Nutrition During an IBD Flare

Getting adequate nutrition during an IBD flare is very important to help support the healing of the gut, minimize weight loss, and prevent malnutrition. It can be challenging to do this, though, as many people have active symptoms in a flare that may interfere with eating. This handout will provide dietary strategies to minimize your symptoms while optimizing your nutrition.

Although everyone is unique in what foods trigger their symptoms, some of the more common food triggers are:

• Insoluble fibre, which is concentrated in the skins, peels, and seeds of fruits and vegetables, whole grains, and whole nuts and seeds.
• Lactose, a sugar found in dairy products; this is more common in people with a history of resections or active disease in their small intestine.
• Caffeine found in regular coffee, tea, Coke, and Pepsi.
• Alcohol such as wine, beer, and spirits.
• Spicy foods, particularly those containing chili and cayenne pepper.
• Fatty foods like chips, donuts, and deep-fried foods.
• Sugar alcohols (xylitol, sorbitol, mannitol, maltitol), most commonly found in sugar-free gum and candies, sugar-free drinks, and some protein bars; some of these are naturally occurring in foods but usually in smaller amounts than processed foods.
• Sugary foods and fluids like candy, pop, and juice.

There are many popular diets for IBD, including the Crohn’s Disease Exclusion Diet, Specific Carbohydrate Diet, and IBD Anti-Inflammatory Diet. For some people, specialized diets may be helpful in certain scenarios. However, they should be used with caution, as they restrict many types of foods. This can make it challenging to meet your nutrition needs. When possible, it can be helpful to get individualized guidance from a dietitian. Patients of the IBD Centre of BC are welcome to book an appointment with one of the Centre’s dietitians.

Strategies to Optimize Nutrition

1. Meal timing and spacing

Many people do better with 4-5 small meals/snacks that are spaced out throughout the day rather than large meals. For those that find this pattern overwhelming, aim to eat at least every 4-5 hours during the day. Some people choose to not eat for extended periods, but this can make it challenging to meet your nutrition needs and it may increase symptoms when you do eat.

2. Pace of eating

To help facilitate better digestion, try to chew your food well and eat slowly. Additionally, minimizing distractions and not multitasking while eating may help.

3. Include protein-rich foods

Your protein needs are higher during a flare than they are in remission. Aim to have one or more protein-rich foods or drinks with every meal and snack. Options include animal protein (meat, poultry, fish), dairy products (milk, yogurt, kefir, cheese), and plant-based protein (beans, lentils, chickpeas, nuts and seeds, soy products).

 4. Add sources of soluble fibre

Soluble fibre helps to thicken stool. It can be helpful both for constipation and diarrhea. Rich sources of soluble fibre include banana, oranges, avocado, oatmeal, barley, beans, chickpeas, ground flaxseeds, and chia seeds. Metamucil, psyllium husk, and partially hydrolyzed guar gum are soluble fibre supplements that can be helpful for some people. However, Metamucil and psyllium husk should be avoided in those with narrowing in their bowel.

 5. Nutrient-rich fluids

Some people find it easier to manage fluids rather than foods during flares. If this is the case, try focusing on having nourishing fluids like nutrient rich soups and smoothies, bone broth, milk (lactose free or a plant-based option if needed), and nutrition supplement drinks, like Boost, Ensure, or Sperri.

 6. Commonly well tolerated foods:

• Fruits: bananas, cantaloupe, honeydew, canned mandarin oranges, and avocado.
• Vegetables: soft, cooked vegetables that have had the skins, peels, and seeds removed (e.g., peeled zucchini, carrots, peeled sweet potato, squash).
• Protein rich foods: skinless chicken or turkey breast, skinless fish, eggs, lean pork and beef, firm tofu, split or pureed lentils and chickpeas, smooth nut and seed butters, and dairy products (lactose free if needed).
• Grains: white rice, white pasta, white crackers, quick cooking or instant oats, barley, couscous, polenta, and refined cereals (Rice Krispies, Cheerios, Crispix, Corn Flakes)
• Snack foods: pretzels, rice crackers, energy balls, and chia pudding

Managing Hydration During a Flare

It is important to get adequate fluid during a flare to prevent dehydration and support healing of the gut. Most people need around 2-2.5 L of fluid per day (8-10 cups), but needs may be increased with excessive diarrhea, vomiting, high ostomy output, high fistula output, exercise, and sweating.  Commonly well tolerated fluids include water, herbal tea, decaf coffee, bone broth, milk (lactose free if needed), and diluted juices. For those who have difficulty maintaining hydration due to high fluid losses, oral rehydration solutions can be helpful. Store bought options include Hydralyte and Pedialyte. You can also make your own by using a recipe like the one below:

• 4 cups water (use 3 cups if adding juice instead of sugar)
• ½ tsp salt
• ½ tsp No Salt® or Windsor Salt-Free Salt Substitute (potassium supplement)
• ½ tsp baking soda
• 2 tbsp sugar or 1 cup of apple juice, orange juice, or grape juice

Flavourings like lemons, limes, or zero-calorie sweeteners can be added, as long as they don’t contain regular sugar. However, it may be best to limit your intake of zero calorie sweeteners during a flare, as they may increase inflammation.

Supplements During a Flare

In addition to nutrition supplement drinks, like Boost, Ensure, or Sperri, there are supplements that may be helpful for people to take in a flare. These include a multivitamin/mineral supplement, vitamin D, fish or algae oil (if diet is lacking in omega 3 fats), and calcium (if diet doesn’t provide enough). Some people may need to take vitamin B12 if they have inflammation or have had resections of their small intestine as well as iron if they have anemia. It can be helpful to have lab work done to know what doses are needed for repletion, as well discussing this with your IBD gastroenterologist or dietitian.

For those who experience nausea, ginger (capsules, tablets, tea, or fresh) may be helpful. In ulcerative colitis, some people choose to try an evidenced-based probiotic. For ulcerative colitis and Crohn’s, there is some evidence that curcumin, when used in high doses, may decrease inflammation.

Non-Dietary Triggers and Strategies

There are other factors beyond just diet that can impact symptoms and inflammation, such as stress, sleep, and physical activity. Some people find non-dietary strategies helpful, such as mindfulness, meditation, yoga, cognitive behavioural therapy (guided by a counselor or psychologist) and gut-directed hypnotherapy.

 

Written by Gina Almasan, RD