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ILEOANAL POUCH & DIET Karen Jackson Dietitian RD, BSc Hons, Sports Nutrition Specialist PG Cert Oxford University Hospitals NHS Trust May 2014 Function of the colon • • • • • Re-absorbs electrolytes e.g. salt (sodium) Re-absorb water Forms stool Fermentation Synthesize & absorb vitamins ( Vit K, B12, thiamine) Post op Guidelines • • • • • Improve nutritional status Light, soft & low fibre Adequate fluid & salt intake Regular eating pattern Re-introduce fibrous foods after 4 wks in small quantities & well chewed • “Restore eating confidence” What should you eat to maintain a healthy body? • In most cases - a healthy balanced diet • CHO (55%) • Fat (30%) • Protein (15%) • 5 food groups 5 Food Groups 1. Fruit & Vegetables 2. Breads, cereals, rice, pasta & potatoes 3. Meat, fish & alternatives 4. Milk & dairy products 5. Fats & sugars 1. Fruit and Vegetables • Excellent source of many vitamins, minerals & antioxidants • Aim for as much variety as possible • Aim for 5 or more serves every day – determine individual tolerance 1 serve =1 medium sized fruit (eg apple, banana, peach, orange) =2 small fruit eg satsuma, plums =2 tablespoons vegetables =1 small glass fruit juice = 1 small bowl of salad Low Fibre Fresh tinned or stewed: Apples, cherries, grapes, melon, banana, plums, pears, peaches, plums (avoiding pips, skin & pith) Carrot,beetroot,courgette lettuce, spinach, squash, pepper, swede, broccoli or cauliflower florets, skinned cucumber & tomato, turnip High fibre Berry fruits, dried fruit, unripe bananas, kiwi fruit, grapefruit, rhubarb, mango, oranges Beans & pulses, chick peas, split peas Brussel sprouts, peas, mushrooms, cabbage, garlic, green beans, okra, onions, leeks & sweetcorn 2. Bread & Cereals • • • • • Starchy foods provide us with energy Excellent source of fibre & B vits Cheap & easy to prepare Base each meal around Opt for lower fibre choices if required – eg sweet potatoes, pasta, noodles, scones, baguettes, crackers, cous cous, rice krispies, corn flakes 3. Meat, fish & alternatives • Protein is essential for growth & repair • Excellent sources of B vits, iron & zinc • Try to have lean & low fat versions where possible: eg lean meat, poultry, fresh fish, oily fish, eggs, soya products, pulses, nuts • 1 – 2 serves day (approx. 45g/11/2 oz) 4. Milk & Dairy foods • Most abundant supply of calcium – major “at risk” nutrient • Good sources protein & energy • Low fat versions have the same amount of calcium • 3 serves day = 1 glass (250ml) milk 1 pot yoghurt 1 matchbox (30g/1 oz) cheese 5. Fats & Sugars • Limit animal fats • Restrict fats/sugar if excess weight is a problem • Practice good oral hygiene • Beware of hidden fats & sugars • Become a label reader Fluid Intake • Very important (rehydrate well) • Thirst is not a good indicator of your hydration status (too late) • Aim 8 - 10 of cups of fluid per day • High pouch output looses water, salt & potassium Types of fluid • Rehydration drinks (sports drinks with added salt, dioralyte, WHO) • Keep tea & coffee to <4 cups/day • Limit fruit juice & sugary/fizzy drinks • Encourage water Special dietary considerations • Calcium intake • Vitamins & minerals • Hydration • High energy The Dysfunctional Pouch • • • • • • • • • • • erratic eating habits high caffeine intake high alcohol intake high fibre diet high fat intake poor fluid intake sorbital intake irritable bowel syndrome food intolerance pouchitis probiotics Probiotics • “Friendly bacteria” in the digestive tract • Pouchitis associated with lack of “good bugs” (Lactobacilli + Bifidobacteria) • Patients with chronic pouchitis remained in remission after taking high dose probiotics (Gionchetti et al., (2000); Mimura et al., (2004) ) • Yoghurt, Yakult, Actimel, capsules, powders (VSL#3) Probiotics • Vary in their efficacy • A small increase in bloating or flatulence when first commenced is normal • Try to take both Bifidus & Lactobacillus and with food preferably • Trial for several weeks - 3 months Foods that thicken output • • • • • • • rice & rice cakes pasta (fresh) & white bread mashed potato apple sauce smooth peanut butter marshmallows & jelly cubes banana (ripe) Increase wind & odour • • • • • • • • broccoli, sprouts, cabbage onion, garlic, leeks, asparagus beans spicy foods carbonated drinks beer eggs differing individual tolerability Increase pouch output • • • • • pulses & leafy vegetables high fibre fruit & veg wholegrain cereals nuts & sweetcorn alcohol, fruit juice & caffeinated beverages • chocolate • fatty foods • food intolerance When to use the Exclusion Diet? • Final dietary step, – when all initial modifications have failed to improve symptoms • Only reliable method of investigating food intolerance • Threshold effect/dose response • Challenge beliefs • Motivated / appropriate client • Support / extra financial burden • Recipes / meal planning / access for support Foods that are likely to cause symptoms • Wheat, rye, oats, barley, corn, potatoes, cows milk, sheeps milk, goats milk, corn oil, veg oil, onions, sweetcorn, garlic, leeks, citrus fruits, tea, coffee inc decaff, squash, sparkling mineral water & processed foods • Foods allowed Rice,Tapioca,Sago, Millet, Buckwheat,Quinoa,Arrowroot, gram flour, soya milk, herbal tea Exclusion Diet cont’d: • State Registered Dietitian who is experienced / interested in food intolerance • 2-3 week period on baseline diet • If symptoms improve proceed to reintroduction of foods • Careful food reintroduction is crucial & support required ++ • Follow up –At start of diet –During exclusion phase –Regularly during reintroduction phase Optimizing Pouch Function 1 • Don’t skip meals, eat small meals regularly • Include foods that thicken output • Avoid eating & drinking at same time Optimizing Pouch Function 2 • • • • • Healthy eating, freshly cooked CHO Fruit & veg to tolerance Consistent fluid intake throughout the day Probiotics Limit foods that cause irritation e.g. spicy Optimizing Pouch Function 3 • • • • Limit food that increases output Limit foods that cause gas Chew food well If active overnight aim to finish eating early in evening • Formal assessment from dietitian in exceptional cases - exclusion diet Good nutrition and healthy eating make a difference! References • Gionchetti P, Rizzello F, Venturi A, et al. Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebocontrolled trial. Gastroenterology (2000) 119:305–9 • Mimural T, Rizzello F, Helfwig U, Poggioli G, Schreiber S, Talbot IC, Nicholls RJ, Gionchetti P, Campieri M, Kamm MA. “Once daily high dose probiotic therapy (VSL#3) for maintaining remission in recurrent or refractory pouchitis”. Gut (2004) 53:108-114 doi:10.1136/gut.53.1.108