Lorraine Maher, specialist Gastroenterology Dietitian

Lorraine is a dietician, who works in the Blackrock Clinic, with a special interest in gut health. 

There are different approaches to diet during a flare and during remission. Regardless of disease, try not overly restrict your diet. Severe restrictions in your diet are the number one cause of weight loss in IBD and weight loss is the number one cause of malnutrition. Support from a dietician is warranted if you struggle identifying food intolerances and/or are losing weight.

?Diet in Active Disease State (during a flare):

The advice changes, but depends on the person:

• If you are in an active stage of the disease, the focus should be on meeting nutritional requirements, rather than restrictive aspects of diet.
• The most effective approach may be to ‘eat little and often’ – smaller frequent meals are better tolerated and can maximise overall nutrition status. If you find that you’re eating, say, less than 50% of your normal intake, you’re running the risk of becoming malnourished. You should think of supplementing your diet, possibly with an oral nutrition supplement which can be recommended by your GP or a dietitian.
• Avoid foods that may increase bowel frequency, such as large quantities of fruit, juices, smoothies, prunes, cruciferous vegetables and caffeinated drinks
• Decrease your alcohol consumption.
• Consider taking a multivitamin and mineral supplement if your appetite is poor and solid foods are not tolerated well. Specific nutrient supplement may be required if you are low in, for example, iron, folic acid, calcium, B12. Remember nutrient deficiency does not always correlate with dietary intake, so should be monitored, particularly in a flare. Your GP or consultant should monitor this for you
• Adequate fluid is really important to avoid dehydration – drinking up to 2L of water a day is recommended
• Sometimes with an inflamed bowel, you may not be able to tolerate dairy. That may be just temporary. You’ll have an idea whether dairy, such as milk or yogurt, is making your symptoms worse and you may switch to lactose-free products or plant-based alternatives at that time. Remember that in many cases this is transient and once the inflammation reduces, you probably will be able to tolerate dairy again,
• A low fibre diet may be appropriate – some people find it can be helpful if the symptoms you’re experiencing are particularly bad. However, a low fibre diet is really only necessary when you are experiencing a fistula or stricture. A dietitian can help you find the optimal balance of fibre in your diet.
• If you have oily or foul-smelling stools, you may have fat malabsorption, due to the inflammation. This may respond well to a low-fat diet. Again it’s worth discussing this with your doctor or dietitian.

Diet Progression following a Flare

When you know the inflammation has reduced, the guide would be to continue to eat what you can tolerate and slowly add back any foods you were omitting so as to diversify your diet. It best to take it slowly, Ultimately, how you will progress depends on you and your particular circumstances.

If you were particularly restricted in the flare up, begin with soft solids (well cooked food that doesn’t need a lot of chewing and has no hard pieces) and then progress to solid food.

You might take a systematic approach, by introducing one or two items every few days to avoid any foods that worsen symptoms. If you ate something one day that made things worse, maybe just eliminate that food (or maybe try again with a smaller portion) or leave and retry a few months down the road again. Don’t think of it as being cut out of your diet forever.

A sensible long term approach would be to increase fibre in your diet as tolerated. Fibre comes from a variety of plant based food – whole-grains (for example bread, rice, potatoes) beans and lentils, fruit, vegetables, nuts and seeds. You may find introducing more soluble fibre sources is better tolerated for example, oats, linseeds, orange, passionfruit, carrots, beans and pulses.What you tolerate tends to be very individual, and that’s where a gut health dietitian can be of much assistance!

If you unintentionally lost weight during the flare up, you should aim to increase total calorie and protein intake following a flare, until you get back to your desired weight. Overall between flares, when you’re in remission, the best approach is to eat as wide a variety of foods as you can tolerate, including fruit, vegetables, whole grains, lean protein, oily fish and moderate intake of dairy products. That will positively impact your overall nutrition status and enhance gut health.

These are some suggestions for first foods that you can have during a flare:

• Ready Brek, Rice Krispies, sometimes porridge, Special K, cornflakes
• Milk yogurt custard, rice pudding – if you tolerate dairy, otherwise you can find plant-based versions of these foods
• Lean protein such as plain tender chicken, turkey or fish
• Steamed or mashed well-cooked vegetables, eg, carrots, parsnips, squash, tomato sauce, bell peppers, peeled cucumber, pumpkin
• Eggs are a great source of overall nutrient content, particularly of protein
• Mashed potatoes, rice or noodles, so you’re getting the idea that they’re soft and easy to digest foods
• In terms of bread, people generally tolerate sourdough or white or spelt
• Limit your intake of juice, because juice can be a trigger for looser stools. Small quantities of juice (up to or less than 150 ml) or diluted juice
• You can stew your fruits or use canned fruits, so you can remove the skin to limit that insoluble fibre. Soft fruits are generally well-tolerated, such as banana, cantaloupe or melon