A question recently came to the ImproveCareNow Registered Dietitian (RD) group about how to choose foods that promote healthy weight loss and control hunger without causing a flare of gastrointestinal (GI) symptoms. By answering questions from our community, the RD group aims to provide valuable tools and information for patients and families to better understand the role of nutrition in managing Inflammatory Bowel Disease (IBD). The RD group encourages partnerships between patients and their care teams, including dietitians, so together they can design a dietary plan to avoid food-related complications from IBD and promote healthy weight maintenance.
Inflammatory Bowel Disease (IBD) frequently causes patients to experience malnutrition and deficiencies of vitamins and minerals. To combat these problems ImproveCareNow has established a Nutrition Algorithm for care teams to follow to concentrate on countering significant weight loss and nutrient depletion. Currently 90% of patients in ImproveCareNow have satisfactory nutrition status. Once satisfactory nutritional status has been achieved, there is another side to IBD nutrition: establishing a healthy diet for weight loss or maintenance.
The Fundamentals of IBD and Nutrition
An important component of managing IBD symptoms is the restriction of trigger foods (foods that cause GI symptoms such as abdominal pain and/or frequent, loose stools). Trigger foods are generally high in fiber or fat, and they may contain lactose, caffeine, alcohol, sugar alcohols, or spicy flavors. Do you know what your trigger foods are? It is important to note that many patients with IBD are not bothered by any foods and don’t have a trigger food.
A simple and reliable tool for identifying foods that are associated with GI symptoms is to keep a food journal. A food journal is a log of what you eat and how certain foods make you feel. A basic food journal template is available on page 59 of the Self-Management Handbook, which you can download for free.
Some patients may have multiple trigger foods in a single food group. Restricting a large number of foods, or a whole food group, can cause patients to avoid other healthy foods such as dairy products, fruits, vegetables, and whole grains. Although IBD may be managed well, and symptoms controlled with restriction of these healthy foods, this can lead to nutritional imbalance and weight gain.
Typical weight management strategies, such as balanced nutrition and portion control, may not seem compatible for a person with IBD. However, the basics can still apply, with some simple modifications. The USDA designed MyPlate to depict a simple model of balanced nutrition and portion control. Fruits, vegetables, grains and protein divide the plate into four quadrants, and a dairy product is included on the side. Vegetables (generally the least caloric food group) make up the largest quadrant. Concentrated sweets and junk foods are excluded from the plan.
Based on the MyPlate model, it would appear that a person who identifies high fiber foods (such as fruits and vegetables) as trigger foods might restrict half the items on this plate! Fortunately, this does not have to be the case. Commonly patients with IBD experience unique trigger foods within certain food groups. Once these foods are identified they can be removed or often modified to improve their tolerability. Remember the food journal? This simple tool is a great way to track and identify specific trigger foods and monitor responses to any food modifications. Here are some common trigger foods and modification tips listed by food group:
Vegetables are naturally high in fiber. The fiber (roughage) in leafy greens and raw vegetables tends to cause the most trouble. Peeling, cooking and/or pureeing vegetables reduces roughage and often eases digestion. Juicing raw vegetables removes fiber and may be necessary for particularly sensitive individuals. Limiting gas-producing vegetables may also provide relief. Gas-producers vary from person to person, but often include the cruciferous family such as broccoli, Brussels sprouts, and cabbage.
Like vegetables, fruits are high in fiber and may be tolerated poorly. Raw fruits, dried fruits and/or fruits with skins and seeds are the most problematic. Soft or processed fruits, such as melon, ripe bananas, and applesauce, are the easiest to digest. Peeling, cooking, pureeing, or using natural canned fruits is helpful. If you’re juicing, mixing fruit juice with vegetable juice improves the flavor tremendously. However, juicing fruit produces a concentrated source of sugar, and portions should be limited to four ounces per day.
The fiber content of unprocessed grains makes them difficult to digest. People with IBD often find it helpful to avoid products made with whole grains. More refined grains with less insoluble fiber are tolerated better, such as refined breads, white rice, regular pastas, noodles, porridges and refined cereals. As it is tempting to overeat in this food group (e.g. the entire breadbasket at an Italian restaurant), portion control is important for healthy weight maintenance.
Lactose intolerance can occur in IBD. When excluding dairy from the diet, it is important to replace calcium and vitamin D with an appropriate alternative. There are many good options to choose from! Lactose free milk, almond milk, coconut milk and rice milk are alternatives that are available in low-fat or light varieties. Low fat yogurt made from dairy may be tolerated, and it is a source of probiotics that may help with IBD. Interested in joining a conversation with patients and parents about the role of probiotics in IBD? Join the community on Smart Patients.
Protein foods are generally well tolerated; especially lean meats, poultry, eggs, nut butters, and tofu. However, whole nuts, seeds, and beans are more difficult to digest. Processing these protein foods eases digestion. For example, peanuts can be blended into peanut butter, sesame seeds into tahini, and garbanzo beans into hummus. Eating a protein at each meal helps to curb appetite. Generally, lean proteins should be portioned at three ounces or less (three ounces is approximately the size of a deck of cards), and higher fat proteins should be portioned at about one ounce (e.g. one whole egg or two Tbsp. peanut butter).
Sample daily meal plan (1600 calories)
Breakfast: 1 cup oatmeal with 1 cup light soy milk and 1 banana with 2 Tbsp. peanut butter
Mid-morning snack: 1 cup low-fat plain Greek yogurt with 1 cup diced cantaloupe
Lunch: 2oz turkey burger open-faced on ½ potato bun with 1 cup roasted carrot “fries”
Mid-afternoon snack: Green juice made from kale, celery, cucumbers, ginger, and green apples
Dinner: 3oz lean meat loaf, ½ cup mashed sweet potatoes (skin removed), steamed asparagus, and 1 cup almond milk
Dessert: ½ cup natural applesauce with cinnamon and 1 full graham cracker
Each patient will have dietary restrictions and needs that are as unique as they are. The recommended approach for all patients is to partner with their care team and, when possible, incorporate the support of a registered dietitian. Patients and RDs will work together to identify foods to avoid, figure out food modifications to try, and develop a personalized diet to minimize GI symptoms while promoting healthy weight and nutrition.
Connecting with an IBD community is helpful for many patients and families. Smart Patients hosts a forum for peers to share their experiences, knowledge and insight. Many lively discussions concerning diet and IBD have already begun: http://www.smartpatients.com/ibd.
Kari Vagstad, RD
Clinical Dietitian, Children’s Hospital of the King’s Daughters, Norfolk, VA
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