Nutrition

1. Tarah O’Malley, MS, RD
Clinical Dietitian
Children’s Hospital Colorado

2.  Identify
nutrition concerns and
complications in Inflammatory Bowel
Disease (IBD)
 Describe current nutrition therapies used in
IBD
 Discuss recommendations for macro and
micronutrient supplementation for IBD

3.  No specific dietary antigen, toxin or diet
product has been linked to cause IBD
 Foods may aggravate symptoms but may
not cause inflammation of the intestine
 Primary goal of diet modifications in IBD to
reduce symptoms, correct deficiencies,
and to promote normal growth

4.  Nutritionand diet modifications should be
individualized per person
 There is not one set diet that is applicable
to everyone with IBD
 Modifications in diet depend on the
symptoms you experience as well as the
location of your disease.

5.  Decreased nutrient intake
• Anorexia
• Fear of eating/stooling
 Nausea, vomiting, abdominal pain,
diarrhea
 Restrictive Diets
 Side effects of medications
• Appetite suppression, taste changes
 Oral ulcerations

6.  Protein needs increased with high stool
output
 Hyper-metabolism for healing/inflammation
 Surgical resections
 Increased vitamin and mineral needs
 Bacterial overgrowth
 Malabsorption
 Blood loss

7.  Malabsorption
• Small Intestine inflammation:
 Poor absorption of nutrients with inflammation
 Degree of malabsorption is related to how much of
small intestine is diseased, location of disease, and if
any intestine has been removed
• Large intestine inflammation:
 Fluid and electrolyte loss from inflamed colon

8.  Increased calorie and protein needs
• Losses from stool output
• Hyper metabolic with inflammation
• Healing
• Breakdown of proteins with infection
• Catch up needs
 Increased fluid needs when having more
stool output

9.  Common deficiencies in IBD:
• Iron
 Often low due to losses with bleeding
 Common in both UC and CD
 DRI: Males: 8-11mg/day/day depending on age
Females: 8-18mg/day depending on age
• Calcium
 Increased excretion with long-term steroid use
 Poor absorption if inflammation in upper intestines
 Decreased intake (lactose intolerance)
 DRI: 1000-1300mg/day depending on age

10. • Vitamin D
 Usually due to poor absorption and minimal intakes
 Low with limited sun exposure
 DRI: 600 IU/day
• Zinc
 Decreased with excessive stooling
 Decreased with long-term ileal disease or resection,
ostomies, fistulas
 DRI: 8-11mg/day depending on age
• Vitamin B12
 Long term malabsorption at the ileum or with ileum removed
 Decreased absorption with gastritis and bacterial overgrowth
 DRI: 1.8-2.4mcg/day depending on age

11. • Magnesium
 Increased losses with stool output
 DRI: Males: 240-420mg/day; Females: 240-360mg/day
• Folate
 Increased requirements with certain medications
(Methotrexate, Sulfasalazine)
 Decreased absorption with inflammation in small bowel
 DRI: 300-400mcg/day
• Other (less common) Fat soluble vitamins: Vitamin A,
Vitamin E, and Vitamin K.
• Complete multivitamins are recommended. Gummy
multivitamins are not usually complete.

12.  Growth often compromised in children with
IBD
• More common in Crohn’s Disease than Ulcerative
Colitis.
• Can have a decreased rate of weight gain and linear
growth (height)
 Causes:
• Poor absorption/utilization of nutrients
• Chronic steroid use
• Overall under nutrition
• Inadequate intakes

13.  Decreased bone mineral density common
in children, adolescents, and adults with
IBD
 Causes:
• Poor calcium absorption
• Common vitamin D deficiencies
• Decreased physical activity
• Chronic steroid use
• Inflammation

14.  Maintenance of adequate vitamin D levels
 Calcium supplementation while on steroids
 Control inflammation
 Increase physical activity (weight baring)

15.  Avoid foods that increase stool output or
make symptoms worse
 Consider liquid nutrition supplements if
appetite is poor
 Eat smaller more frequent meals
 Choose nutrient dense foods
 Consume a diet from a variety of food
groups

16.  Reduce greasy or fried foods in your diet
(may increase diarrhea)
 Decrease concentrated sweets in diet
 Avoid lactose in diet, if not tolerated
• May have disease impairing production of lactase
 Avoid gastric irritants: spicy foods, alcohol,
caffeine, carbonated beverages

17.  Temporary while in a flare
 Avoiding insoluble fiber may help to reduce
symptoms and pain during periods of
inflammation
• Soluble fiber- Helps to absorb excess fluid in the
colon: oats, soft parts of fruits, starchy vegetables.
• Insolube fiber- “roughage”: seeds, nuts, whole-
grains, tough skins.

18.  Cook vegetables thoroughly
 Peel fruits and vegetables
 Avoid seeded vegetables or fruits
 Try to eat soft, fleshy fruits

19. RECOMMENDED FRUITS AND VEGETABLES ON A LOW
FIBER DIET:
• Apples (peeled) • Carrots
• Banana • Cauliflower (cooked well)
• Avocado • Peppers (roasted without
• Cantaloupe skin)
• Honeydew • Squash (skins removed)
• Plum (peeled) • Tomato sauces (without skins
• Watermelon (seedless) or seeds)
• Peach (peeled/canned) • Green beans

20. FRUITS AND VEGETABLES TO AVOID ON A LOW FIBER
DIET:
 Fruits with seeds  High fiber/gas causing
• Blackberries vegetables:
• Blueberries • Broccoli
• Cherries • Beans
• Grapes • Brussels sprouts
• Raspberries • Celery
• Strawberries • Corn
 Fruits with membranes: • Cucumber
• Grapefruit • Onions
• Orange • Peas
• Raisins • Zucchini

21.  Enteral Nutrition Therapy
 Specific Carbohydrate Diet
 Maker’s Diet

22.  Formula provided through NG tube usually
overnight.
 Some studies show no difference in type of
formula used. Formula with broken down
protein (peptide based) providing 80-90%
of estimated needs.
 Small amounts of solid foods by mouth
 Useful to induce remission in CD
 Unknown method of actions

23.  Pros
• Has been proven to induce remission (similar to
steroids), currently being studied as an option for
maintenance therapy
• Minimal side effects
• Improves nutrition status and growth
 Cons
• Usually requires placing a nasogastric tube
• Hooked up to a feeding pump overnight
• Expensive
• Not as beneficial in those with UC

24.  Reducing poorly digestible carbohydrates
to lessen symptoms of gas, cramps, and
diarrhea
 Concept is to alter the micro flora of the
gut by removing carbohydrates that may
promote growth of “harmful” bacteria.
 No concentrated sugars, dairy products,
grains, or legumes.
 Currently safe for short term use, gradually
re-introducing foods

25.  Pros
• High in vegetables and lean meats, complete if
followed correctly
• Can help to identify foods that you do not tolerate
 Cons
• Currently supported only by patient testimonials,
not by systematic studies.
• Difficult to follow
• May include foods that are not well tolerated

26.  Focuses on four components of total
health: physical, mental, spiritual, and
emotional.
 Consists of a phased approach
 Recommended foods are unprocessed,
unrefined, and untreated with pesticides or
hormones

27.  Pros
• High in fruits and vegetables and whole grains,
avoids processed foods
• Website and book offer good resources
• Encourages well balanced eating
• Focuses on well being
 Cons
• Expensive
• No proven effects or scientific studies
• May include foods that are not well tolerated

28.  Probiotics/Prebiotics
 Omega-3 fatty acids
 Herbal supplements
 Multi vitamins/ minerals
 Oral nutrition supplements

29.  Probiotics, or good bacteria, may be
helpful in restoring the good flora to your
intestines
 Prebiotics stimulate growth of the natural
bacteria
 Studies have shown a significantly smaller
percentage of relapses with probiotic use
in CD and pouchitis
 No significant difference in percent of
relapse for UC

30.  Found in fatty fish such as salmon,
mackerel, herring, and sardines as well as
some nuts
 Studied due to their anti-inflammatory
properties
 Decreased rate of relapse from remission
shown in CD, not demonstrated in UC
 For adults: 2-4g (EPA + DHA) per day
recommended dose or you can eat fish 2-3
times per week

31.  Aloe, Garlic, Echinacea, Evening Primrose
 May help to control symptoms and ease
pain as well as enhance feelings of well
being and improve quality of life
 Intended to be used in conjunction with
conventional treatment
 The efficacy of many herbal supplements
is currently unknown

32.  Often need more than the DRI for repletion
 May require supplementation when not able
to get adequate amounts through diet alone
 DRI differs for age and sex
 Risk for toxicity with too much
supplementation of vitamin and minerals
 Many vitamin/mineral levels can be checked
by blood draw
 Discuss need for supplementation with MD
and RD

33.  Supplemental calories and protein
 Often needed to maintain weights,
especially when intake is poor
 Liquid may be tolerated better by some
 Examples: Boost, Ensure, Pedisasure,
Carnation Instant Breakfast, home-made
smoothies.

34.  Gradually add foods back into diet
 No specific diet restrictions while in a flare
 Continue to eat from a variety of food
groups
 Goal for well balanced nutrition

35.  Nutrition plays a very important role in the
management of patients with inflammatory
bowel disease
 No one nutrition formulation works best for
all people with IBD
 Need for routine monitoring for growth,
intake, weight trends, and vitamin status
 More research is needed to determine
roles of various supplements in IBD

36.  Yamamoto, T. Dietary interventions in patients with inflammatory bowel
disease. Practical Gastroenterology. 2011; 16: 10-26.
 Vigianos, K, Bector, S, McConnell, J, Bernstein, C. Nutrtion assessment of
patients with inflammatory bowel disease. Journal of Parenteral and Enteral
Nutrition. 2007; 31:311-319.
 Yamamoto, T, Nakahigashi, M, Umegae, S, Matsumoto, K. Enteral nutrition
for the maintenance of remission in Crohn’s disease: a systematic review.
European Journal of Gastroenterology & Hepatology. 2010; 22 (1): 1-8.
 Mullin, G. Micronutrients and inflammatory bowel disease. Nutrition in
clinical practice. 2012; 27:136-137.
 Eiden, KA. Nutritional considerations in inflammatory bowel disease.
Practical Gastroenterology. 2003; 5: 33-54.
 Gerasimidis, P, McGrogan, P, Hassan, K, Edwards, CA. Dietary
modifications, nutritional supplements and alternative medicine in pediatric
patients with inflammatory bowel disease. Alimentary Pharmacology &
Therapies. 2008; 27: 155-165.
 LeLeiko, N, Pinkos, B, Trotta, J, Kawatu, D. Nutrition in inflammatory bowel
disease. Medicine & Health Rhode Island. 2009; 92 (4): 131-134.
 Crohn’s and Colitis foundation www.ccfa.org