A comprehensive guide on IBD management

IBD stands for inflammatory bowel disease. It is the disease that signifies the ongoing inflammation of your digestive tract. This inflammation is usually chronic. Chronic refers to something that is going on for a long period of time.

And inflammation refers to the condition where due to an infection or an injury, the site of infection/injury gets red, swollen and sore.

Moreover, IBD has two major forms, Crohn’s disease and Ulcerative Colitis. These diseases are relatively rare but the prevalence is increasing and observed more in elderly.

Also learn about FODMAP diet and its benefits. FODMAP diet: Benefits, diet plan and food list

What are the risk factors of IBD?

• Age: it generally occurs often in the age of 15-30 and for some it may also get observed in adulthood.
• Sex: it affects both the genders equally.

It is observed that IBD is more prevalent in the urban as well as developed areas as compared to the rural.

What are the causes of IBD?

The cause of the IBD is not completely understood. But it involves the interaction of the gastrointestinal system with the immune system, genetic as well as environmental factors. Over time, it is seen that genes also play a role in the risk factor and cause of IBD.

If we talk about environmental factors, then we all are familiar with the micro-organisms living in our GI tract and the interaction of dietary components. Diet does play an important role when it comes to the IBD and its management.

Now, if we discuss the role of the immune system in the cause of this disease, there is a decreased immune defense against the increased antigen (foreign substance attacking the body). Furthermore, decreased immune response plays an important role in the causation of this disease. As there is an inflammatory response in this condition, there is damage to the body’s own cells and thereby increasing further inflammation. This causes the formation of ulcers in the intestines and also results in the malabsorption of the dietary components.

Let’s discuss Crohn’s disease and Ulcerative colitis (UC) in detail.

Crohn’s disease and UC share some common characteristics such as diarrhea, fever, weight loss, anemia, food intolerances, malnutrition, growth failure. And other characteristics which are not related to intestines such as liver related conditions, arthritis, and even skin-related conditions.

Moreover, malnutrition becomes a lifelong problem with patients with Crohn’s disease as compared to ulcerative colitis. Due to the malabsorption of nutrients in the body, malnutrition becomes an inescapable condition in these diseases. The body is not able to absorb sufficient nutrients. Which further leads to low immune response and increased inflammation. Thereby making it a vicious cycle or loop.

Now, you might wonder what is the difference between these two forms of IBD. Well, the difference is as follows:

	Ulcerative Colitis	Crohn’s disease
Presentation	Bloody diarrhea	Perianal disease, mass in abdomen, abdominal pain
Gross pathology	Rectum always involved,Moves continuously	Rectum may not be involved,Can occur anywhere along the GI tract
Microscopic examination	Thin wallFew stricturesNo granulesLow inflammationDeeper ulcers	Thick wallStrictures commonGranulomas presentHigh inflammationShallow ulcers

Inflammatory bowel disease dietary management

Diet can be an environmental factor that triggers IBD and usually the triggers are not so uniform. You might see that one person may get triggered by a specific food item whereas another might get triggered by some ingredient or totally different food item. It is very important to observe the pattern of triggers and also to mark the food items you think you might have intolerance for.

But diet is also a remedy for IBD. You can manage your IBD forms with proper dietary modifications and recommendations. 

Persons with IBD are at increased risk of nutrition problems for a host of reasons related to the disease and its treatment. Thus, the primary goal is to restore and maintain the nutrition status of the individual. Foods, dietary and micronutrient supplements, and enteral as well as parenteral nutrition may be used to accomplish that mission. 

There is no single dietary regimen for reducing symptoms or decreasing the flares in IBD. Diet and specific nutrients play a supportive role in maintaining nutrition status, limiting symptom exacerbations, and supporting growth in pediatric patients. 

Energy:

Energy needs of patients with IBD are not greatly increased (unless weight gain is desired). Generally, when disease activity increases basal metabolic rate, physical activity is greatly curtailed and overall energy needs are not substantially changed. 

Protein:

Protein requirements may be increased, depending on the severity and stage of the disease and the restoration requirements. Inflammation and treatment with medications induce a negative nitrogen balance and cause a loss of lean muscle mass. So, to maintain positive nitrogen balance, 1.3 to 1.5 g/kg/day of protein is recommended.

Fats:

Omega-3 fatty acid supplements in Crohn’s disease significantly reduce disease activity. Use of omega-3 fatty acids or fish oil supplements appears to result in a significant medication-sparing effect, with reductions in disease activity. In cases in which fat malabsorption is likely, supplementation with foods made with medium-chain triglycerides may be useful in adding calories. And also serving as a vehicle for fat-soluble nutrients.

Carbohydrates:

Excessive intake of lactose, fructose, or sorbitol may contribute to abdominal cramping, gas, and diarrhea; and high fat intake may result in steatorrhea. However, the incidence of lactose intolerance is no greater in patients with IBD than in the general population. Patients with IBD who tolerate lactose should not restrict lactose-containing foods because they can be a valuable source of high-quality protein, calcium, and vitamin D. 

Minerals and vitamins:

Supplemental vitamins, especially folate, B6, and B12, may be needed. Also, minerals such as iron and trace elements to replace stores or for maintenance because of mal-digestion, malabsorption, drug-nutrient interactions, or inadequate intake. Diarrhea can aggravate losses of zinc, potassium, and selenium. Patients who receive medications may also need supplemental calcium and vitamin D. 

Dietary fiber:

Patients with strictures or partial bowel obstruction benefit from a reduction in dietary fiber or limited food particle size. In other words, follow a low residue diet to relieve abdominal pain and diarrhea.

Fluids and Electrolytes:

It is important to drink adequate amounts of fluid. Fluid requirements increase during or after episodes of diarrhea and with exercise. You should also make sure that you also replenish losses of electrolytes from diarrhea. Sodium, chloride and potassium as well can be replenished by drinking drinks, such as ORS.

Probiotics and prebiotics:

Probiotic foods and supplements have the ability to modify the gut microbiota and potentially modulate gut inflammatory response. Multi-strain probiotic supplements have been shown to be beneficial in maintaining disease remission in patients with UC. However, a different probiotic supplement at a lower dose did not significantly reduce symptoms. Specific probiotic supplements also appear to be useful for induction and extension of remissions in pediatric and adult UC. 

Moreover, regular intake of prebiotic foods such as oligosaccharides, fermentable fibers, and resistant starches can beneficially affect the gut microbiota. In addition, fermentation of prebiotics leads to increased production of short-chain fatty acids, creating a more acidic and less favorable environment for opportunistic bacteria. 

Probiotic Foods	Prebiotic Foods
Plain Yogurt	Oat groats, Steel-cut Oats
Aged Cheeses	Bananas
Fermented veggies	Ground Flax seed, chia seed
Kefir	Garlic, Onions
	Barley (for non-celiac patients)
	Chicory root, acacia root
Pickles	Artichokes (Jerusalem and globe)
Raw honey	Leeks
Fermented Cabbage	Asparagus
	All vegetables, some fruits

Role of Fermented cabbage juice in inflammatory bowel disease:

You might have heard about the role of fermented cabbage juice in the management of IBD. It helps to reduce inflammation. And also the other symptoms of gut disorder especially in the case of Crohn’s disease and ulcerative colitis. As there is chronic inflammation of the digestive tract in both of these forms of IBD, fermented cabbage juice helps to reduce that.

Moreover, many researches on fermented cabbage juice suggest that it helps to heal the gut. You might not be aware of, but cabbage is brimming with various micronutrients and it also possesses antioxidant properties. This property aids in the reduction of inflammation of the gut in IBD.

Role of Wheat-grass juice in inflammatory bowel disease:

Many studies suggest that wheatgrass juice can be used in the IBD management. Especially in the case of ulcers, it helps to reduce rectal bleeding and reduce the inflammation of large intestines. Studies also suggest that wheatgrass juice helps in ulcerative colitis recovery. 

You might be wondering why we are talking about taking juices in place of whole fruit or vegetables. Well, a low dietary fibre diet is recommended in the management of IBD. Whole fruits and vegetables are rich in dietary fibre and that can irritate the digestive system. And therefore, it is better to consume juices instead of whole fruits or vegetables. 

What is the role of a ketogenic diet in Crohn’s disease?

A ketogenic diet is basically a high-fat and low-carbohydrate diet which consists of about 80 % fat, 15 % protein and 5 % carbs. Generally, your body’s primary source of fuel is glucose which is made from the carbs that we eat. When you don’t eat enough carbs, your body goes into ketosis and starts to make ketones from fat, which are used as a secondary energy source. 

There is also emerging evidence that the underlying cause of IBD is a bacterial imbalance in the gut. Gut bacteria survive on sugar and carbohydrates, so by starving them, you can restore balance to your gut bacteria. By doing this, it will help you to reduce symptoms and will also improve your health.

Moreover, a ketogenic diet is low in FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols). These FODMAPs are classically associated with irritable bowel syndrome but may also play a role in Crohn’s disease. And it’s possible that a reduction in FODMAPs is the real reason behind reduced Crohn’s symptoms.

What is the role of Paleo diet in Ulcerative colitis?

The paleo diet includes eating foods like meat, eggs, fruits, vegetables, and nuts. The paleo diet limits the amount of whole grains, dairy, refined sugar, and starchy vegetables that you generally eat. It encourages increasing the amount of healthy fats in your diet, including omega-3 fatty acids.

Following the paleo diet means avoiding foods such as cereals and whole grains, dairy products, legumes, processed foods, refined sugar, potatoes, refined vegetable oils and salt.

Moreover, these restricted foods items may include known common triggers of UC flare-ups.

• As starchy foods cause gas and increase the amount of stool you produce so eliminating these foods could relieve your symptoms.
• Avoiding dairy products can also help you manage symptoms. These symptoms include diarrhea, abdominal cramping, and gas as dairy intolerance is common among those with UC.
• Paleo diet helps you to get higher amounts of antioxidants in your diet from eating more fish and healthy fats. Omega-3 and other antioxidants encourage healing. They may have a protective effect on tissues, reducing inflammation and symptoms.
• The paleo diet allows you to get more B vitamins and other nutrients that you miss out on by keeping whole grains in your diet. People with UC often suffer from nutrient deficiencies because of rectal bleeding, chronic diarrhea, and poor appetite.
• The paleo diet doesn’t include beans and other legumes. These foods may aggravate your bowels and increase stool output and gas.
• Meat, fish, and poultry contain heme iron, which is more easily absorbed by the body than non-heme iron found in plants. People with UC have a high risk of iron deficiency anemia from chronic diarrhea and bloody stools. So, consuming meat, fish and poultry helps you to provide enough iron to correct your iron deficiency.

(Source: https://www.healthline.com/health/ulcerative-colitis-take-control/paleo-diet#paleo-diet-benefits )

What is the role of Intermittent fasting in inflammatory bowel disease?

Intermittent fasting is an umbrella term that describes many different fasting cycles. Rather than focusing on what foods are eaten, it focuses more on when foods are eaten. One theory behind the potential benefits of intermittent fasting is that it can lead to changes in your gut bacteria. It will help to create an anti-inflammatory environment in the intestines and will also restore the gut barrier.

However, it is important to know that achieving these benefits is less about the timing of eating, but rather an overall reduction in the amount of food being eaten. So, for those who are looking for a structured approach to eating, intermittent fasting may be a helpful way to limit excess food. Also, eating a wide variety of whole grains, fruits, and vegetables during periods of remission can help feed our gut microbiome and achieve similar results.

Source: https://www.ibdcentrebc.ca/2021/07/intermittent-fasting-on-ibd/ 

Foods to avoid:

• Fatty, fried foods
• Spicy foods
• Meats
• Creamy sauces
• High-fiber foods including raw fruits and vegetables
• Nuts, seeds, and beans
• Caffeinated beverages
• Sweets including candy, soda, and juice
• Alcohol

Food to eat/enjoy:

• Applesauce
• Bananas
• Oatmeal
• Lean poultry or fish, plain
• Eggs
• Mashed potatoes
• Canned fruit
• Rice
• Noodles
• White bread
• Diluted juices
• Plain cereals
• Fermented products such as cabbage

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