys, lungs, nerves and mus
-------------------------------------------------------- ^ page 16
The informed patient
cles, and for blood coagulation (clotting) and cell division.
Deficiency manifests itself, for example, in osteoporosis
and muscle cramps. Causes for calcium deficiency
include a deficiency in albumin (the transport protein
for calcium in the blood), diarrhea, fistula formation,
a disturbance in lipid absorption, vitamin D deficiency
and the long-term use of cortisone preparations, which
inhibit absorption in the bowel and increase excretion
through the kidney. Patients requiring long-term treatment
with cortisone preparations should assure a regular
supplementation of calcium (10001500 mg/day) and
vitamin D (5002000 IU/day) in combination with other
nutrients that promote healthy bone metabolism, such
as vitamins C and K, and zinc. This is especially true in
patients with lactose intolerance (lactose malabsorption)
who consume a diet low in lactose. Calcium is present in
large amounts in milk and dairy products, as well as in
some varieties of vegetables (broccoli, cabbage, fennel,
leeks), in high-calcium mineral waters (> 300 mg/liter)
and in sesame. The guidelines of professional societies
recommend a daily calcium intake of 1000 mg, a third of
which amount is provided with a single slice of hard
cheese. Calium intake should be spread over several
meals. A light late meal rich in calcium (cheese sandwich,
yoghurt etc.) reduces the process of bone destruction
that is especially pronounced at night. Supplementation
with nutritional preparations should always be discussed
with your treating physician. Calcium preparations
should always be taken between meals and never
taken on an empty stomach.
Potassium is important for the energy and electrolyte
metabolism, for heart and muscle function, for the electrical
conduction of nerves and for regulation of the
blood pressure. Potassium deficiency can present with
muscle weakness, constipation, bowel paralysis or disturbances
of cardiac function. Potassium losses are
-------------------------------------------------------- ^ page 17
frequently caused by diarrhea. Foods rich in potassium
include bananas, potatoes, avocados, apricots, dried
fruits, spinach, mushrooms, skim milk products, cocoa
drinks and whole grain products. Excessive washing of
vegetables and cooking with too much liquid reduces
the potassium content of foods. An adults recommended
daily allowance stands at about 2000 mg. Here, too,
supplementation with nutritional preparations should
occur only after consulting the treating physician.
Zinc, because of its wide range of functions in a variety
of biological processes in the human body, is one of the
most important trace elements. Zinc is necessary for
growth, cell division, sexual development, regenerative
processes, night vision, the immune system and immune
defenses, wound healing, skin and hair, the sense of
taste and the appetite. It also has antioxidant properties.
Zinc deficiency leads to growth retardation and skeletal
deformities, disorders of sexual maturation, erectile dysfunction,
malnutrition, hair loss, dermatitis (skin inflammation),
weight loss, disturbances of taste, night blindness,
increased susceptibility to infection, diarrhea and
abnormal healing of wounds and fistulae.
Patients with IBD are especially at risk for the development
of zinc deficiency since several possible causative
factors may coincide. On the one hand, there is increased
loss due to intestinal bleeding, diarrhea, fistulae
and chronic inflammation; on the other, zinc intake may
be reduced due to inadequate dietary consumption and/
or malabsorption in the bowel associated with an albumin
deficiency. As with magnesium and calcium, the
long-term use of cortisone preparations can result in an
increased renal excretion of zinc, leading to deficiency. It
is thus especially important that patients with IBD receive
adequate zinc: This trace element has a positive effect
on the inflammatory process and strengthens the immunity.
For example, diarrhea refractory to treatment may
-------------------------------------------------------- ^ page 18
The informed patient
often be due to zinc deficiency; zinc is lost to a great
extent with the stool. With zinc replacement, however,
the diarrhea often improves rapidly. Zinc deficiency is
more frequently encountered in patients with Crohns
disease than in those with ulcerative colitis. Foods rich in
zinc include beef, pork, poultry, eggs, milk, cheese, oysters,
grain sprouts, poppy seeds, sunflower seeds, liver,
wheat, oats, Brazil nuts, cashews and cocoa.
Zinc deficiency in patients with IBD should be counteracted
by zinc replacement in the form of tablets/capsules
or parenteral (intravenous) nutrition. Not all zinc
preparations are absorbed equally well by the body. This
is due to the fact that there are both organic and inorganic
zinc compounds. Organic zinc compounds, such
as zinc-histidine, are more reliably absorbed and utilized
by the body than are the inorganic compounds. Because
of potential interactions with the bodys iron and copper
metabolism, the intake of zinc preparations with a zinc
content above 30 mg should only be done under the
supervision of a physician. In addition, it is important that
the zinc preparation be taken on an empty stomach at
least one hour before the next meal. Because of interactions
with the copper metabolism, patients receiving
long-term zinc supplementation should have regular
monitoring of the copper level.
As a general rule, because of potential side effects and
interaction with other nutrients, the use of mineral, vitamin
and trace element preparations should always be
discussed with your treating physician. Special care
should always be exercised when multivitamin and mineral
preparations are combined with other preparations
with the goal of dietary supplementation. In cases of extensive
malnutrition with weight loss, a comprehensive
consultation with a dietician and the use of artificial nutrition
in the form of specially formulated liquid preparations,
tube feedings or infusion therapy are essential.
-------------------------------------------------------- ^ page 19
5. How can I adapt my diet to the different disease
phases?
5.1 Diet
during
an
acute
inflammatory
flare
Although there are no general nutritional recommendations
for patients with Crohns disease or ulcerative colitis,
nutritional therapy has distinct advantages for patients
experiencing an acute inflammatory flare. The primary
goal is to prevent malnutrition before it starts. A
first requirement, however, is to determine the degree to
which the bowel can tolerate the presence of food,
which depends on the extent and severity of the inflammation
and patients other symptoms. During mild inflammatory
flares or during remission (the phase in which
the inflammation subsides), it may be sufficient to eat
according to the guidelines of a light full diet (see chapter
5.2). If a light full diet is not sufficient to maintain patients
nutritional status, an alternative is the use of special
high-calorie liquid diets (formula feeding). If malnutrition
has set in, the professional societies recommend
the additional intake of about 500 kcal per day using
these formula diets.
Patients with severe diarrhea must assure adequate fluid
intake. Non-carbonated water and tea are generally well
tolerated. Juices (especially made from citrus fruits), carbonated
beverages, and strong coffee and tea are usually
less well tolerated. Serious losses of fluid and electrolytes
should be replaced with a solution made according
to the criteria of the World Health Organization
(WHO). This solution contains sodium, potassium, chloride,
citrate, bicarbonate and glucose in amounts best
suited for fluid replacement.
In very severe inflammatory flares, patients may require
to be maintained on parenteral nutrition for several
weeks. If possible, nutritional intake through the bowel,
-------------------------------------------------------- ^ page 20
The informed patient
either as oral liquid diet or tube feedings, should be preferred
to nutrition provided by intravenous infusion.
5.2 Diet
as
the
acute
flare
resolves
Once the signs of inflammation begin to subside, patients
can resume a normal diet. There is no firm evidence
that patients benefit from a gradual building up of
the diet. Experience, however, would suggest that a
step-wise progression to a normal full diet makes sense,
especially from a psychological point of view, in order to
reduce patients frequent anxiety about resuming a normal
diet.
It is useful to begin with easily digested foods high in
carbohydrates, such as zwieback, oat or rice meal and
low-fat broths. If these foods are well tolerated, the next
step adds white bread, jams, honey, strained and
cooked fruit, diluted fruit juices, strained and boiled soft
vegetables (e.g. carrots, spinach), cooked and strained
lean meat with a low-fat sauce, rice, low-fat mashed potatoes,
pasta, porridge made with skim milk (0.3%) and
low-fat curds. Patients should also divide their food intake
over several small meals (about five).
In the next step, patients menus can be further advanced
with the addition of some fats (spreads and for
cooking), low-fat dairy products (1.5%; caution with lactose
intolerance), reduced fat luncheon meats, lean fish,
low-fat bakery items, stewed fruits and well-tolerated
vegetables (e.g. cauliflower, celery, zucchini, young kohlrabi
etc.). During this period, patients should still avoid
raw produce, including lettuce and uncooked fruit.
If patients continue to tolerate the dietary progression,
they can be advanced to a light full diet, always considering
patients individual nutritional intolerances, such
as lactose intolerance. The principles of light full diet are
-------------------------------------------------------- ^ page 21
presented in tables 2 and 3. The food choices permitted
according to light full diet are especially suitable in cases
in which there remains uncertainty about what foods can
be eaten. As the patient becomes increasingly free of
symptoms, remaining restrictions can be reduced, while
still being guided by individual tolerances. General statements
to avoid certain foods are not useful.
Although patients with IBD usually report intolerances of
individual foods more frequently than do healthy persons,
recent studies have found that classical food allergies
do not occur more frequently than in the general
population. Symptoms may, however, be triggered by individual
intolerances: Experience has shown that persons
with digestive disorders tend to react with bloating,
diarrhea and pain to coarsely milled grains and nuts and
products made from them, as well as vegetables of the
cabbage family, legumes, fatty and fried foods, fruits with
hard peels (plums, gooseberries etc.), vegetables cut
into large chunks, vegetables picked in vinegar, juices of
acidic fruits. Products made for diabetics containing a
large amount of fructose may make diarrhea worse.
Foods enriched with sugar substitutes such as xylitol,
sorbitol or isomaltose may cause digestive symptoms in
sensitive persons.
IBD patients without stenoses (narrowing of the bowel)
can eat high-fiber foods as part of a balanced healthy
diet. In particular, so-called soluble fiber (contained in
large amounts in fruit, vegetables, potatoes and whole
grain products) binds water, thus helping to thicken the
stool and reduce the frequency of bowel movements. Intestinal
bacteria break down these substances into short
chain fatty acids, which serve the intestinal mucosal
membrane as a direct energy substrate and contribute
to maintaining healthy bowel function. Whole grain products
made from finely milled grain are generally better
tolerated than those made from coarsely milled grains or
those containing whole grains (table 2).
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The informed patient
Table 2: Principles for developing a light, well-tolerated diet in
disorders of the digestive tract
Prefer low-fat foods and food preparation methods Begin with low-fiber foods but, as tolerated, gradually increase fiber content in
the diet with vegetables, fruit, potatoes and finely milled whole grain products Avoid foods associated with gas production (e.g. cabbage)
Avoid legumes Vegetables and fruit should be steamed rather than eaten raw Avoid foods known to be poorly tolerated Assure adequate hydration: Drink 23 liters of liquid per day Avoid carbonated beverages Avoid foods that are too cold, too hot or too spicy Six to seven small meals are better than three large ones Be relaxed when eating and chew your food well Pureed foods may be better tolerated
Table 3: Foods that can be selected for a light full diet
Usually better tolerated*:Usually more difficult to digest:
Meat
Lean meat: beef, veal, pork, venison,
lamb, poultryMeatFatty cuts of beef, veal, pork (. knuckles),
venison, lamb, poultry, innardsLuncheon meatsLean cold veal or pork roast, cooked
ham without fat, cured raw ham, corned
beef, beef gelatin, beef sausage, poultry
sausage, lean meat in souse; less fre-
quently or in small amounts: boiled or
cooked pork sausage (high fat content)
Luncheon meatsSmoked meats; all fatty and heavily
spiced sausages such as liverwurst,
blood tongue, headcheese, salami,
raw ham and ready-to-eat meat or
sausage saladsFishTrout, pike, perch, rosefish, sole, cod-
fish, flounder, pollack, shellfish, halibutFish
Eel, salmon, carp, mackerel, tuna fish
in oil, herring, canned fish, ready-to-eat
fish saladsEggsUp to 23 eggs per week in easily
digested forms such as scrambled eggs,
omelette or soft-boiledEggsEggs in fatty or hard-to-digest forms,
such as hard-boiled, sunny-side up,
egg saladMilk and dairy productsLow-fat milk, buttermilk, sour milk, yo-
ghurt and yoghurt products, sweet and
sour cream in small amounts, curds and
curd products, all mild cheeses up to
45% fat content, fresh cheeseMilk and dairy productsIce cream and cream in large amounts;
all sharp cheese varieties
23
-------------------------------------------------------- ^ page 23
Usually better tolerated*:Usually more difficult to digest:
FatsButter, vegetable margarine, vegetable
oil in moderation
FatsBacon, lard, strongly heated and
browned fats, mayonnaise in any formBulk foods and side-dishesCooked potatoes, mashed potatoes, rice,
milk rice, porridge, pasta, bleached flour,
oatmeal, sago, barleyBulk foods and side-dishesPotatoes baked in fat, French fries,
potato salad, ready-to-eat musli blendsBread
At first, multigrain bread, Graham
crackers, zwieback, biscuits, crackers,
white bread, toast bread; breads and
rolls made from fine-milled whole grain
flour as toleratedBread
Fresh bread, all types of bread and rolls
made from coarsely milled whole grain
flour, especially with cornsBakery itemsLow-fat items, such as yeast-risen
pastries and biscuits; cookies, if low-fatBakery itemsFatty and sweet items such as cream
tortes, layered, filled or short-cake and
anything baked with fatBoiled vegetablesEggplant, cauliflower, green or wax
beans, fennel, chicory, cucumbers,
carrots, kohlrabi, beets, stock beets,
spinach, celery, peeled tomatoes,
asparagus, zucchiniVegetables
All vegetables, raw or as a salad;
legumes, cucumbers, cabbage, red
cabbage, green cabbage, Savoy cab-
bage, Brussels sprouts, peppers, mush-
rooms, leeks, onions, vegetables picked
in vinegarLettuceHead lettuce in low-fat oil and/or
yoghurt dressingsLettuceAll other types of lettuceRaw fruitBananas, melonsRaw fruitAll other types of fruitStewed fruitsAll steamed or cooked fruits except
those known to be poorly tolerated;
pineapple in moderationStewed fruitsGooseberries, currants, plumsSpicesAll green herbs (dried, fresh or frozen),
nutmeg, caraway, bay leaves, juniper
berries, pimento, vanilla, cinnamon,
lemons, tomato paste, mustard in small
amounts, use salt sparinglySpices
Horseradish, chives, onions, garlic,
all sharp spices such as pepper, chili,
paprika, curry; ready-to-eat sauce mixes
should be highly diluted because of the
high salt contentBeveragesNon-carbonated mineral water, tea,
juices diluted with waterBeveragesLiquor, white and red wine, coffee,
carbonated beverages
SnacksLow-fat baked snacksSnacks and sweetsSweets in general, nuts, chips* This list is based on experience. In highly sensitive persons, even some of the
foods listed in the column usually better tolerated may be problematic.
-------------------------------------------------------- ^ page 24
The informed patient
5.3 Diet
during
the
inactive
phase
It is important to remember that an acute inflammatory
flare is not caused by the wrong food or drink. Many
different factors are involved in the origin of the disease
and the triggering of acute flares. Diet is only one of
many factors being discussed in this regard. There is
currently no scientifically proven evidence at this time
that there is any special diet suitable for maintaining remission
or prolonging the interval during which you are
free of symptoms. However, because a good nutritional
status may correlate with a low disease activity, it is important
that patients in remission eat an adequate and
balanced diet.
In assessing the nutritional status, the first piece of information
is the body weight. A rapid assessment of the adequacy
of body weight is provided by the so-called Body-
Mass Index (BMI). Ideally, this number should be between
20 and 25 but should never fall below 18 (figure 4).
Formula for calculating BMI:
Body mass in kilogramsBMI =
Body height in meter.
Formula for calculating BMI:
Body mass in kilogramsBMI =
Body height in meter.
Any undesired weight loss is a warning sign for
malnutrition and should be investigated by your
physician!
-------------------------------------------------------- ^ page 25
Body height (m)
Body mass (kg)
Body height (m)
Body mass (kg)
Body height (m)
Body mass (kg)
Body height (m)
Body mass (kg)
Figur
FigurFigure 4:
e 4:e 4: BMI table
BMI tableBMI table
In the absence of complications, patients in remission
are advised to plan their diets according to the 10 rules
of the German Nutrition Society (Deutsche Gesellschaft
fur Ernahrung, DGE; table 4), taking into consideration
any individual intolerances (figure 5).
Table 4: Constructing a balanced diet according to the 10 rules of the
German Nutrition Society (DGE)
1. Eat a variety of foods
Enjoy the great variety of available foods. Criteria for a balanced diet include a wide
range of foods, suitable combinations and appropriate amounts of foods high in
nutrients but low in calories.
2. Increase your intake of products made from grains and potatoes
Bread, pasta, rice, grain meal (whole grain is best) and potatoes contain practically
no fat but are rich in vitamins, minerals, trace elements, dietary fiber and second-
ary vegetable substances. Prepare these foods with limited amounts of fat.
3. Vegetables and fruit Take Five Each Day!
Enjoy five servings of vegetables and fruit each day fresh, whenever possible, or
only briefly cooked, or one serving as juice ideally at each main meal and with
between-meal snacks. This provides you with large amounts of vitamins, minerals,
dietary fiber and secondary vegetable substances, such as carotinoids and flavo-
noids. This is the best thing you can do for your health.
-------------------------------------------------------- ^ page 26
The informed patient
4. Milk and dairy products every day; fish once or twice a week; meat,
sausage and eggs in moderation
These foods contain important nutrients such as calcium (milk, dairy products),
iodide, selenium and omega-3 fatty acids (in sea fish). Meat is important because of
its high content of available iron and vitamins B1, B6 and B12. About 300600 grams
of meat and sausage per week are adequate for these requirements. When pur-
chasing meat and dairy products, select those that are low in fat.
5. Limit fat and foods that are high in fat
Fat provides essential fatty acids. Foods that contain fat also contain fat-soluble
vitamins. Fat is very high in calories, hence, too much fat in the diet can promote
overweight. Too many saturated fatty acids increase the risk for disorders of lipid
metabolism with significant consequences for the cardiovascular system. Select
oils and fats from vegetable sources, such as rape-seed and soybean oil, and also
choose margarines and spreads made from these sources. Also watch for invisi-
ble fat that is contained in many meat, dairy and bakery items, sweets and espe-
cially in fast food and ready-to-eat products. A total of 6080 grams of fat per day
is sufficient.
6. Sugar and salt in moderation
Sugar, together with foods and beverages made with sugar or its derivatives, such
as glucose syrup, should be taken only occasionally. Be creative with herbs and
spices and limit your use of salt. Use salt that contains iodide and fluoride.
7. Get enough fluids
Water is absolutely essential to life. Drink at least 1.5 liters of fluid every day.
Water is best whether carbonated or not other low-calorie beverages. Alcoholic
beverages should be consumed only occasionally and in small amounts.
8. Increase taste with careful preparation
Cook your foods at the lowest temperatures possible. As far as possible, make
cooking fast, with little water and little fat. This preserves foods natural taste,
protects nutrients and prevents the formation of substances that may be danger-
ous.
9. Take time, enjoy your food
Knowing what you eat helps you to eat right. Your eyes can help your appetite.
Take your time when eating. This makes eating fun, helps you to increase the vari-
ety of your meals and improves the sense of satisfaction when you eat.
10. Watch your weight and keep active
Balanced nutrition goes well with adequate physical activity and exercise
(3060 minutes per day). At your ideal weight you feel good and you promote
your health.
27
-------------------------------------------------------- ^ page 27
Figure 5: DGE-Ernahrungskreis, Copyright: Deutsche Gesellschaft
fur Ernahrung e.V., Bonn
6. Are there dietary factors that might prolong the
inactive phase in IBD?
Many patients would prefer to reduce or even stop medication
during symptom-free phases. Associated with
this are questions regarding diet or nutritional factors
that may help prolong such phases. The following sections
discuss factors that in studies have shown some
hope for positively influencing the length of remission.
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The informed patient
6.1 Prebiotics,
probiotics
and
synbiotics
Prebiotics are soluble nutrients (short-chain carbohydrates)
that promote the growth and reproduction of
useful bacteria (bifidobacteria, lactobacilli), thus exerting
a positive influence on the intestinal flora.
Common substances used as prebiotics include oligosaccharides
such as inulin, fructo-oligosaccharide (FOS)
and galacto-oligosaccharide (GOS), which are not absorbed
in the small bowel and thus reach the colon unchanged.
In the colon, prebiotics are fermented by resident
bacteria. Fermentation results in the formation of
short-chain fatty acids (SCFA) and gases (CO2, H2). The
fermentation of inulin and FOS results in formation of
large amounts of butyrate, which is an essential growth
factor for the mucosal membrane in the colon and serves
as an important regulator of the local immune defenses.
Another important aspect is the promotion of bifidobacteria
and other non-pathogenic intestinal flora. This is
important in preventing the overgrowth of pathogenic
(disease-causing) microbes (table 5).
Although our understanding of the effects of prebiotics
in the bowel is increasing, results of clinical studies have
not yet shown clear and significant advantages in terms
of health promotion associated with the use of prebiotics.
Some preliminary studies have shown evidence that
certain prebiotics may have an effect in maintaining re-
Table 5: Effects of prebiotics
Selectively stimulate the growth of bifidobacteria and lactobacilli
Serve as substrates for production of short-chain fatty acids, CO2 und H2
Increase stool volume
Increase fecal caloric content
Reduce the growth of pathogenic bacteria, such as Clostridia
Reduce the penetration of pathogenic bacteria into the mucosal membrane
Increase calcium absorption
-------------------------------------------------------- ^ page 29
mission, especially in ulcerative colitis. Prebiotics such
as inulin, FOS and GOS are natural components of food.
Inulin and FOS are found in chicory, artichokes, leeks,
garlic, onions, wheat, rye and bananas. GOS are found
in large concentrations in human milk. It is known that, in
infants, GOS is a strong promoter of the growth of bifidobacteria
and lactobacilli.
Probiotics are living microorganisms that, when ingested
into the human body, produce health-promoting effects
beyond their basic nutritional and physiological effects.
In order to be classified as a probiotic, a microorganism
must fulfill defined criteria. Probiotics must be
natural, non-pathogenic components of the intestinal
flora. They must remain unchanged during their passage
through the colon and they must be able to multiply in
the bowel (table 6). The most widely used probiotics include
lactobacilli, bifidobacteria, E. coli Nissle 1917,
streptococci and the yeast Saccharomyces boulardii.
More recently, combinations of more than one probiotics
have enjoyed increasing use. Whether a combination of
different microbes is superior to a single probiotic agent
cannot be answered definitively at this time.
Under certain conditions probiotics may be successfully
used for preventing recurrence in ulcerative colitis. The
data on preventing occurrence of inflammation in the
pouch (pouchitis) are also interesting. Several clinical
studies have confirmed the efficacy of a probiotic mix-
Table 6: Effects of probiotics
Restore the integrity of the bowels mucosal barrier
Prevent microbial translocation
Eliminate toxins and eradicate microbial pathogens
Advantageously modulate the intestinal immune system
Produce bacteriocins Reduce the intestinal pH
-------------------------------------------------------- ^ page 30
The informed patient
ture (lactobacilli, bifidobacteria, Streptococcus thermophilus)
in pouchitis. In these studies, both the development
of pouchitis and disease recurrence were reduced
in comparison with patients receiving placebo.
A new indication for probiotics is lactose intolerance.
Mixtures of pre- and probiotics are called synbiotics. It
is believed that the two components mutually complement
each other in their effects and reinforce them. Currently,
there is increased marketing of foods enriched
with pre- and/or probiotics. Their role in the treatment or
prevention of individual diseases has not yet been conclusively
studied.
6.2 Low-sulfur
foods
Sulfur-containing substances in food, if fermented by the
metabolism of bacteria in the colon, may contribute to
the formation of sulfides. Studies in animals have shown
that sulfides may injure the mucosal membrane of the
colon and cause changes that resemble those seen in
patients with ulcerative colitis. Preliminary studies point
to certain eating habits in patients with ulcerative colitis
that may indicate a potential correlation with disease activity,
namely, a possibly longer duration of the symptomfree
interval in patients whose diet contains smaller
amounts of sulfur-containing substances. The current
state of research, however, does not yet permit a definitive
statement on whether a diet low in sulfur may be
beneficial in patients with ulcerative colitis.
-------------------------------------------------------- ^ page 31
Out-take: sulfur in foodsRelatively high amounts of sulfur are found in foods
with high protein content and in products that have
been preserved with sulfate compounds. Foods with
high protein content include cheeses, meat and fish
and products processed from them. Examples of sul-
fate-containing additives and preservatives are sub-
stances designed with the E-numbers E220 to E228.
These substances are found mainly as preservatives in
dried fruits and vegetables and in potato products. Sul-
fur compounds may also be used as preservatives in
beer, fruit or sparkling wines (including alcohol-free va-
rieties), mead (honey wine) and liqueurs. Current regu-
lations do not require manufacturers to declare the sul-
fur content of these beverages.
Out-take: sulfur in foodsRelatively high amounts of sulfur are found in foods
with high protein content and in products that have
been preserved with sulfate compounds. Foods with
high protein content include cheeses, meat and fish
and products processed from them. Examples of sul-
fate-containing additives and preservatives are sub-
stances designed with the E-numbers E220 to E228.
These substances are found mainly as preservatives in
dried fruits and vegetables and in potato products. Sul-
fur compounds may also be used as preservatives in
beer, fruit or sparkling wines (including alcohol-free va-
rieties), mead (honey wine) and liqueurs. Current regu-
lations do not require manufacturers to declare the sul-
fur content of these beverages.
6.3 Formula
supplements
Individual studies have found that patients with Crohns
disease may experience prolonged remission maintenance
when they add formula supplements in the form
of an orally consumed liquid diet. The currently state of
knowledge is inadequate to make a general recommendation
in this regard.
6.4 Fish
oil
and
omega-3
fatty
acids
Some small studies have found that a diet enriched with
omega-3 fatty acids may have a positive effect on remission
maintenance at least in Crohns disease. Omega-3
fatty acids are found especially in oil derived from ocean
fish with naturally high fat content caught in cold waters.
Omega-3 fatty acids are known to inhibit the release of
substances that promote inflammation. The use of fish
oil preparations should not be started without first consulting
your treating physician since no general therapy
-------------------------------------------------------- ^ page 32
The informed patient
recommendations regarding the use of omega-3 fatty
acids have yet been made with regard to their efficacy in
patients with inflammatory bowel diseases. Better than
using fish oil preparations is the regular (two to three
servings per week) consumption of fish, such as salmon,
mackerel or herring. In addition to omega-3 fatty acids,
fish also contain high-quality protein.
7. Are there things I must consider in terms of
nutrition if I have been diagnosed with bowel
stenosis (narrowing)?
A frequent complication in patients with Crohns disease
is the development of narrowing of the bowel (stenoses).
They occur most often near the end of the small bowel
(terminal ileum) and frequently necessitate the surgical
removal of segments of the small bowel. The choice of
foods depends on the diameter at the site of the stenosis.
If the stenosis is an obstacle to the passage of intestinal
contents, a diet low in dietary fiber is often recommended.
This helps prevent the development of certain
painful conditions ranging up to obstruction of the bowel.
Patients with stenoses should avoid high-fiber foods like
asparagus, fennel, green beans and spinach, foods like
cabbage, onions and legumes that contribute to bloating,
as well as hard-skinned fruits (e.g. plums, gooseberries
etc.), citrus fruits, grapes, nuts, seeds, whole grain
products and dietary fiber preparations. Patients with
very significant narrowing may require strained foods or
formula diets that do not contain dietary fiber.
-------------------------------------------------------- ^ page 33
efrmKos, 23.04.2010 18:10 :
34 - 60
8. What can I do about fatty stools and diarrhea
related to bile acids?
Bile acids are normally absorbed in the terminal ileum
and recycled (figure 6). Inflammation or surgical removal
of this bowel segment, however, has the result that
the bile acids reach the colon and are excreted with the
stool. The increased excretion of bile acids results in yellow-
colored, watery diarrhea (cholegenic diarrhea) with a
gradual depletion of the bodys bile acid pool. Bile acids
play an important role in the digestion of lipids in that
they allow the emulsification of dietary fat in tiny droplets
in the small bowel. Persons with a bile acid deficiency
experience disturbances of lipid metabolism and fatty
stools (steatorrhea).
Liver
Colon
Terminal
ileum
Bile acid release
still normal
Fat intake
still normal
Reduced bile acid
absorption
Synthesis 1,5 g/day
Release 14,5 g/day
Re-absorption 13,0 g/day
Loss 1,5 g/day
Water influx
Bile acids
Figure 6: Bile acid circulation
-------------------------------------------------------- ^ page 34
The informed patient
Patients with fatty stools should replace some of their
dietary fat intake with easily digested mid-chain triglycerides
(MCT fats). These special fats are sold in health
food stores in the form of oil and margarine, and are also
used in the preparation of special foods such as processed
cheese and hazelnut-nougat desserts. Patients
should also use low-fat foods and food preparation
methods that do not add large amounts of extra fat.
9. How does lactose intolerance develop and how
should I change my diet?
Patients with inflammatory bowel diseases may develop
a temporary intolerance of lactose (milk sugar), especially
during an inflammatory flare. The inflammatory process
involves the mucosal membrane of the small bowel
resulting in the reduced production of lactase, the enzyme
responsible for the digestion of lactose. This limits
the digestion of lactose and may lead to lactose intolerance.
During the remission phase, however, patients
with IBD do not experience lactose intolerance at a rate
that is higher than that observed in the general population.
If a breath test confirms the diagnosis of lactose intolerance,
patients should avoid lactose-containing
foods (see table 7) for at least the next three to four
weeks. Because most patients tolerate small amounts of
lactose, individual testing of tolerance is recommended.
Patients with lactose intolerance may still tolerate moderate
amounts of foods such as hard and sliced cheese
and sour milk products. This is important for supplying
the bodys calcium requirements and reducing the risk of
osteoporosis. It is important that lactose-containing
foods be taken in small amounts spread out over the
whole day. For example, one slice of hard cheese supplies
about a third of the bodys recommended daily allowance
of calcium. On the other hand, there is an in
-------------------------------------------------------- ^ page 35
Table 7: Foods containing lactose
Milk (all fat levels) obtained from mammals, e.g. cow, sheep, goat, mare All products made from milk or milk powder, e.g. milk mix beverages, pudding,
cocoa, sweets containing milk, dessert creams made with milk, porridge made
with milk, beverages with dairy base, milk powder, protein concentrates
(e.g. sports diets)
Condensed milk (all fat levels), cream, dairy coffee creamer, milk powder Sour milk products such as sour milk, buttermilk, kefir, yoghurt (including with
fruit), curds, fresh cream, sweat and sour cream Processed cheese (hard, slice, soft and sour milk cheese contain very low
amounts of lactose), cottage cheese Milk ice, milk chocolate, nougat, cream bonbons, caramel bonbons, nut-nougat
cream, pralines, various candy bars, candy fillings etc.
Ready-to-eat products with added lactose, such as instant mashed potato
powder or cream soups, complete ready-to-eat meals, cream sauces, salad
dressings; frozen meat, fish and vegetable products may contain lactose Sausages, liverwurst, canned sausage, low-calorie sausages Some types of crisp bread, milk biscuits, cakes, cookies, crackers, bread and
cake mixes, musli mixes Infant formula Butter and margarine (contain small amounts of lactose)
Some medications, laxatives, artificial sweeteners and bran preparations for
digestive enhancement
creasing variety of so-called lactose-free or low-lactose
dairy products available in supermarkets. Calcium may
also be supplied in the form of high-calcium mineral waters
(at least 150 mg/liter, > 300 mg/liter is better), calcium-
enriched fruit juices, high-calcium vegetables such
as broccoli, beets, green cabbage, celery and fennel, as
well as soy milk fortified with calcium.
10. When is artificial nutrition necessary and what
do I need to know?
Because liquid and tube feeding is more effective and is
associated with fewer side effects than parenteral nutrition
(infusion of solutions containing nutrients), they
should be preferred to infusions. Liquid or tube feeding
-------------------------------------------------------- ^ page 36
The informed patient
solutions are also called formula diets or astronaut diets.
They consist of liquid nutrient blends of varying composition
that were initially developed for use during space
travel.
Today, we understand liquid and tube-feeding solutions
as dietetic preparations blended for patients with specific
health problems that supply all essential nutrients.
These include so-called fully balanced, usually high molecular-
weight diets in which all main nutrients are present
in their natural, undigested form (table 8). Products
from different manufacturers offer a wide variety of flavors
and are available with and without added dietary
fiber. Fiber should be avoided by patients during an
acute flare and in those in whom stenoses have been
diagnosed, since they may plug the narrowed bowel
segment.
So-called elemental or low molecular weight diets with
pre-digested and easily digestible nutrients are available.
The nutrients contained in these diets are mostly
absorbed in the upper segments of the small bowel.
These can be used in patients with significant reduction
in nutrient absorption. The more severe the inflammation
Table 8: Classification of liquid and tube feeding products according
to nutrient substrates
High molecular-weight substrates (nutrient-defined diets)
Caloric content: 12 kcal/ml With or without dietary fiber Standard diets: intact protein, long-chain carbohydrates (polysaccharides),
compound sugars (oligosaccharides), long-chain fatty acidsModified diets: e.g. with increased protein content or with mid-chain fatty acids
Low molecular-weight substrates (chemically defined diets)
Caloric content: 1 kcal/ml
Without dietary fiber Oligopeptide diets: partially digested proteins (oligopeptides), compound sugars
and simple sugars (monosaccharides), mid-chain fatty acids
-------------------------------------------------------- ^ page 37
in bowel segments responsible for absorption, the more
restricted is the digestive performance and the more limited
the capacity of the bowel to absorb nutrients. In
predigested diets, the main nutrients, such as proteins,
are present, at least in part, in the form of amino acids,
which explains their unpleasant taste. More recently, various
manufacturers have introduced fat-free solutions for
use in patients with significant reduction of fat digestion.
For acute flares of Crohns disease occurring in children,
it was actually shown that exclusive use of formula feeding
for six to eight weeks was more effective than therapy
with corticosteroids (cortisone). For this reason, enteral
nutrition using formula diets is always preferred in
children. With respect to efficacy, studies found no difference
between low and high molecular-weight formulas.
In studies with adults, evidence did not show formula
nutrition to be superior to cortisone therapy, although
it was superior to placebo. This means that, even in
adults, the exclusive use of a formula diet makes sense
and can help reduce the side effects associated with
cortisone therapy.
In adults, however, it is not so easy to demand the degree
of discipline expected in children. For this reason,
the long-term exclusive nutrition with formula diets in
adults is mostly limited to patients in whom medications
have proven ineffective. For better long-term acceptance,
the liquid diet can be applied through a nasogastric
tube or a temporary percutaneous tube into the
stomach. Your treating physician will provide you with
complete information about the different available options.
There are no confirmed data regarding the efficacy of
special diets or nutrition therapies on disease activity in
the acute phase of ulcerative colitis. Nevertheless, artificial
nutrition may be essential for assuring adequate
supplies of nutrients in patients with severe disease,
such as in cases of toxic megacolon.
-------------------------------------------------------- ^ page 38
The informed patient
Therapy with liquid or tube feeding does not necessarily
require hospital admission. Enteral liquid diets can be
administered by services providing home care. These
agencies work together with the manufacturers and care
providers. Based on the physicians prescription, they
deliver nutritional products and the necessary technical
adjuncts, such as pumps and tube systems. They also
train family members and other caregivers when this is
needed.
In order to prevent unnecessary complications when
using liquid or tube feeding, the following precautions
should be observed. First, it is important to start slow
with the amount of liquid nutrition and increase this gradually.
In the first days, it is recommended to start with a
small amount (250500 ml/day) and, if the patient tolerates
this, to gradually increase the amount. Liquid diets
should also be started slowly and consumed in small
swallows. Patients with lactose intolerance should be
given liquid diets free of lactose. In cases of stenoses, a
liquid diet free of dietary fiber must be chosen. If the liquid
diet or tube feeding represents the patients complete
enteral intake, it must be planned in such a way as
to be balanced and cover the patients total daily requirements.
Additional fluid intake is absolutely necessary.
Once opened, cans of liquid nutrition must be refrigerated
if they are not immediately used. They must be discarded
after 24 hours, even if refrigerated. The liquid
should not be consumed in large amounts if ice-cold.
If digestion of lipids is restricted, patients may benefit
from a fat-free diet or a diet containing MCT fats, which
are more easily digested. A low molecular-weight diet
(partially digested proteins and MCT fats) can be considered
for patients with extensive and severe inflammation.
If patients do experience intolerance reactions, such as
increased diarrhea or nausea and vomiting, the first
measure is to reduce the amount given and to give the
-------------------------------------------------------- ^ page 39
reduced amount over a longer period of time. Switching
from a high to a low molecular-weight solution can also
be helpful.
In especially severe cases, as in patients with high-grade
stenoses, massive fistular systems and symptoms of intestinal
obstruction (ileus/subileus symptoms), it may be
temporarily necessary to completely avoid any intake
through the gastrointestinal tract. Nutrition is then provided
by means of infusion therapy, in which all necessary
nutrients broken down into the smallest building blocks
are administered directly into the circulating blood. With
parenteral nutrition, all nutrient substances are dissolved
in water and applied through a central venous catheter
directly into the blood stream (figure 7). The gastrointestinal
tract is allowed to rest, which in most cases results
in a rapid resolution of signs of inflammation. Before parenteral
nutrition is selected, it is important to always as-
Blood flow
< 100 ml/minute
Blood flow
> 1000 ml/minute
Venous
access
Figure 7: Venous access for parenteral nutrition
-------------------------------------------------------- ^ page 40
The informed patient
sess the possibility of enteral nutrition therapy. When
given for a long time, parenteral nutrition is almost always
associated with changes in the mucosal membrane
of the small bowel (atrophy of the villi), which
makes the subsequent transition to a normal diet more
difficult. Patients should, therefore, whenever possible,
continue to take small amounts of liquid diet by mouth
or, prior to ending parenteral nutrition, be re-accustomed
to enteral nutrition by giving small amounts of liquid diet
and/or crackers or white bread. This helps prevent atrophy
of the villi and slowly rebuild the intestinal mucosa.
Long-term administration of parenteral nutrition can also
be done at home. Patients require placement of a longterm
central venous catheter. If administered at home,
however, parenteral nutrition requires the highest hygienic
standards in order to avoid infection of the catheter. In
these cases, the help of a home-care service or other
healthcare provider agency is indispensable.
Advantages of enteral over parenteral nutrition:
More natural form of nutrition
Less expensive
Associated with fewer risks
Simpler to advance diet with natural foods,
because no atrophy of colonic mucosal folds
11. What must I do after surgery involving the
bowel?
There is no uniform diet recommendation for patients
who have undergone creation of a stoma or pouch. Depending
on the function of the remaining bowel, a patients
individual tolerance for every food and method of
preparation must be determined (figure 8). In the buildup
to a full diet, patients should add no more than one
new food item introduced in small quantities. If possible,
-------------------------------------------------------- ^ page 41
a)
Removal of
the jejunum
b)
Removal of
the ileum
c)
Total removal of
the colon and
large segments of
the small bowel
Figure 8: Short-bowel syndrome according to the type of resection
-------------------------------------------------------- ^ page 42
The informed patient
foods and your reactions to them should be documented
in a journal or diary.
11.1 Special
dietary
factors
to
be
considered
after
creation
of
an
ileostomy,
jejunostomy
or
ileoanal
pouch
An ileostomy is an artificial outlet for the bowel, which
ends in the lower part of the small bowel. With a jejunostomy
the bowel outlet is placed in the jejunum, above
the final segment of the small bowel (ileum). An ileoanal
pouch is created when the lower segment of the small
bowel is connected directly with the rectum after surgical
removal of the colon. In all of these situations, loss of
the colon means loss of this organs function of thickening
the stool.
Under normal conditions, about 10001500 ml of water,
together with minerals and other nutrients, are absorbed
by the colon each day. In addition, removal of the colon
results in acceleration of the entire bowel transit, reducing
the time available for digestion and absorption of nutrients.
Further limitations of function occur when portions of the
ileum and/or jejunum are removed. Although the entire
small bowel is preserved in cases of ileoanal pouch creation,
there may be increased excretion of bile acids,
which can worsen the diarrhea. Patients with shortened
ileum should receive regular supplementation with vitamin
B12 in the form of injection.
The goal of nutrition therapy is, depending on the function
of the remaining bowel, to prevent losses of water
and electrolytes and also the chemical irritation of the
stoma or bowel outlet by substances in foods. Stabilization
of stool consistency and frequency takes eight or
even 12 weeks after placement of an ileostoma or ileoanal
pouch. At this point, patients can expect about
three to five liquid to porridge-like stools per day.
-------------------------------------------------------- ^ page 43
The shorter the residual bowel, the lower the probability
that the remaining bowel segments will be able to compensate
for lost function. Even with extensive resection
of the small bowel, however, the absorptive capacity of
the remaining bowel slowly improves, such that a stable
situation is achieved after about 12 months.
Patients with very watery diarrhea, and during the adaptation
phase in general, often benefit from eating constipating
foods, such as potatoes, rice, oatmeal, bananas
or finely grated apples. If needed, bulking foods and
fluid-binding preparations such as pectins or other fiber
preparations (e.g. psyllium husk) can be used to further
thicken the stool. If there is excess elimination of lipids,
the dietary recommendations for fatty stools should be
observed (see chapter 8).
The body requires about three liters of fluid per day. Well
suited are beverages such as tea, non-carbonated mineral
water, dilute juices and especially electrolyte drinks.
A daily urine amount of at least one liter per day is
evidence of adequate fluid intake. This should be
checked regularly and patients should also pay attention
to the color of the urine, which should be light yellow.
Patients with short residual bowel (short-bowel syndrome),
and particularly immediately after surgical removal
of bowel segments, should drink especially between
meals in order not to overload the bowel. Sodium
losses can be compensated by a daily salt intake of
69 grams in the form of salted meat or vegetable broths
and salted baked wares.
In general, patients are advised to take a diet high in dietary
fiber, including a lot of vegetables, fruit and whole
grain products. Fiber helps thicken the stool and bind
bile acids. The first step is constructing a diet based on
the principles of light full diet described in tables 2 and 3.
This helps you achieve a balanced diet according to the
guidelines of the professional societies. In cases of heavy
diarrhea and high ostomy losses, patients should take
-------------------------------------------------------- ^ page 44
The informed patient
several (five to six) small meals spread out over the day
and also take care to evenly distribute their fluid intake
over the day.
Patients who have undergone removal of the colon often
find that they are again able to eat certain foods that had
triggered symptoms in the acute phase of the disease,
so that they have a greater variety of food options. Experience,
however, shows that ostomy patients should
avoid foods that irritate, damage or block the outlet, including
foods with long fibers, shells and hard-to-digest
components that may not be sufficiently macerated by
chewing. These include asparagus, green beans, celery,
fennel, corn (maize), tomato skin, mushrooms, hardskinned
fruits (plums, gooseberries), grape seeds, citrus
fruits, popcorn and hard meats.
Despite compliance with nutritional recommendations,
patients with extensive bowel resections may experience
nutrient losses, especially during the adaptation phase
and in cases of persistent heavy diarrhea and ostomy
losses. The supply of minerals and trace elements (potassium,
calcium, magnesium, iron, zinc), together with
vitamin B12 and the fat-soluble vitamins A, D, E and K
may become critical, as can the bodys fluid and caloric
intake. Replacement of these losses may only be partially
possible using oral preparations. In many cases, the
addition of injections or even long-term infusion therapy
(parenteral nutrition administered at home) may be required
for replacement of fluid, energy and nutrient deficits.
11.2 Special
dietary
factors
to
be
considered
after
creation
of
a
colostomy
A colostomy is an artificial bowel outlet originating from
the colon. Goals of treatment include achieving normal
stool consistency and frequency as well as minimizing
-------------------------------------------------------- ^ page 45
passage of intestinal gas, the development of odors
(tables 9 and 10) and preventing skin irritation at the
ostomy site.
At the beginning of oral food intake, the stools are still
watery and soft. In this situation, patients can orient
themselves on the principles of light full diet (chapter
5.2, tables 2 and 3). After an adaptation phase of about
two weeks, most patients with a functioning residual
colon achieve normal stool consistency. The foundation
of nutrition therapy after advancing the diet and com-
Table 9: Effect of food on the production of intestinal gases
Anti-bloating effectsBloating effectsCaraway/caraway oil/caraway tea Carbonated beverages/sparkling wine/
beerBlack carawayCaffeinated beveragesFennel teaFresh fruits/pearsAnis teaRhubarbWhortleberries/whortleberry juice Legumes/cabbage/peppers/onions/
garlic/asparagus/beets/mushroomsCranberries/cranberry juiceFresh bread/pumpernickelYoghurt Eggs/egg products/egg noodles/
mayonnaise
Table 10: Effects of foods on the development of odorant substances
Anti-odor effectsPro-odor effectsParsley Cabbage/beans/asparagus/mushrooms/
onions/garlic/chivesLettuceEggs/egg-based productsSpinach Meat/meat products, especially smoked
meatsCranberries/cranberry juiceAnimal fatsWhortleberries/whortleberry juice Fish/fish products, especially smoked
and fried/crab, lobsterYoghurt Cheese
Spices
-------------------------------------------------------- ^ page 46
The informed patient
pleting the adaptation phase is a schedule of regular
meal times with regulated activities and the avoidance of
rushed eating. The diet should consist of a variety of
foods high in fiber without special restrictions on the
choice of foods just as with persons without bowel problems.
11.3 Special
dietary
factors
in
patients
with
increased
oxalic
acid
excretion
Patients with extensive removal of the small bowel, especially
of the ileum (lower end of the small bowel), with
preservation of the colon, have an increased risk for developing
kidney stones due to the increased excretion of
oxalic acid through the kidneys. This increased excretion
of oxalic acid results from disturbances of lipid digestion.
Under normal conditions, oxalic acid forms insoluble
compounds with calcium from the food and these are
excreted with the stool. As a result of bowel resection,
the amount of undigested fatty acids increases and
these bind with calcium to form so-called calcium soaps.
This also means that less oxalic acid is bound in the
bowel and more is absorbed into the body. Oxalic acid is
excreted through the kidney, where an increased oxalic
concentration in the presence of calcium leads to deposit
of insoluble salts that accumulate to form calcium
oxalate stones.
To help prevent this, foods high in oxalic acid should be
avoided and a reduced-fat diet rich in calcium should be
started (table 11). If tolerated, each meal should include
at least a small amount of milk or dairy products. A
more effective measure is the daily intake of calcium
(12 grams/day). Because the calcium absorption in the
bowel is limited, excess oxalic acid is bound in the bowel
and excreted.
-------------------------------------------------------- ^ page 47
Table 11: Foods rich in oxalic acid and calcium
Foods rich in oxalic acid avoid
Foods rich in calcium prefer
Rhubarb Spinach Beets Sorrel Peanuts Cocoa Chocolate Coke beverages Excessive amounts of tea Pudding Yoghurt Cheese Milk Buttermilk Kefir Dairy products (curds contain small
amounts of calcium!)
12. How helpful is dietary fiber?
Fiber is a component of foods of vegetable origin that
belongs to the carbohydrates. In the human digestive
tract, these substances are not, or only partially, digested
and thus reach the colon unchanged. They are classified
as soluble or insoluble depending on the degree to
which they can be dissolved in water. The most important
sources of dietary fiber include grains, vegetables,
potatoes, fruit and seeds. Soluble fiber (e.g. pectin, FOS,
glucans) found in large amounts in guar seed flour, oats,
barley, plantago and pectin-rich fruits such as apples
and pears. Insoluble fiber, including cellulose, hemicellulose
and lignin, are found mainly in whole grain products.
Bacteria in the colon metabolize fiber to short-chain fatty
acids, which serve as nutrients for the colons mucosal
membrane. As such, short-chain fatty acids and the soluble
fiber from which they are derived play a direct role
in maintaining the health of the colons mucosal membrane.
Various studies have shown that different kinds of
soluble fiber may help reduce the recurrence rate in patients
with ulcerative colitis and generally act to reduce
inflammation.
-------------------------------------------------------- ^ page 48
The informed patient
The actual content of soluble fiber in many natural foods
is fairly low. For example, three apples contain only about
3 grams of pectin. Thus, use of preparations made with
soluble fiber may be helpful. Concentrates of apple pectin,
plantago seed pod (psyllium) and guar seed flour in
powder form are currently available.
Besides maintaining the health of the colons mucosal
membrane, dietary fiber has other positive effects:
Because of its ability to bind water and act as
bulking agents, fibers (especially soluble) act to
regulate the bowel movements. That means that
they are useful both in constipation and diarrhea by
acting to thicken loose stools and soften hard stools.
They bind toxins, preventing their absorption into
the body.
They bind bile acids which may, if they remain in
the colon too long, have a carcinogenic effect.
Foods rich in dietary fiber are an essential part of a balanced
diet even in patients with inflammatory bowel diseases.
Especially in the remission phase, high-fiber foods
are normally well-tolerated by IBD patients. A diet high in
fiber does not necessarily mean eating foods typically
associated with high fiber content, such as coarse whole
grain bread, dried fruits, sauerkraut and other types of
cabbage. Easily digested, but still high-fiber foods include
whole grain toast bread, bananas, cooked fruits
and vegetables, mashed potatoes, oatmeal, applesauce
and bakery items made with finely milled whole grain
flour.
Fiber requires water for its bulking action. Adequate fluid
intake is therefore crucial. This is especially true when
using fiber concentrates. Only during an acute flare or in
the presence of stenoses (narrowing of the bowel due to
scar tissue formation) should patients avoid foods high
in fiber.
-------------------------------------------------------- ^ page 49
13. Are there any ingredients in foods that I
should avoid?
Carrageen, a food additive and stabilizer, has been
shown in animal experiments to cause intestinal ulcerations,
bloody stool and increased permeability of the
intestinal mucosal membrane. This has not been shown
to occur in humans. Whether there is a connection between
carrageen and inflammatory bowel diseases remains
controversial.
Carrageen is derived from algae and may be found in
alcoholic beverages, cocoa drinks, biscuits, desserts,
ice cream, instant products, milkshakes, dessert toppings,
salad dressings or frozen bakery items. If present,
it must be listed on the label. Because of its controversial
role in association with IBD, most manufacturers of
formula diets have stopped using this additive.
14. Do sweets, sugar and refined carbohydrates
worsen the course of the illness?
Numerous epidemiological studies have examined the
question of whether sugar and refined carbohydrates
represent a potential triggering factor for Crohns disease.
As early as the 1970s, data from studies showed
that patients with inflammatory bowel diseases often
consumed large amounts of sugar (beverages, sweets)
and refined carbohydrates (bleached flour, corn flakes
etc.). The fact that these patients, especially ones suffering
from Crohns disease, did consume large amounts of
sugar and refined carbohydrates, however, is most likely
a result of these foods being more easily digested than
whole grain products. Population studies that have investigated
changes in the rate of these diseases over
the past 50 years did not provide data that confirmed
the hypothesis that a change in peoples sugar con
-------------------------------------------------------- ^ page 50
The informed patient
sumption during this period correlated with the increasing
number of cases of inflammatory bowel diseases.
More recent large studies, however, have identified a
connection between the consumption of foods that are
high in sugar with the increasing rate of inflammatory
bowel diseases, although it is difficult to assess the actual
impact of this observation within the context of the
general changes in lifestyle that have occurred over the
past five decades. Also unclear are the findings of patient
studies which investigated the correlation between
diets high in refined carbohydrates and low in dietary
fiber with the length of remission. The currently available
data, therefore, do not permit definitive conclusions regarding
the connection between sugar, refined carbohydrates
and inflammatory bowel diseases.
At this time, patients with inflammatory bowel diseases
are subject to the same recommendation issued for
healthy persons (see table 4). Patients should, however,
always consider any individual intolerances and construct
their diet according to the phase of their illness
and any specific recommendations in response to complications
(stenoses, artificial bowel outlet etc.).
15. Can I drink alcohol?
There is no known correlation between alcohol and the
development of inflammatory bowel diseases. There are
also no data available regarding the effect of alcohol on
the clinical course of IBD. Whether alcoholic beverages
cause digestive complaints in relation to the stage of the
disease must be tested on an individual basis. Both the
amount, type and alcohol content of the respective beverage
must be considered. Liquor in particular may irritate
the mucosal membrane of the upper digestive tract
and patients are generally advised to avoid such beverages.
-------------------------------------------------------- ^ page 51
It is a general principle that regular consumption of alcohol,
especially when excessive, can cause serious damage
to health. The risk of damage to the liver must always
be kept in mind, especially by patients who at the
same time are taking medications that are metabolized
in the liver.
It is known that alcohol-related liver damage can occur
with regular consumption of 10 grams of alcohol per day
in women and 20 grams per day in men. Ten grams of
alcohol corresponds to about 100 ml of wine or 250 ml
of beer.
16. What type of nutrition is essential for my
baby?
As has been explained in chapter 2 (Can the wrong diet
trigger IBD?), there is no confirmed connection between
certain nutritional factors and the development of IBD.
Only in the case of breast feeding is there evidence for a
reduced risk of developing IBD in breast-fed infants. Especially
with regard to minimizing the risk of developing
allergies, the general recommendation is to breast feed
exclusively for at least four to six months before introducing
pap.
17. What changes can I make in my diet to
prevent development of osteoporosis?
Patients with inflammatory bowel diseases are at increased
risk for loss of bone mass, the associated reduction
in bone density and the early occurrence of osteoporosis.
Osteoporosis is defined as the reduction in
bone mass that exceeds that considered normal for the
patients age and gender. In an advanced stage, osteo
-------------------------------------------------------- ^ page 52
The informed patient
porosis is associated with an increased risk for bone
fractures and deformations.
Throughout our lives, the osseous tissue of the bone is
subject to a continuous process of building and maintenance.
This means that the bone is constantly being built
up, destroyed and again rebuilt. Up to about 30 years of
age, the building processes predominate; as we age, the
processes of bone destruction become more and more
prominent (figure 9). Thus, humans reach their peak
bone mass at about age 30 years. This peak or maximum
bone mass depends to a large extent on individual
factors, which include a persons genetic background,
as well as other factors that are subject to external influence.
Important factors include the adequate supply of
calcium and vitamin D, as well as the degree of physical
activity during childhood, adolescence and early adult
life. Accordingly, illnesses such as IBD, especially when
Bone
density
100 -
80 -
60 -
40 -
20 -
0 -' 2 ' 0 4 ' 0 6 ' 0 8 ' 0 Age
[years]
Maximum
bone density
Menopause
Zone of
increased fragility
MenWomen
Figure 9: Lifetime changes in bone mass
-------------------------------------------------------- ^ page 53
they first occur in childhood, can exert a negative effect
on early bone metabolism and negative affect the maximum
achievable bone mass.
One of the most important risk factors (table 12) for developing
osteoporosis in advancing age is the female
menopause, since the resulting deficiency in the female
sex hormone estrogen promotes reduction in bone mass
and in bone density. Bone mass can be assessed using
the so-called DEXA technique, standing for Dual Energy
X-ray Absorptiometry. With this method, a weak beam
of radiation is directed toward the bone: The degree to
which the bone absorbs the radiation correlates with the
bones density.
Patients with IBD must differentiate between osteoporosis
risk factors caused by the IBD from those which affect
the general population.
General risk factors include, for example, age, female
sex (after menopause), an increased occurrence in the
family history, occurrence of menopause before age
45 years, low body weight (BMI < 18; for BMI see chapter
5.3), lack of exercise, excessive alcohol consumption
and tobacco smoking.
Risk factors for reduced bone mass that are closely
associated with IBD are given in table 12. Compared
with the normal population, however, it would appear
that a majority of IBD patients are not subject to an
increased risk of developing osteoporosis. On the one
hand, reduced bone density occurring in the context of
an acute event especially in younger individuals may
almost fully regenerate; on the other hand, it appears
that the simultaneous occurrence of several risk factors,
including those independent of IBD, is required for osteoporosis
to develop. Thus, given appropriate prophylactic
measures and suitable therapy, the risk of developing
typical symptoms (more frequent fractures, verte
-------------------------------------------------------- ^ page 54
The informed patient
Table 12: IBD-associated risk factors for osteoporosis
Risk factor Explanation
Systemic steroids
(cortisone)
Cortisone-containing preparations promote the destruction
of bone mass.
High disease activity
and duration
During the active inflammatory phase, mediator (messen-
ger) substances called cytokines are released in the body
that have a negative effect on the balance between bone
formation and destruction at the cellular level. Patients with
frequently recurring flares or disease activity have a higher
probability of developing osteoporosis.
Malabsorption, small
bowel loss greater
than one meter
Inflammation or loss of small bowel segments can result in
restricted absorption of nutrients. If the absorption of calci-
um and/or vitamin D are affected, there is a reduction in bone
mass. Lactose intolerance is also a form of malabsorption
(see also in chapter 9: Lactose intolerance). The avoidance
of calcium-rich dairy products as a therapeutic measure
contributes significantly to the increased risk of osteoporo-
sis. This can be minimized by a careful choice of foods.
Insufficient exercise
Maintaining bone mass is dependent to a high degree on
physical activity, which may be significantly limited by fac-
tors such as long hospital stays. Regular exercise, by stabi-
lizing the muscles, has a positive effect on bone formation.
Crohns disease
Because Crohns disease often severely impacts the small
bowel, there is a higher risk for reduced absorption of nutri-
ents necessary for the bone metabolism in Crohns patients
than in those with ulcerative colitis.
Low body weight
(BMI < 18)
Low body weight is frequently due to inadequate nutritional
intake or metabolism. In addition, a low body weight is usu-
ally associated with low muscle mass.
bral fractures, skeletal deformations), appears limited to
patients with a severe disease course.
Prophylactic measures include regular exercise, the
avoidance of additional risk factors such as smoking or
excessive alcohol consumptions, and bone-healthy
nutrition. The basis for a balanced, healthy diet that contains
all the nutrients necessary for healthy life in appropriate
amounts is contained in the guidelines of the professional
societies (see chapter 5.3 The ten rules of the
DGE). We have already discussed the many functions of
-------------------------------------------------------- ^ page 55
the nutrients vitamin D and calcium and their extreme
importance for healthy bone metabolism. For normal
bone formation and maintenance, many other important
nutrients are required, including protein, vitamin C, vitamin
K, fluoride, zinc and copper.
Because a large proportion of the vitamin D in the human
body is formed as a result of sunlight on the skin, the
use of vitamin D preparations should be considered in
the winter months and in patients confined to bed for
long periods. In patients with lactose intolerance (see
chapter 9), only about 350 mg of calcium are absorbed
daily, compared to the recommended daily allowance of
1000 mg. Here, the diet must be modified to include
foods other than dairy products that are high in calcium
or to include calcium supplementation in other forms.
This has also been covered in chapter 9. Therapy of
manifest osteoporosis includes supplementation with
calcium and vitamin D preparations, as well as a number
of highly effective medications.
Sodium, which is a main component of table salt, promotes
calcium excretion in the kidney. For this reason,
excessive use of salt and the consumption of highly salted
foods and dishes should be avoided. Calcium excretion
is also increased by caffeine: Hence, the excessive
consumption of coffee should be avoided, especially in
the presence of other risk factors (e.g. inadequate calcium
intake, smoking) or in manifest osteoporosis. Coffee
may also be consumed with a large portion of milk.
18. What dietary supplements are recommended?
The use of dietary and nutritional supplements, such as
vitamin or mineral preparations, or trace elements, can
only then be recommended when an actual deficiency of
the respective nutrient has been identified or in those
-------------------------------------------------------- ^ page 56
The informed patient
cases in which, because the function of certain segments
of the gastrointestinal tract has been so severely
impacted, patients can be expected to develop inadequate
absorption of individual nutrients. This is the case,
for example, when patients require surgical removal of
the ileum, the last segment of the small bowel. These
patients require injections of vitamin B12 at regular intervals.
In addition, patients with IBD are especially prone
to developing zinc deficiency, which may require the administration
of zinc preparations. If zinc supplementation
is necessary, patients should take care to always use organic
zinc compounds (such as zinc-histidine), because
these are more efficiently metabolized by the body than
are inorganic zinc compounds. A complete overview of
potential nutrient deficiency situations and what can be
done about them can be found in section 3: Nutritional
deficiencies in IBD: How do they occur and what can I
do?
19. Are there special recommendations in
pregnancy?
In general, patients without disease complications are
given the same recommendations for diet and nutrition
during pregnancy as are given to healthy women.
If complications occur or in patients in whom nutritional
deficiencies can be expected, individual dietary counseling
in cooperating with your treating physician is recommended.
20. What must I consider while traveling?
There are no general dietary recommendations when
traveling. During the remission phase, traveling is normally
unproblematic. Because patients with IBD often
-------------------------------------------------------- ^ page 57
experience diarrhea, one should always assure adequate
fluid intake. Hence, make sure you have an adequate
supply of beverages when traveling by automobile and
on hiking or cycling trips. This is especially true when
traveling in areas with less developed infrastructures,
where you may not always be able to purchase what
you need. When traveling further from home, the availability
of specific foods, even in countries of Western
Europe, may vary. IBD patients should be careful when
trying new and unfamiliar foods, since these may not be
well tolerated. Problems are especially likely with spicy
or greasy foods. When dining, request information on
the methods of food preparation.
Because IBD patients, due to the potentially compromised
barrier function of the intestinal mucosal membrane,
may be more susceptible to bacteria responsible
for gastrointestinal infections, every effort should be
made to assure that foods eaten are hygienically unobjectionable.
In order to avoid an unnecessary exposure
to infection, finding out about the hygienic standards of
your proposed destination should be part of vacation
planning. Especially in countries with a warm climate and
in which Western hygienic standards cannot be reliably
expected, you should consider the following points:
Avoid the consumption of tap water: For oral hygiene
and for cooking and washing foods, the use of packaged
drinking water is recommended.
In restaurants, drink only sealed beverages without
the addition of ice cubes.
Eat only freshly peeled fruit that has been washed
prior to peeling with heated, packaged drinking water.
Do not forget to wash your hands before peeling.
Eat only freshly boiled vegetables or prepare raw vegetables
the same way as fruit.
Lettuce should also be washed prior to consumption
with heated, packaged drinking water.
-------------------------------------------------------- ^ page 58
The informed patient
The fundamental rule for fruit and vegetables is: peel
it, boil it or forget it.
Eat meat, poultry and fish only well-done since contaminating
microorganisms can cause serious gastrointestinal
infections. Even medium cooked meats
should be avoided when abroad.
Consume only pasteurized, sterilized or boiled milk
and dairy products.
Avoid foods that are prepared and sold at kiosks or
street-side snack bars and patronize restaurants that
meet hygienic standards. Such information can be
obtained in guide books, from your travel agency or
from local tourist information outlets.
Summary
Although diet and nutrition represent important factors in
the treatment of inflammatory bowel diseases, there is
no specific Crohns or colitis diet. Although certain
dietary habits have been suspected of playing a role in
the development of these diseases, there is no scientifically
proven evidence. One should not automatically believe
general dietary rules or dogmatic pronouncements.
Diet and nutrition should be tolerable. It must meet your
individual needs and be adapted to your disease phase.
In such cases, diet and nutrition have a positive effect on
how you feel and on your illness.
In summarizing, the following recommendations can be
made:
It is important to address individual intolerances and
other factors, such as complications. Here, speaking
with an experienced physician or dietician can be
very helpful. Dont forget to complete your nutrition
record.
-------------------------------------------------------- ^ page 59
There is no convincing evidence for the efficacy of a
special diet or nutritional therapy in terms of remission
maintenance.
During your symptom-free interval, you should take a
balanced and adequate diet based on the recommendations
of the specialized professional societies
(see information, chapter 5.3), including a high content
of dietary fiber. Attention must always be paid to
patients individual nutritional intolerances.
Nutritional therapy during an acute inflammatory flare
orients itself on the severity of the inflammation and
any associated factors, such as stenoses and reduced
ability to digest nutrients. In the absence of
specific complications, patients can take a light, full
diet.
In the presence of stenoses or other obstacles to unhindered
bowel passage, a low fiber diet is necessary.
Patients experiencing fatty stools should replace a
portion of dietary lipids with mid-chain triglycerides
(MCT lipids). In order to help prevent kidney stones,
patients should consider a diet low in oxalic acid and
include dairy products and/or calcium at meals. You
should discuss these options with your physician.
Patients with nutritional deficiencies should add formula
or liquid supplements in the amount of about
500 ml per day.
General recommendations for supplementation with
vitamins or trace elements are not beneficial in patients
without complications. If, however, nutritional
deficiencies are diagnosed, replacement should specifically
target nutrients in which patients are deficient.
The intake of nutritional supplements should always
be discussed with your treating physician.
-------------------------------------------------------- ^ page 60
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Current investigations are focusing on whether foods
containing sulfur or sulfurated additives are responsible
for the inflammatory changed in ulcerative colitis.
[GR]
Aktuelle Untersuchungen beschäftigen sich
mit der Frage, ob schwefelhaltige Lebensmittel oder
schwefelhaltige Zusatzstoffe mit für die entzündlichen
Veränderungen bei Colitis ulcerosa verantwortlich sind.
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