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  • Keeping a food symptom diary may help to identify foods that increase symptoms
  • Other fat-soluble vitamin deficiencies are more rare, but can occur and are more often associated with ileal disease or resection.Overall, there is a risk for deficiencies of A,D,E,K, Zinc, B12 and Iron with ongoing “flares” and intestinal damage. ADEK,Zinc and B12 mostly with Crohn’s and Iron with both Crohn’s and Colitis.Signs and symptoms of vitamin deficiencies include: loss of hair, spooning of fingernails, scaly or abnormally dry skin, changes in balance/coordination, muscle weakness, visual disturbances, neurological changes (numbness/tingling), taste changes, delayed wound healing.Complete multivitamins are usually recommended (examples of these are Flintstones complete chewable, Centrum kids complete, Centrum complete, and One-A-Day vitamins) Reminder about the FDA regulations
  • Herbal supplements including aloe, garlic, Echinacea, and evening primrose have been recommended for the aid of symptoms in Inflammatory bowel disease. The action of each herbal supplement can vary and there is currently very limited research on most herbal supplements. Aloe vera, for example is thought to have ant-inflammatory properties, some people with mild to moderate ulcerative colitis who drink aloe vera juice have reported reduced symptoms, however, this effect has not been demonstrated in scientific studies. Herbal supplements can also have adverse side effects, aloe does act like a laxative for some causing increased output. We cannot advocate for or against the use of these supplements and/or substances due to lack of scientific evidence supporting their use. It is important to let your physician know if you are taking an herbal supplement. Also the FDA does not regulate the content of herbal
  • Nutrition

    1. 1. Tarah O’Malley, MS, RD Clinical DietitianChildren’s Hospital Colorado
    2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 14.  Maintenance of adequate vitamin D levels Calcium supplementation while on steroids Control inflammation Increase physical activity (weight baring)
    15. 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. 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. 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. 18.  Cook vegetables thoroughly Peel fruits and vegetables Avoid seeded vegetables or fruits Try to eat soft, fleshy fruits
    19. 19. RECOMMENDED FRUITS AND VEGETABLES ON A LOWFIBER 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. 20. FRUITS AND VEGETABLES TO AVOID ON A LOW FIBERDIET: 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. 21.  Enteral Nutrition Therapy Specific Carbohydrate Diet Maker’s Diet
    22. 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. 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. 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. 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. 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. 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. 28.  Probiotics/Prebiotics Omega-3 fatty acids Herbal supplements Multi vitamins/ minerals Oral nutrition supplements
    29. 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. 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. 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. 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. 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. 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. 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. 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