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Why nutrition is important
One very important part of therapy for inflammatory bowel disease (IBD),
which includes Crohn's disease and ulcerative colitis, is proper nutrition.
During the onset of these diseases or during "flare-up" times, your
appetite may be poor and you may lose weight. Malnutrition (poor or inadequate
nutrition) can develop because of the following.
- Decreased food intake
- Nutrients lost through diarrhea
- Increased nutritional needs
- Possible effects of the medications you are taking
Your growth may be slowed or interrupted if you eat poorly for long periods
of time.
Some drugs, such as corticosteroids (prednisone), may increase your appetite.
Both the quality and quantity of the nutrients in your diet are important. Even
if you eat more calories, it is still important for you to eat a well-balanced
diet so that you get a variety of nutrients. Calories, protein, fat, complex
carbohydrates, vitamins and minerals are needed to replace those lost
through diarrhea and to promote healing of your intestines.
Your doctor or dietitian will discuss your "best" weight with you.
Your nutrition therapy is based on:
Your best weight ___________________
Caloric needs ______________________
Meeting your nutrient needs
Although you may not always feel like eating, it is important that you meet
your calorie and protein needs. A healthy diet may make you feel better and help
your body heal and grow.
When you're feeling well, you may be able to eat almost anything. However,
most people need to make changes in their diets, especially during flare-up
times. Decreasing fiber and/or foods containing lactose are the most common
changes made during flare-ups. These topics are covered later in the booklet.
Liquid supplements may also be helpful when you find it difficult to eat enough.
If you are having trouble meeting your caloric and protein needs, be sure to
discuss this with your doctor or dietitian.
You may need to take vitamin and mineral supplements to replace the nutrients
that your body is not absorbing properly.
This handout includes information to help you obtain the proper nutrients.
Your nutrition needs will change depending on how you feel. Discuss how you feel
with your doctor and dietitian before making changes in your diet. There is no
single diet for IBD, but certain suggestions can help. After following the diet
for a while, you will know which foods you need to avoid.
Your mission: Good nutrition
Your mission is to eat and drink all the calories you need to make sure your
body stays well nourished. The best approach is to begin with the following
plan. Remember, even during flare-ups, you should try to eat at least the
minimum number of servings from each of these food groups:
- Protein
- Dairy Group
- Starches and Other Grains
- Fruits and Vegetables
- Extras
Protein
Eat at least 2 to 3 servings every day. The serving size for the meats
listed below is 2-1/2 to 3 ounces.
- Beef
- Cheeseburger
- Veal
- Lamb
- Fish
- Hot Dog
- Egg
- Chicken
- Pork
- Ham
- Luncheon meats
- Turkey and other poultry
The serving size for meat alternatives
- 1 cup casseroles or combination dishes
- 1/2 cup cooked beans or peas
- 1 cup soy milk
- 1/2 cup tofu
- 2 tablespoons of peanut butter
All meats are high in protein. You also get protein from dairy foods
and some protein from breads, cereals and vegetables. Depending on your
weight and nutritional status, you may need more protein than recommended
above. Your dietitian will suggest eating more protein when necessary.
To increase calories
- Add extra gravy or sauces (not spicy).
- Use spreads like mayonnaise or margarine on your sandwiches.
- Buy fish canned in oil (like tuna).
- Eat peanut butter and jelly sandwiches.
- Add hard-cooked eggs to vegetables or sandwiches
Dairy group
Eat at Least 3 to 4 servings every day
You may need to choose low-lactose alternatives, or
take a calcium supplement, if you are lactose intolerant.
The serving size for the dairy foods listed below is one cup:
- Cream
- Milk
- Pudding
- Cottage cheese
- Ice Cream
- Yogurt
- Milkshakes
- Custard
The serving size for the dairy foods listed below is:
- 1/2 cup macaroni and cheese
- 2 ounces cheese
The foods listed above are high in protein and calcium. Dairy foods
that are high in calories but low in calcium include sour cream, cream cheese
and whipped cream.
To increase calories:
- Add instant breakfast mix to your milk either the whole packet or just
part of it).
- Add fruit canned in heavy syrup to yogurt or cottage cheese.
- Add grated cheese (like Parmesan) or your favorite shredded cheese to
casseroles, salads and soups.
- Choose whole milk instead of low-fat milk.
- Choose flavored yogurt instead of plain.
Starches and other grains
Eat at Least 6 to 11 servings every day
The serving size for the starches listed below is one slice of:
- White, Italian, French, whole-wheat, rye (seedless) and sweet breads
(example: banana or pumpkin bread without nuts).
Also, one serving is:
- Muffin, small
- Dinner roll
- Pancake, 4 inch across
- Biscuit, 2-1/2 inch across
- Waffle, 4-1/2 inch square
- French toast
- Doughnut, small
The serving size for the starches listed below is:
- 1/2 hamburger bun
- 1/2 hot dog bun
- 1/2 English muffin
- 1/2 bagel
- 4 saltines
- 3/4 cup ready-to-eat cereal
The serving size for the following starches is 1/2 cup:
- Fried rice
- Noodle mixes
- Potatoes
- Stuffing (dressing)
- Rice
- French fries
- Potato mixes
- Noodles and macaroni
Depending on your weight, you may need to eat more servings from this group.
To increase calories:
- Spread breads with butter, margarine, jelly or cream cheese.
- Add extra butter or margarine to your rice, potatoes and noodles.
- Add sugar, brown sugar, honey or syrup to hot cereal.
- Eat pre-sweetened cereal.
- Add extra syrup and butter or margarine to pancakes, waffles or French
toast.
- Try casseroles with potatoes or noodles.
Fruits and vegetables
Eat 5 to 9 servings every day
The serving size for the fruit and vegetables listed below is:
- 1 medium-sized fresh fruit
- 1 avocado
- 1 cup raw vegetables
- 1/2 cup cooked vegetables (canned, frozen and fresh)
- 1/2 cup fruit juice
- 1/2 cup vegetable juice
- 1/2 cup canned fruit
- 2 tbsp raisins
To increase calories:
- Add extra butter or margarine, grated cheese and/or chopped hard-cooked
eggs to vegetables.
- Add yogurt, cottage cheese or ice cream to fruit canned in heavy syrup.
- Add whipped cream to fruit.
- Eat vegetables with a "dip."
For extra calories. . .
Juice
Choose cranberry, grape, pineapple or apricot. These
juices have more calories than orange or apple juice.
Fruit
Choose bananas and dried fruit--they have more calories
than "watery" fruits like apples or plums.
Milk
Add powdered milk or instant breakfast mix to milk or
milkshakes.
Hot cereal
Prepare cereal with milk and add powdered milk, butter or
margarine, peanut butter, honey or syrup.
Cold cereal
Choose dense cereals such as granola over puffed cereals.
Toast
Spread toast with a generous amount of butter or margarine
and jam.
Sandwiches
Choose hearty, thick breads. Fill generously with sandwich
fillings.
Soups
Choose hearty soups like barley and minestrone and cream
soups over thin broth. Add evaporated or powdered milk to boost
calories. Garnish with Parmesan cheese and crackers.
Salads
Add cheese, meats, beans and tuna fish.
Meats
Sautй in olive oil and breadcrumb toppings.
Snacks
Try oatmeal raisin cookies, banana and other sweet breads,
yogurt, pudding, milkshakes, hot chocolate, bagels and peanut butter.
So you thought you knew how to chew . . .
Did you ever laugh when your mother told you to chew your food? Well, she
was right. Chewing your food completely is especially important if you have IBD.
There may be times when your small bowel becomes narrowed, either because of IBD
or surgery, and pieces of food can obstruct or block your bowel.
A narrowed bowel is one reason why you need to chew your foods well. Another
reason is to help you better absorb the nutrients you need to feel better and
to grow.
To help make sure that you are chewing completely, remember:
- Always make time for your meals. Don't eat when you're in a hurry.
- Stay focused on the task of eating.
- Minimize distractions in the area where you eat.
To slow down your eating:
- Cut your food into small pieces and chew it thoroughly.
- Put your fork down after each bite of food.
- Swallow completely before taking another bite.
Don't eat when you are:
- Talking
- Reading
- Watching TV
- Not concentrating on chewing well
Other tips that can help you chew well:
- All foods swallowed must be chewed completely. Remember that large pieces
of food can cause obstructions and may pose a choking hazard.
- Avoid nuts, seeds, dried fruits and tough skins on fruits, vegetables and
grains. Examples: peas, corn, grapes.
What to do on flare-up days
Your body still needs the same amount of nutrition, or even more, during
flare-up days. During a flare-up, your appetite may be particularly poor. In
such cases, it may help to avoid eating three large meals. Instead, break up the
same amount of food into six to eight mini-meals throughout the day.
If you still find it difficult to meet your caloric and protein needs, you
may want to try liquid nutritional supplements. These drinks have all the
nutrients found in regular foods and are easier to digest. Ask your doctor or
dietitian to recommend one.
Depending on individual tolerances, some people find they have an especially
difficult time digesting fiber and lactose during flare-ups. If you experience
difficulty with these foods, consult with your doctor or dietitian. He or she
may recommend a low-lactose and/or low-fiber diet.
Why you may need a low-lactose diet
A low-lactose diet will help you avoid the gas and bloating you feel after
eating dairy products. A lack of the enzyme lactase may cause your problems with
dairy products. Lactase is an enzyme produced by the small intestine that helps
the body digest lactose, the sugar found in milk and dairy products. When there
is not enough lactase, the sugar in milk is not digested. This causes bloating,
diarrhea and gas.
In addition to milk, there are other foods that contain lactose. The foods
listed below contain lactose and should be eaten in very small quantities or
avoided. Reports suggest that smaller amounts of lactose-containing food may be
better tolerated for many who are lactose intolerant. You may need a low-lactose
diet only temporarily.
Avoid the following foods if you have trouble with dairy products:
- Milkshakes, eggnog, malted milk and other milk-based beverages
- Cream, ice cream, sherbet, yogurt, cheese and whipping cream
- Pudding, custard, cream soups, cream sauces, butter and other foods made
from milk
- Crackers and cookies that contain milk solids
Read all food labels carefully
The number of foods that contain small amounts of milk products may surprise
you. If you are severely lactose intolerant, you may need to avoid
any food products that contain milk, lactose, casein, whey, curds, or non-fat
dry milk and dry milk solids. Kosher foods
are often acceptable.
There are several products you can buy to replace milk or to
"treat" the lactose in milk. Discuss these products with your doctor
or dietitian before purchasing them.
Milk products are the major food source of calcium, a mineral necessary for
healthy bones and teeth. When you avoid milk products, you may need to take a
calcium supplement. Discuss different brands of calcium supplements with your
doctor or dietitian.
When low fiber may be necessary
Following a low-fiber diet during a flare-up may help reduce your symptoms.
Once the flare-up is over, you should add fiber back into your diet and resume
your normal eating habits.
While following a low-fiber diet, avoid:
- Nuts, seeds, skins and popcorn. This includes tomato skins, corn, crunchy
peanut butter, meats with whole spices, and the skin or casing on meats
- All raw fruits, except bananas
- All raw vegetables
- Dried fruits and coconut
- Canned fruit cocktail and canned pineapple
- Coarse whole-grain breads, bran cereals and granola
- Mushrooms
- Dried beans and peas
But, be sure to:
- Cook vegetables well enough so that they can be easily cut using the side
of a fork.
- Consider your past tolerances to foods before consuming anything in large
amounts.
When you need medications
There are different medications that your doctor may give you to help
relieve the pain and swelling or inflammation of your bowel. The most common are
sulfasalazine, mesalamine, corticosteroids and immunomodulators. Sometimes, you
may only need to take one medication, and at other times you may need to take
several.
Sulfasalazine and Mesalamine
Sulfasalazines (brand name Azulfidine) and mesalamines (brand names Asacol,
Pentasa and Rowasa) decrease inflammation, especially in the colon, and are used
to treat mild to moderate symptoms of IBD. These drugs can also help to prevent
your symptoms from coming back.
Neither of these drugs is as strong as prednisone, and they can be used over
a longer period of time. Like any medication, sulfasalazines and mesalamines do
cause some side effects in some patients. This should be discussed with your
doctor.
Sulfasalazines and mesalamines interfere with your body's absorption of
folacin, a vitamin. While you are taking either of these drugs, it's important
for you to eat foods high in folacin. These include:
- Liver
- Leafy vegetables, such as lettuce, cabbage and spinach, unless you have
been told to avoid these
- Orange juice
- fruits
- yeast
- fortified breads and cereals
Your doctor may recommend a folic acid supplement to ensure an adequate
intake of folacin.
Prednisone and its side effects
Corticosteroids, such as prednisone, also decrease inflammation and are used
when symptoms are more severe. As your symptoms go away, the dose of
prednisone can be slowly decreased to stopped.
Prednisone often causes side effects. You may experience all or some of the
following side effects:
- Moodiness
- Restlessness
- Rounder face, doctors call this "mooning"
- Increased body hair
- Increased acne
- Increased appetite
- Sodium, salt, and water retention
- Calcium loss
Calcium supplements
Calcium plays an important role in building strong bones and teeth, as well
as in heart and muscle function. What may come as a surprise is that
approximately 90 to 95 percent of your lifetime bone mass is formed before the
age of 20.
Osteoporosis is the disease of porous, brittle bones often associated with
stooped posture and bone fractures in the latter years of life. You may think
the disease is of little concern in your youth. In reality, this is the most
critical time to safeguard yourself from osteoporosis.
Prednisone's side effects will disappear when the
medication is reduced or stopped.
If you are taking prednisone, it is especially important that you eat foods
high in calcium, such as dairy products and green leafy vegetables. If you're
not getting enough calcium, your doctor or dietitian may recommend that you take
a calcium supplement. Talk to your doctor or dietitian to find out what your
individual calcium needs are and ensure that they are being met.
Enteral nutrition
If weight gain or maintenance continues to be a problem, your doctor may
feel that enteral nutrition
or tube feeding is necessary.
Enteral nutrition is most commonly given through a tube, which runs through
the nose into the stomach (naso-gastric route). Often, the nutrition can be
given overnight so that you are free to go about your normal activities,
including eating, during the day.
Enteral feeding can also be given through a gastrostomy tube (G-tube). This
is a tube that is surgically placed through the abdominal wall into the stomach.
These feedings can be given overnight or during the day. The G-tube is typically
used when enteral nutrition is needed for a longer period of time. Once your
weight has returned to an acceptable range, your doctor may decide to
discontinue enteral nutrition.
Enteral nutrition may also be used as the primary therapy for Crohn's
disease. Your doctor or dietitian can discuss the benefits and drawbacks of this
therapy.
Parenteral nutrition
Parenteral nutrition is nutrition delivered through a catheter placed into a
large blood vessel. This is used when the gastrointestinal (GI) tract is unable
to handle food. Typically, this is used only on a short-term basis since
parenteral nutrition has more risks, such as the possibility for infection.
Mission: Accomplished
Proper nutrition plays a very important role in helping you to feel better
and allowing your body to heal. While it may sometimes be hard for you to eat
right, especially during the onset of a disease or during a flare up, it is
still essential that you get the nutrients your
body needs. The guidelines outlined in this handout can make it easier for you to eat a
well-balanced diet. By referring to and following the information provided, you
can ensure that you accomplish your mission of getting enough calories and
nutrients, which will help you maintain a healthy body.
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