If you have recently been diagnosed as having ulcerative colitis or Crohn's disease, your first reaction might have been one of shock that you have an illness which could affect you for the rest of your life. You may also have felt some relief that at last you have a diagnosis, which explains why you may have been feeling so tired and unwell. There may now be many questions running through your mind ? an important one being "What can I eat?" We hope this article will help you to understand more about how your diet can affect you and the sort of foods you can eat.

What is inflammatory bowel disease?

Inflammatory bowel disease (IBD) refers to the inflammatory conditions of the intestine known as ulcerative colitis and Crohn's disease. In both, the intestines become swollen, inflamed and ulcerated. Ulcerative colitis involves the colon or large intestine.

Crohn's disease can involve any portion of the gastro-intestinal tract from the mouth to the anus. Another distinguishing feature of Crohn's disease is that the inflammation characteristically extends through all layers of the intestinal wall, whereas with ulcerative colitis, it affects only the lining of the colon. Sometimes it is easy to distinguish ulcerative colitis from Crohn's disease ? if inflammation in the small intestine or elsewhere is seen, then the diagnosis is Crohn's, since ulcerative colitis is confined to the colon (large intestine). However, if there is only inflammation in the colon, it could be ulcerative colitis or Crohn's. In this case, different tests are used to look for the pattern of inflammation that is unique to Crohn's.

Symptoms

There is a wide variety of symptoms commonly associated with inflammatory bowel disease and may include fatigue, poor appetite, weight loss, abdominal pain or cramping, nausea, diarrhoea, bloody diarrhoea (more likely in ulcerative colitis), urgent and frequent bowel movements, anaemia, fever, arthritis, eye problems, skin changes such as mouth ulcers and blood vessel problems. Rarely, people may note constipation as a presenting feature.

Complications specific to ulcerative colitis include perforation of the colon, dilation of the colon (toxic megacolon) and strictures or narrowing of the colon. Complications related to Crohn's disease include gallstones, intestinal narrowing leading to obstruction, and abnormal tracts (fistulas) between adjacent tissues. Additionally, one of the first signs of Crohn's disease in children is failure to thrive or poor growth. The symptoms will vary in severity from person to person, and may flare up or improve at different times. Many patients will experience short or long periods of remission, when they are free from symptoms ? cycles of exacerbation and remission. Only in rare cases, when complications occur, is the disease fatal.

What causes ulcerative colitis and Crohn's disease?

Although there has been much research, so far the causes are unknown. Auto-immunity plays a role in this disease, but the factors that trigger it are not all known. There have been many suggestions such as viruses, bacteria, diet, stress and smoking, but there is no definite evidence that any one of these is the cause of inflammatory bowel disease. A family history of IBD may increase risk.

How is IBD treated?

While there is no medical cure for IBD, several medications ? including sulfa drugs, corticosteroids, immunosuppressive agents and antibiotics ? are used to reduce inflammation of the bowel tissue, permitting healing of the bowel and relief of symptoms. Promising new drugs are often being evaluated in clinical trials conducted at certain medical centres. Other drugs may be given to relax the patient or to relieve pain, diarrhoea or infection. When medical treatment does not control the disease, or when the side effects of steroids or other drugs threaten a person's health, surgery may be the treatment of choice.

Surgical removal of the diseased bowel for Crohn's disease offers temporary relief; it is not a permanent cure because the disease is likely to recur. Narrowed areas (called strictures) cause special problems in Crohn's disease, especially when they occur in the small intestine, because they can lead to partial or complete blockages in the bowel. Surgical removal of the effected area may lead to a condition called short-bowel syndrome, in which not enough bowel is left to absorb adequate nutrients from food. For ulcerative colitis, surgery to remove the large intestine with or without the rectum, is a permanent cure. An opening, called a stoma, is made in the abdominal wall ? stool passes through this opening and collects in an external pouch. This procedure is also sometimes used to treat people with Crohn's disease.

About 20 to 25 percent of ulcerative colitis patients eventually require surgery for removal of the colon, however most people with ulcerative colitis will never need to have surgery. If surgery ever does become necessary, you may find comfort in knowing that after the surgery, the colitis is cured and most people go on to live normal, active lives.

Colon cancer risks

Inflammatory bowel disease increases the likelihood of gastro-intestinal cancers but ulcerative colitis places the patient at a higher risk than Crohn's disease. People with ulcerative colitis face an increased risk of developing colon cancer, especially if the entire colon is involved and the disease exists for many years. It's important, therefore, to look for early signs that cancer may be developing. If the doctor finds evidence of pre-cancerous changes (dysplasia), it means the patient is more likely to develop cancer and should receive regular follow-up exams.

Aetiology of malnutrition

Because of direct involvement in the gastro-intestinal tract, IBD presents nutritional problems which need to be recognised and managed. During an attack of ulcerative colitis or Crohn's disease there are increased nutrient requirements with increased cell turnover, fever and diarrhoea leading to loss of protein, calories, minerals, vitamins and electrolytes. However, chronic risk for undernutrition occurs in those afflicted with Crohn's disease rather than ulcerative colitis. People can become malnourished for a variety of reasons:

  • Anorexia (loss of appetite) leading to decreased food intake can be disease-induced from avoidance of food due to abdominal pain, diarrhoea and nausea.
  • Malabsorption may occur due to decreased intestinal absorption from the disease or resection. Up to 50 percent of the small intestine can be resected without significant problems. If resection of greater than 75 percent resection occurs then severe malabsorptive problems ensue. Also, specific areas of resection or disease can pose problems. For example resection of the duodenum, which is the first portion of the small intestine, can lead to malabsorption of iron, calcium and folate. Resection of the terminal ileum or disease involving that area may lead to vitamin B12 deficiency because this is where B12 is normally absorbed. Vitamin B12 deficiency is uncommon in ulcerative colitis. Bile salt deficiency after ileal resection may lead to fat malabsorption and concurrent fat-soluble vitamin (vitamins A, D, E, and K) malabsorption. Additionally, the enzyme (lactase) in our intestine that helps us digest milk sugar (lactose) may be in short supply if that part of the intestine is diseased or surgically removed (the jejunum).
  • Medications prescribed in the treatment of IBD may lead to specific deficiencies if supplementation does not occur. Corticosteroids may decrease calcium and vitamin D absorption. Sulfasalazine interferes with folate absorption, and aggravate hypersensitivity and intolerances. Cholestyramine affects fat soluble vitamin absorption if given in high amounts.

    How important is my diet?

    The goals of dietary intervention may differ depending upon the age of the patient. For example it is known that 15 to 46 percent of the paediatric population suffers from growth failure and a diet plan for that group may be quite different than for the adult with IBD. Also the extent of surgical resection, location of the resection and the activity of the disease all play a role as to what will be the focus of diet plan.

    While no special diet for IBD is given, patients may be able to control mild symptoms simply by avoiding foods that seem to upset their intestine. Overall, the most important consideration is for adequate calories, protein, minerals, vitamins and water to maintain a good nutritional status. When regular food alone does not seem to be maintaining growth or weight, nutritional supplementation may be warranted. A doctor may screen for certain deficiencies or refer a patient to a dietician to offer an individualised nutritional care plan. Different disease states will dictate specific alterations in the diet but with a good understanding of basic nutritional practices, a healthy diet may be achieved.

    Eating a healthy balanced diet is as important for the person with Crohn's disease or ulcerative colitis as it is for anyone else. During a severe attack, it is particularly important to eat well to replace lost nutrients.

    It is common to have pain after eating. Usually, it's not related to the diet itself, but rather the response of the intestine to eating the food. If you find that you can eat a normal mixed diet without any ill effects, then continue to do so.

    You may find that some foods seem to make your diarrhoea worse, such as fruits, nuts, spicy or fatty foods. If these seem to affect you, it is worth reducing the amount you eat or avoiding them altogether. Other dietary facts to consider:

    Low fibre diets are used for those patients with active phase of the disease or when strictures arise to prevent obstruction. Avoid large amounts of roughage and fibre, such as hard fruits, raw vegetables, whole wheat breads and cereals. Stay away from anything that has visible seeds eg strawberries, kiwi fruit, cucumbers, baby marrow, corn etc, as these may irritate the lining of the gut. Also, remove any skins of fruit and veggies.

    Cook all vegetables and only eat soft fruits that will be gentle on the gut. Nuts and dried fruits are also another form of roughage and should therefore not be eaten. You will slowly introduce these foods as your condition improves. High-fibre diets are recommended during remission periods to aid in bowel health.

    Fat restriction may be imposed on patients with short bowel syndrome where fat malabsorption may occur. Eat a low-fat diet and adopt low-fat cooking methods. This type of dietary restriction is also used to prevent calcium deficiency. Unabsorbed fatty acids can bind with calcium and form soaps, making the calcium unavailable. Decreasing the fat intake may lessen steatorrhoea (fatty diarrhoea).

    Lactose reduction may be quite an important part of the diet. Symptoms of lactose intolerance include abdominal cramping, gas, bloating and diarrhoea. Those people with Crohn's disease involving the jejunum are more at risk for lactose intolerance.

    It is important to sort out symptoms of active Crohn's disease from lactose intolerance. Also it is important to note that many people with lactose intolerance, including those with IBD, can tolerate a small amount of lactose in their diet while others require stricter avoidance. It is also necessary to recognise the fact that many people with IBD are not lactose intolerant. In some cases, the intolerance may even be temporary depending on the activity of the disease. Milk products are rich in many valuable nutrients such as protein, calcium, phosphorus, iodine, niacin, riboflavin, vitamin B12 and vitamin D. Dairy products vary in their lactose content, for example, cottage cheese and yoghurt have small amounts of lactose compared to other dairy products and are therefore well tolerated.

    Here are some other suggestions:

  • Strictly avoid alcohol, caffeine-containing beverages, all other sources of caffeine, and all stimulant drugs.
  • Avoid products sweetened with sorbitol or fructose as these can aggravate diarrhoea.
  • The diet should provide adequate protein to support active phase of disease.
  • Controlling stress and avoiding foods that cause immediate discomfort may reduce aggravation of symptoms.

    Nutritional supplements that may be helpful:

    Omega-3 fish oil has anti-inflammatory activity. As a result, researchers have studied the effects of fish oil in the treatment of UC. In a four-month, double-blind trial, people with UC who were given fish oil required lower levels of prescription anti-inflammatory drugs. Other improvements were noted (such as weight gain), all of which suggested better health. Another study found a modest reduction in the need for anti-inflammatory steroids but no benefit when people were experiencing no symptoms. Other research shows at least some positive effects from the use of fish oil for people with UC.

    Your doctor should be consulted before long-term use of more than 3 to 4 grams of fish oil, since a high intake has been reported to elevate blood sugar levels. Side effects from omega-3 fatty acids include nose bleeds (because of reduced blood clotting), gastro-intestinal upset, and "fishy" burps.

    Glutamine may be useful for ulcerative colitis because this amino acid serves as a source of fuel for cells lining the intestines and is important for immune function.

    Inflammatory bowel disease is a disease with an unpredictable course. But advances have made it easier to manage and research promises more options for future treatment. As can be seen from this article, diet plays an important role in the management of this disease, but is something that can still be enjoyed.