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Nutrition & Diet |
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This booklet sets out to answer the questions most commonly asked about nutrition and diet in people with Crohn's disease or ulcerative colitis. You may have been told that you have one of these conditions, or you may have a close relative, friend or partner with it. If you are a patient, your specialist or surgeon will probably have told you the basic facts about your disease, but dietary questions are often forgotten when dealing with the diagnosis of a chronic illness. If this booklet can both fill in some of the gaps in your knowledge, and help to allay your natural anxieties, then it has served its purpose.
"Diet is not the cause and it is not the cure." This is simply the most important issue regarding diet and IBD. Many people are looking for some magic bullet that will solve all their troubles; eliminate their symptoms and allow them to reduce, or stop, their medication. It does not exist. Some people are lucky and find a food that has aggravated them and eliminating it does make a difference. For others, a change of eating habits towards a more "healthy" diet also helps. However we are all different and there is no diet that works for all.
Is allergy to certain foods a contributory factor in ulcerative colitis or Crohn's disease? At one time it was thought that milk, and milk products such as cheese, might adversely affect some patients with Crohn's disease and ulcerative colitis. It is now realised that some of these people cannot absorb the special sugar (lactose) in milk and that the presence of this unabsorbed sugar in the intestine can cause diarrhoea after drinking milk without necessarily making the inflammation worse. Lactose malabsorption is present in 35% of people with Crohn's disease and 20% of people with ulcerative colitis but not all these people need to restrict their intake as lactose has no effect on the activity of IBD. In fact, most people with ulcerative colitis and Crohn's disease can take milk without ill-effect. At present there is no evidence that sensitivity to any other food may cause or aggravate the inflammation.
Does resting the intestine help the inflammation? It seems commonsense that eating or drinking may irritate an inflamed intestine. For this reason periods of starvation have been advocated, but there is no evidence that this is helpful, rather it can be harmful by weakening the body. An alternative approach is to give a specially designed mixture that is well absorbed so that little residue reaches the colon. Astronauts use this type of diet so that they do not need to use the lavatory for many days while on space flights. At present the results of using this type of diet in ulcerative colitis or Crohn's disease are uncertain. The diets are liquid, expensive and tend to be unpalatable, so they are reserved for special situations. Equally, giving food entirely into a vein, rather than by mouth, is a treatment usually reserved for those who cannot absorb food for some reason.
Is it helpful to take more or less fibre than usual in the diet? A few patients, usually those with inflammation confined to the part of the colon just above the anus, are troubled by hardness of the stools. These people may be helped by taking one or two tablespoons of natural bran each day as this simple treatment softens the stools. There is no evidence that bran helps all patients with colitis or Crohn's disease. A low fibre diet, omitting many vegetables and most fruit, has been traditionally advised for patients with diarrhoea. As discussed below most patients with colitis or Crohn's disease can eat a normal or near-normal diet without making diarrhoea or pain worse. The usefulness of the strict, traditional "low residue" diet is now seriously questioned, though it is recognised that an excess of fruit can make diarrhoea worse, just as it can cause diarrhoea in healthy people. For this reason most doctors advise their patients to take a normal nutritious diet unless particular foods appear to cause unpleasant symptoms.
Is alcohol harmful? There is no evidence that alcohol taken in moderation makes the inflammation worse. Some healthy people notice bowel looseness after certain wines or beer, and people with colitis or Crohn's disease who notice the same thing will naturally avoid the types of alcohol that upset them. Alcohol can add an extra effect to medicines or tablets taken to reduce anxiety, relieve depression or help with sleep. One drug, sometimes used in the treatment of Crohn's disease, metronidazole (Flagyl®), can interact with alcohol in a way that is not dangerous but may make a person who takes the combination feel unwell. People who take any of these treatments should avoid, or be especially careful, about taking alcohol, but alcohol does not interact with or influence the effectiveness of other drugs used in the treatment of colitis or Crohn's disease.
Do particular foods aggravate diarrhoea? Liquid stools are due to failure of the small intestine and/or colon to absorb fluid because the lining is inflamed and unable to function properly, or because a substance is present that cannot be absorbed. An excess of fruit, onions in some people, beer, or very spicy or fatty foods, may give healthy people diarrhoea. Such foods may aggravate the diarrhoea in people with colitis or Crohn's disease but it is doubtful if any of them do harm. It seems sensible for patients to avoid foods that they know cause them diarrhoea but apart from this they should eat normally. When the capacity of the small intestine to absorb fat is impaired, even a normal amount of fat in the diet may cause diarrhoea. Such people may benefit from restriction of fat in the diet. Many patients with ulcerative colitis cannot wait when they feel the urge to go to the lavatory, regardless of whether the stool is liquid or solid. This symptom is generally due to sensitivity of the inflamed rectum and there is no evidence that a change of diet influences this sense of urgency except in so far as the number of stools can be reduced as already described.
Do particular foods cause pain? Abdominal cramps may occur when there is a narrowing of the intestine so that the intestinal muscle has to contract forcibly to push the contents through the narrowed area. In this situation lumps of indigestible food such as gristle, fibrous vegetables, orange pith, dried fruits, mushrooms or nuts may aggravate the pain because a lump of food lodges at the site of narrowing and the intestinal muscle contracts very strongly to push it through. When one or more narrowed areas of intestine are present, as may happen in Crohn's disease, pain may be relieved by avoiding large meals and by leaving out these indigestible items of food, and chewing all food to a puree in the mouth before swallowing.
Do particular foods aggravate wind? Wind largely arises from bacterial fermentation of food residues in the colon. Failure to absorb fat or milk sugar, as already described, may lead to flatulence helped by a low-fat or low-milk diet respectively. Food such as cabbage, broccoli and onions can lead to the formation of wind in normal people and therefore should also be taken in moderation in patients with IBD. If you find yourself with problematic wind after eating a particular food you may find it best to avoid it altogether.
Can inflammation affect the body's need for food? Inflammation severe enough to cause fever increases the body's need for energy. If there is much fluid loss from the diseased intestine, the body loses protein, and perhaps blood. Eating nutritious food in this situation is therefore advantageous. Loss of weight, or failure of a young person to grow normally, is an indication to seek medical advice. It may be that not enough food is being eaten or that absorption of food is impaired. During illness, when appetite is poor, special food supplements, often based on milk, can be helpful. It is very important that foods rich in protein, such as milk, cheese, eggs, fish and meat, are eaten at this time to compensate the losses of protein that tend to occur from inflamed intestine and to encourage healing.
May diarrhoea increase the body's need for fluid? Whenever fluid losses from the intestine are greater than normal, as when fluid stools are passed several times a day, the body needs more fluid and salt than usual. Usually drinking more is enough. However, other treatments may be advised if fluid losses are very great. A special solution of salt and glucose (or sugar) in water may then be prescribed. In hospital, fluid losses sometimes have to be replaced by giving fluids into a vein.
Can an abnormality of the small intestine affect the body's supply of food? Nourishment can be used as energy or incorporated into the tissues only if it passes across the small intestinal lining. In Crohn's disease the small intestine may become inflamed and sometimes part of the small intestine becomes so severely diseased that a segment has to be removed by surgery. In these circumstances food may not be absorbed normally and the tissue may be deprived of essential foodstuffs even though a normal diet is eaten. Reduction of fat in the diet may be helpful because the intestine's reserve capacity for fat absorption is limited more than that for carbohydrate or protein. People with a limited capacity for absorption may need to take more total food than average and take it divided into small frequent portions or snacks. Special measures may be needed to ensure that adequate fluid and minerals are taken as well as food.
Are vitamin and other supplements helpful? Deficiencies of specific vitamins, minerals or nutrients can occur in people who are eating a normal diet because there is a defect of absorption or a source of loss. For example, people with Crohn's disease who are treated surgically by removal of part of the lower small intestine may be unable to absorb Vitamin B12 and so need to have this vitamin by injection. A few other people with Crohn's disease involving the small intestine can require extra amounts of other vitamins by mouth to overcome difficulties in absorption. Patients with ulcerative colitis, on the other hand, can lose blood from the intestine so that the body becomes short of iron and extra iron is needed. Apart from these and other specific deficiencies which are diagnosed by the doctor on the basis of blood tests and for which he will then advise treatment, there is no evidence that mixed vitamin supplements are necessary or helpful for most patients with ulcerative colitis or Crohn's disease.
What should I do when I have a flare-up? If you get a flare-up go straight to your doctor. When you have a flare your gut may not absorb enough food. Do not have large amounts of raw fruit and vegetables. DO NOT STOP EATING. Try having white bread and use a nutritional supplement such as Complan or Ensure made up with milk or water. These do not replace a meal but add to calorie intake. Note: Do not use sports supplements, such as body bulking products, as their protein content is very high which can place a lot of stress on the kidneys.
Conclusion For most people with ulcerative colitis and Crohn's disease emphasis is placed on the known positive benefits of a good mixed diet rather than on the less certain benefits of restricting what is eaten. People who become ill and lose weight, and especially young people who become ill and stop growing, need more food than average to supply their daily needs. In certain circumstances restriction of milk, fat or high residue foods can be helpful but restriction should only be undertaken on medical advice. Most people with ulcerative colitis and Crohn's disease find that they can take a normal mixed diet without difficulty, avoiding only a few excesses or specific foods which can equally upset people who are in good health. A few people with Crohn's disease are liable to develop specific deficiencies due to difficulty in absorbing particular nutrients and these deficiencies can be overcome with supplements prescribed on medical advice. Other deficiencies, for example due to blood loss in colitis, can also be treated by a supplement given with the diet if blood tests suggest that this is necessary. There is at present no evidence that extra vitamins, or special food supplements are needed by the majority of sufferers from ulcerative colitis or Crohn's disease.
What CAN I eat? -anything that does not upset you.
What SHOULD I eat? -nourishing foods to maintain your weight and strength.
What EXTRA do I need? -supplements in special circumstances as recommended by a dietician.
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