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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).

    -------------------------------------------------------- ^ page 22
    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.

    -------------------------------------------------------- ^ page 28
    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.

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  3. #3

     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
    S84e 17-11/2008/5.000 Konk
    -------------------------------------------------------- ^
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  8. #8

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