Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Nutrition & IBD: Choices for Adults and Kids Content • • • • • Overview of adult and pediatric IBD Impact of IBD on nutrition Overview of diets often used by IBD patients Eating well with IBD Choosing supplements with IBD Is Food the Friend or Enemy? • Many people with IBD cannot tolerate certain foods when feeling well and during flares • Although associations have been and are being investigated, no conclusive evidence that diet can cause or cure IBD • Nutrition and diet are important to IBD management What You Eat is Important • Diet is the actual food that is consumed (“What you eat”) • Nutrition refers to properly absorbing food and staying healthy (“How you eat”) • IBD is not related to food allergies (immune response) but symptoms may be worsened by food intolerance (non-immune response) • Diet may affect the symptoms of IBD, but not the inflammation • Proper diet and nutrition may improve symptoms of IBD and overall wellness Overview of IBD Chronic autoimmune diseases with a genetic component that affect the gastrointestinal (GI) tract CROHN’S DISEASE • Patchy, full-thickness inflammation • Anywhere from mouth to anus • Mostly affects small intestine • Extraintestinal Indeterminate manifestations Colitis 10%-15% ULCERATIVE COLITIS • Continuous, superficial inflammation • Colon and/or rectum • Extraintestinal manifestations The Effect of IBD on Digestion • Crohn’s disease (CD) • Ulcerative colitis (UC) – If small intestine is affected, digestion and absorption of nutrients may be affected – Poor absorption and inflammation in colon may also cause diarrhea – Small intestine works normally – Inflamed colon causes urgency and does not reabsorb water properly, resulting in diarrhea The Effect of IBD on Nutrition IBD patients are at an increased risk for: • • • • • Nutritional deficiencies Weight loss Iron deficiency Folic acid deficiency Vitamin B12 deficiency Heller A. Eating Right with IBD. 2004. • Mineral/electrolyte deficiencies • Dehydration • Osteoporosis • Growth retardation in children The Effect of IBD on Growth • Growth often affected in children with IBD – More common in CD than in UC – Seen both before and after disease is diagnosed • Decreased rate of growth and height – Adult height compromised – CD: 32-88% – UC: 9-34% • Growth is a good marker for disease activity The Effect of IBD on Growth The Effect of IBD on Growth • Causes of poor growth – Intestinal inflammation – Steroids – Poor nutrition • Disease location • Early treatment after diagnosis is crucial Bone Health in Children to Adults • Decreased bone mineral density (amount of mineral in bone) is common in people with IBD due to: – Poor calcium absorption/intake (i.e., limited dairy and dark leafy vegetable intake) – Vitamin D deficiency – Decreased physical activity – Inflammation • Peak bone mass occurs by age 30-32 • Steroid use (repeated, and or prolonged more than 6 weeks) increases short- and long-term risk Heller A. Nutrition Screening and IBD Nutritional evaluation may include: • Patient history • Physical exam and laboratory studies: – – – – – – – – – Height and weight Blood count (CBC) Biochemical profile, magnesium Inflammatory markers (CRP, ESR) Serum iron studies, including ferritin Albumin and pre-albumin Folic acid/Vitamin B12 25 OH vitamin D Bone density testing (DEXA) – if concerned about low bone density Heller A. Eating Right with IBD. 2004. Adult IBD Nutritional Goals • Maintaining an adequate intake of protein, carbohydrates, and fat, as well as vitamins and minerals, is necessary for good health • Communicating regularly with your healthcare team is important! – Identify deficiencies or problems in advance – After surgery, there may be different needs – People with j-pouches and ostomies may have different needs Principles of Good Nutrition Maintaining good nutrition is key to: – Medications being more effective – Healing, immunity, and energy levels – Preventing or minimizing GI symptoms and normalizing bowel function Is There a Special Diet for Patients With IBD? NO, THERE AREN’T ANY SPECIAL DIETS FOR IBD • Some diets may be used to help identify trigger foods or relieve symptoms • Several diets advertised specifically for managing IBD inflammation – Many claims are supported by a small number of subjects – Most have not been proven scientifically – Benefits have not been confirmed in formal studies Diets That May be Prescribed Diet Description Elimination Diet Keeping a food and symptoms diary over several weeks to help match symptoms to “problem foods.” Low-fiber with Low-residue Diet Minimizes the intake of foods that add bulk residue to stool (e.g., raw fruits, vegetables, seeds, nuts). Often used in patients with strictures or during flares. May be restricted in certain vitamins, minerals, and antioxidants. Needs monitoring. Total Bowel Rest Period of complete bowel rest during which patients are nourished with fluids delivered intravenously. May be useful short term with medication. May be used to treat short bowel syndrome. Other Diets Diet Description Gluten-free Diet Excludes grains that contain the protein gluten. Used primarily in patients with celiac disease. Decreases complex carbohydrates which may affect bowel function. Clear Liquid Diet Period of bowel rest during which patients get nourishment from clear liquids. Considered nutritionally inadequate even with clear liquid supplements. Elemental Diet Consists of nutrients in their simplest form. High in carbohydrates, low in fats. Used in Europe as primary treatment for CD, but not considered as good as other treatments. FODMAPs Acronym for Fermentable, Oligo-, Di- and Monosaccharides, and Polyols. Diet minimizes consumption of these fermentable carbohydrates to manage GI symptoms, including diarrhea, gas, and bloating. More commonly used for IBS. Heller A; Scarlata K. Today’s Dietitian. 2010. Popular Diets Diet Description The Specific Carbohydrate Diet™ Reducing poorly digestible carbohydrates to lessen symptoms of gas, cramps, and diarrhea. Consists mainly of meats, vegetables, oils, honey. South Beach Diet™ and Atkins Diet™ Both South Beach and Atkins diets restrict carbohydrates. Very strict diet at beginning followed by long-term eating plan. Decreases complex carbohydrates which may affect bowel function. The Maker’s Diet Focuses on four components of total healthphysical, mental, spiritual, and emotional. Consists of a phased approach. Recommended foods are unprocessed, unrefined, and untreated with pesticides or hormones. *Note: none of these diets have been studied with scientific or clinical rigor to prove they have a direct benefit for IBD patients. Enteral Nutrition Provides support for deficiencies in calories and/or macro- and micronutrients in the form of a liquid supplement. • Administered through - Nasogastric tube (NG tube) from nose to stomach - Gastrostomy tube (G-tube) from abdominal wall to stomach • Helpful for children with IBD to ensure adequate nutrition when: - Appetite is poor - Concerns about growth - Complications in gaining weight • Tube feedings can be given at night • Oral supplements (e.g., Ensure®) can be useful but do not require tube feedings Parenteral Nutrition Delivered through catheter placed into a large blood vessel • More complications than enteral nutrition • Requires specialized training to administer • Rarely necessary Diet Research • Research studies on the relationship between diet, nutrition, and IBD are limited • Most studies are small, resulting in anecdotal outcomes • Diet may have impact on disease, but research has been inadequate to show how – Different mechanisms proposed: effect on immune system, gut bacteria Hou JK, et al. Am J Gastroenterol . 2011; Korzenik J; Lewis J. Diet Research: Associations 2011 review article showed associations between dietary intake and risk of IBD Fats and Meats • High dietary intakes associated with an increased risk of IBD Fiber and Fruits • High dietary intakes were associated with decreased risk of CD Vegetables • High dietary intake was associated with decreased risk of UC Take-home points • • • Limitations with review (different studies, majority were retrospective) No particular foods, but component common to many foods may have a role Studies did not explore role of diet on current disease activity Albenberg LG, et al. Curr Opin Gastroenterol. 2012; Korzenik J; Lewis J. Key Messages Diet Has Not Been Shown to: Diet Can Diet Should be • Cause IBD • Help symptoms while disease is being treated in other ways • Individualized based on: 1. Which disease you have (CD vs. UC) 2. What part of intestine is affected 3. Disease activity (remission vs. flare) 4. Individual caloric and nutritional needs • Prevent IBD • Provide sustainable disease control alone without the help of maintenance therapy • Improve nutritional status and overall wellness Eating Well with IBD • People with IBD should maintain as diverse and nutrient-rich diet as they can • When experiencing a flare, you may need to avoid foods that worsen symptoms • Be flexible and focus on what you can eat – Follow your experience, and keep track of foods that trigger symptoms • USDA site (www.choosemyplate.gov) has general recommendations on healthy eating, and sample meal plans Heller A. Eating Right with IBD. 2004; Bonci L. American Dietetic Association Guide to Better Digestion. 2003. Nutrition Basics Macronutrients – Carbohydrates • Provide energy • Simple: digested quickly (e.g., sugar, honey, lactose) • Complex: longer to digest (e.g., starches, fiber in vegetables, legumes, grains) – Protein • Provide “building blocks” for bones, muscles, cartilage, skin, and blood, as well as enzymes and hormones • May need more when experiencing inflammation or recovering from inflammation – Fat • Often viewed as bad, but has important role in providing energy and essential fatty acids; needed to absorb some vitamins • Saturated, monounsaturated, polyunsaturated Kane S. IBD Self-Management. 2010; Roscher B. How to Cook for Crohn’s and Colitis. 2007; USDA. choosemyplate.gov. Nutrition Basics Micronutrients – Vitamins • • • • Substances that the body cannot manufacture Necessary for a variety of biochemical processes Body must obtain them, mostly from animal sources Fat-soluble (A,D,E,K) and water-soluble (B vitamins, folic acid, vitamin C) – Minerals • Elements that do not form chains • Necessary for a variety of biochemical processes • Include sodium, potassium, iron, magnesium, calcium, zinc Stein SH, Rood RP, eds. Inflammatory Bowel Disease: A Guide for Patients and Their Families. 1999. Water: The Forgotten Nutrient • Fluid intake essential for people with IBD • Average person should ingest 64 oz of water per day or 8 (8 oz) glasses per day – Does not include alcohol or caffeine • Diarrhea can cause dehydration Other options for keeping hydrated • Oral rehydration solution (e.g., Pedialyte®) • Water-diluted sports drinks or juices – Dilution prevents excessive sugar intake • Water with electrolytes Avoid caffeinated or carbonated beverages Dalessandro T. What To Eat With IBD. 2006; Roscher B. How to Cook for Crohn’s and Colitis. 2007. Tips for Healthy Eating with IBD • • When feeling well, people with IBD can eat a normal, balanced diet When experiencing symptoms, may need to adjust diet: – – – – – – – Eat more small, frequent meals Eat in a relaxed atmosphere Avoid high fat or greasy foods Limit spicy or highly seasoned foods Avoid trigger foods Limit high-fiber foods Consider nutritional supplements Heller A. Eating Right with IBD. 2004; Bonci L. American Dietetic Association Guide to Better Digestion. 2003. Types of Fiber Soluble Fiber Insoluble Fiber Soluble – dissolves in water Insoluble – not soluble in water Absorbs water in GI tract, forms smooth, gel-like consistency in bowel Draws water into GI tract, increases bulk Beneficial for diarrhea sufferers Food moves more quickly through bowel Slows food and increases absorption Increases movement of food, decreasing absorption Examples – Pectins (e.g., citrus, carrots, jelly) Gums (e.g., seaweed, agar) Mucilages (e.g., oats) Examples – Cellulose (e.g., Brussels sprouts, cabbage, kale, wheat bran) Lignin (e.g., celery, flaxseed, sesame seeds) Kane S. IBD Self-Management. 2010; Dalessandro T. What To Eat With IBD. 2006; Roscher B. How to Cook for Crohn’s and Colitis. 2007. Fiber Needs • Either type of fiber may cause bloating and gas • Recommended daily intake: 25 grams for women, 38 grams for men (best obtained from food sources) • Children should consume the number of grams equal to their age +5 • If you reduced your fiber intake during a flare, slowly increase when you are feeling better (only a few grams per week) Kane S. IBD Self-Management. 2010; Slavin JL, J Am Diet Assoc. 2008. Control IBD Symptoms Avoid “trigger” foods Not all IBD patients are affected by the same foods Common foods that may cause GI discomfort: • • • • • • • • High-fiber foods (e.g., nuts, raw, leafy vegetables) High-fat foods (e.g., greasy, fried foods) Caffeine (e.g., coffee, tea, soda, chocolate) Alcohol Carbonated beverages Dairy (lactose) Sugar alcohols in sugar-free foods (e.g., sorbitol) Spicy foods Use food diary to help identify “trigger” foods Vegetables When experiencing a flare: • Cooked, pureed, or peeled vegetables may be better tolerated • Select vegetables that are easier to digest (e.g., asparagus, potatoes) • Avoid vegetables that are gas-producing or have a tough skin (e.g., broccoli, Brussels sprouts) • Add vegetable stock to rice or pasta for additional nutrients Heller A. Eating Right with IBD. 2004; Dalessandro T. What To Eat With IBD. 2006. Fruits When experiencing a flare: • Cooked, pureed, canned, or peeled fruit may be better tolerated • Select fruits that are easier to digest and have less insoluble fiber (e.g., applesauce or melon) • Avoid fruits with high fiber content (e.g., oranges, dried fruit such as raisins) Heller A. Eating Right with IBD. 2004; Dalessandro T. What To Eat With IBD. 2006.; Bonci L. American Dietetic Association Guide to Better Digestion. 2003 Carbohydrates When experiencing a flare: • Carbohydrates that are more refined with less insoluble fiber may be better tolerated – Examples: oatmeal, potato, sourdough, and French breads • Avoid carbohydrates with more insoluble fiber, such as grains with seeds and nuts Dalessandro T. What To Eat With IBD. 2006; Roscher B. How to Cook for Crohn’s and Colitis. 2007. Protein • Protein needs may be greater during inflammation When experiencing a flare: • Lean sources of protein may be better tolerated – Excess fat can lead to poor absorption and may make symptoms worse – Examples: fish (salmon, halibut, flounder, swordfish), chicken, eggs, and tofu • Try smooth nut butters (peanut, almond, cashew) • Avoid fatty, fried, or highly processed meats, as well as nuts and seeds Heller A. Eating Right with IBD. 2004; Dalessandro T. What To Eat With IBD. 2006; Roscher B. How to Cook for Crohn’s and Colitis. 2007; Kane S. IBD Self-Management. 2010; USDA. choosemyplate.gov. Tips for Eating Out There is No “IBD-safe” Menu • Don’t go out feeling too hungry • Don’t be afraid to make special requests • Call ahead or review menu online • Eat smaller portions • When in doubt, keep it simple – Go for boiled, grilled, broiled, steamed, poached, or sautéed options – Limit sauces and spices Crohn’s & Colitis Foundation of America. Take Charge. 2006. Promoting Growth and Bone Health • Control inflammation through treatment – Induce remission – Maintain remission • Ensure adequate caloric intake – For some, high calorie supplements or tube feedings may be needed • Avoid long-term or repetitive steroid use • Ensure adequate calcium and vitamin D Heller A. Eating Right with IBD. 2004. Importance of Calcium Calcium consumption important for IBD patients due to: • Increased risk of osteoporosis • Poor intake of dairy due to avoidance, allergies, lactose intolerance, etc. • Medications such as corticosteroids 1200-1500 mg per day is recommended (400-500 mg at a time) How to get 1200-1500 mg per day: • Consume three servings of calcium-rich foods daily, such as milk (regular, lactose-free, fortified almond or soy), yogurt, cheese, tofu, dark leafy vegetables, or canned fish with bones • Add a calcium citrate supplement if needed Heller A. Eating Right with IBD. 2004; Dalessandro T. What To Eat With IBD. 2006; Scarlata K. Today’s Dietitian. 2010. Supplements for IBD Multivitamin/multimineral formula • Absorbability: liquid or powder-filled options may be better tolerated, metabolized faster • Look for United States Pharmacopeial Convention (USP) symbol: guarantees it has met quality standards of organization Supplements that are often recommended: Highly absorbable calcium supplement • 1200-1500 mg as calcium citrate (split into 3 doses) Vitamin D – Helps absorption of calcium • Supplement with 1000 IU daily Dalessandro T. What To Eat With IBD. 2006; Kane S. IBD Self-Management. 2010. Supplements to Discuss with Healthcare Team Folic Acid • 800 mcg to 1 mg per day Vitamin B12 • Monthly intramuscular injection may be given to patients with ileitis or with significant ileal resection Iron, when necessary • Must be determined by deficiency present, excess iron can be toxic • Usual dose is 8 to 27 mg, taken one to three times a day Zinc, when necessary • Deficiency may be due to diarrhea, fistulas, inflammation • Recommended supplement typically 15 mg/day Probiotics • “Good” bacteria that restores balance to the intestines • May help for maintenance of UC, pouchitis • Found in fermented foods such as yogurt, kefir, kimchee Omega-3 fatty acids (fish oils) • Large, well-controlled trials showed no benefit in CD Heller A. Eating Right with IBD. 2004; Dalessandro T. What To Eat With IBD. 2006; Kane S. IBD SelfManagement. 2010. Supplements That May Worsen Symptoms • Angel’s trumpet: decreases motility (anticholinergic hyoscyamine, scopolamine) • Alder buckthorn: increases motility (anthraquinone laxative) • Aloe latex (anthraquinone laxative) • Cascara (anthraquinone laxative) • Castor oil (ricinoleic acid laxative) • European buckthorn (anthraquinone laxative) • Fo – ti (anthraquinone laxative, potential hepatotoxin) • Rhubarb (anthraquinone laxative) • Senna (anthraquinone laxative) Heller A. Eating Right with IBD. 2004; Natural Medicines Comprehensive Database. 2004. Summary • Every case of IBD is different • Generally, people with IBD should eat a well-balanced, nutrient-rich diet when feeling well and should not feel limited by their disease • When experiencing a flare or complication (such as a stricture), may need to adjust diet – Make sure you are meeting your calorie and nutrient needs Summary Take things day-by-day and plan meals • Prepare a shopping list to ensure caloric and nutrient intake is achieved • Read food labels • Keep a food diary – CCFA-prepared food diary is available at: www.ccfacommunity.org, click on Resource Center tab → Work with healthcare team to make sure nutrition needs are met! EXAMPLE OF AN IBD MEAL PLAN Breakfast: 1 cup plain low-fat Greek yogurt ½ cup Cheerios® ½ cup sliced peaches Snack: 1 hard boiled egg ¾ cup honeydew melon Lunch: ¼ lb cooked lean ground turkey meat divided on 2 corn or flour tortillas, topped with slices of avocado, shredded Bibb lettuce, and mild salsa (as tolerated) Snack: 1 small banana spread with 1 tbsp creamy all-natural nut butter Dinner: 1 cup cooked penne pasta with 1-2 tbsp olive oil, fresh herbs, well-cooked broccoli florets, and cooked shrimp Nutrition and Diet Resources • American Society of Parenteral & Enteral Nutrition – www.nutritioncare.org • Academy of Nutrition & Dietetics – www.eatright.org • Find a registered dietitian – www.eatright.org/programs/rdfinder • The American Association of Nutritional Consultants – www.aanc.net • USDA foods for wellness information – www.choosemyplate.gov • CCFA Community Forum – Diet Forum – www.ccfacommunity.org • CCFA “I’ll Be Determined” – Diet Module– www.ibdetermined.org • CCFA Website – www.ccfa.org Questions and Answers Contributors Beth K. Arnold, MA, RD, LD, CCFA AL/NW FL Chapter Board President Tracie Dalessandro, MS, RD, CDN, Registered Dietitian, Private Clinical Practice, Briarcliff Manor, New York Arthur D. Heller, MD, Private Practice, New York, NY Michael Kappelman, MD, University of North Carolina, Division of Pediatric Gastroenterology, Co-Chair, Professional Education Committee, CCFA National Scientific Advisory Committee Sandra Kim, MD, University of North Carolina, Division of Pediatric Gastroenterology, Co-Chair, Pediatric Affairs Committee, CCFA National Scientific Advisory Committee Joshua Korzenik, MD, Brigham and Women's Hospital James Lewis, MD, PhD, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Raymond and Ruth Perelman School of Medicine , Chair, CCFA National Scientific Advisory Committee Richard Rood, MD, Medical Director, Inflammatory Bowel Disease Program, Digestive Disease Division, University of Cincinnati College of Medicine David T. Rubin, MD, Associate Professor of Medicine, Co-Director, Inflammatory Bowel Disease Center, Program Director, Fellowship in Gastroenterology, Hepatology and Nutrition, University of Chicago Medical Center Laura Walls, MPH, RD, Research Coordinator, University of North Carolina, Division of Pediatric Gastroenterology Colleen Webb, MS, RD, CDN, Registered Dietitian, Weill Cornell Medical Center References Albenberg LG, Lewis JD, Wu GD. Food and the gut microbiota in inflammatory bowel diseases: a critical connection. Curr Opin Gastroenterol. 2012;28(4):314-320. Bonci L. American Dietetic Association Guide to Better Digestion. Hoboken, NJ: John Wiley &Sons, Inc, 2003. Crohn’s & Colitis Foundation of America. No reservations: how to take the worry out of eating out. Take Charge. 2006:13-14. Dalessandro T. What To Eat With IBD: A Comprehensive Nutrition and Recipe Guide for Crohn’s Disease and Ulcerative Colitis. New York, NY: CMG Publishing; 2006. Heller A. Eating Right with IBD. In: Patient Education Symposium 2004; New York, NY: Crohn’s & Colitis Foundation of America, Greater New York Chapter. Hou JK, Abraham B, El-Serag H. Dietary intake and risk of developing inflammatory bowel disease: a systematic review of the literature. Am J Gastroenterol. 2011;106(4):563-573. James A. Inflammatory bowel disease and nutrition. About Kids Health Web site. http://research.aboutkidsheath.ca/ofhc/news/CLMNABD/5522.asp. Published October 5, 2006. Updated February 2, 2010. References (cont). Kane S. IBD Self-Management: The AGA Guide to Crohn's Disease and Ulcerative Colitis. Bethesda, MD: AGA Press; 2010:143-175. Lucendo AJ, De Rezende LC. Importance of nutrition in inflammatory bowel disease. World J Gastroenterol. 2009;15(17):2081-2088. Roscher B. How to Cook for Crohn’s and Colitis. Nashville, TN: Cumberland House; 2007. Scarlata K. The FODMAPs approach — minimize consumption of fermentable carbs to manage functional gut disorder symptoms. Today’s Dietitian. 2010;12(8):30. Slavin JL, American Dietetics Association Positions Committee Workgroup. Position of the American Dietetic Association: Health Implications of Dietary Fiber. J Am Diet Assoc. 2008;108:1716-1731. Stein SH, Rood RP, eds. Inflammatory Bowel Disease: A Guide for Patients and Their Families. 2nd edition. Philadelphia: Lippincott-Raven, 1999. United States Department of Agriculture. choosemyplate.gov. www.choosemyplate.gov. Accessed June 29, 2012.