Crohn’s disease: help your nutrition clients deal with it

Crohn's disease is an inflammatory bowel disease. It can occur anywhere in the GI tract, from the mouth to the anus, but is most common in the ileum and colon. The area of inflammation may be small or may extend interspersed throughout the GI tract, and may affect several layers of tissue.

In this article we tell you all about this disease and the nutritional support that should be given to these patients.

About Crohn's disease

The exact cause of Crohn's disease is unknown, but in light of current evidence, it is thought to be a combination of genetic, environmental, and immune system factors.

Each time the immune system is activated by a pathogen, such as mycobacteria, pseudomonas or listeria, there is a dysregulated immune response that leads to further inflammation. The inflammation spreads, and the immune system progressively "invades" the mucosa and goes deeper and deeper. The immune cells try to "swallow" all the cells they consider harmful and destroy them, which can result in an ulcer on the intestinal wall.

What are the symptoms of this disease?

The symptoms of Crohn's Disease can range from mild to severe and vary from person to person. They can change over time, with periods of remission and periods of flare-ups or attacks. They also differ depending on the site of inflammation.

However, the most common symptoms are abdominal pain and diarrhea, blood in the stool, tiredness, and fatigue. These symptoms have multifactorial causes, either from the disease itself or from causes associated with the disease, such as weight loss as a result of flares/aggravations or sleep deprivation if you get up frequently at night with pain or diarrhea. Generalized malaise, mouth ulcers or canker sores, and loss of appetite are also reported.

If in appointment the client mentions the presence of diarrhea and/or blood in the stool, it is important to be aware of a possible localized injury in the large intestine. The blood that comes from the damaged intestinal wall comes out in the stool. As the intestinal wall is damaged, the cells lose their ability to absorb water, which causes water to be excreted along with the stool and causes diarrhea. If the tests detect a vitamin or mineral deficit, or even anemia, the location of the lesion should be in the small intestine. This is the site of absorption of various nutrients, which causes malabsorption of nutrients, leading to nutritional deficits.

Crohn's Disease can also cause problems beyond the intestines, developing pathologies that affect areas such as:

• The joints, with the onset of arthritis, with special focus on the arms and legs; 
• The eyes, the most common disease being episcleritis, which turns the layer of tissue that lines the sclera (the white area of the eye) red, sore, and inflamed; ; 
• The skin, with erythema nodosum, consisting of painful skin nodules;
• The bones, with individuals with Crohn's Disease being at greater risk of developing osteoporosis; 
• The liver, with the possible appearance of gallstones;
• The kidneys, resulting from the fact that inflammation in the small intestine causes malabsorption of fat, which binds to calcium. This leads to increased levels of oxalate, which is then absorbed and deposited in the kidneys, where it can form stones.

These are called extraintestinal manifestations and occur frequently during the active phase of the disease, and most are uncommon. Nonetheless, it is important to be aware, during the appointment, of any signs or symptoms that the client may mention.

What is the treatment?

Crohn's Disease is usually described as chronic, which means that it is permanent and incurable. However, medication helps control gastrointestinal symptoms by reducing the levels of bacteria in the gut and the immune response.

Nutritional Treatment

Nutritional therapy is an important aspect in the management of Crohn's disease. As highlighted previously, people with Crohn's disease tend to experience malnutrition and weight loss due to diarrhea, abdominal pain, and a decreased ability to absorb nutrients from food. This, of course, has an impact on their nutritional status. As such, here are some recommendations:

• Dietary changes: A diet low in dietary fat and fiber may be recommended to help reduce symptoms. Some people may also benefit from enteric diets for a short period of time. 
• Supplements: Vitamin and mineral supplements, such as iron, vitamin B12, and calcium, may be recommended to help correct any deficiencies, mainly in the form of an injection.
• Parenteral nutrition: Involves obtaining nutrients intravenously. Can only be performed in a hospital setting and is used when a person is unable to obtain sufficient nutrients through food or enteric nutrition.
  
  

What to prioritize and what to restrict?

Cereals

Cereals are common staple foods. Whole grains are often considered to provide the most nutritional benefits, because they are rich in fiber and nutrients. However, when the disease is in an acute stage, the presence of fiber can be problematic. Therefore it is suggested to limit the amount of whole grain intake. According to the Crohn’s and Colitis Foundation of America (CCFA), individuals with Crohn's disease may benefit from a low-fiber low-residue diet to help manage intestinal stress and flare-up symptoms.

Prefer:

• Rice and rice pasta
• Potato
• Corn flour and polenta
• Oatmeal
• Gluten-free bread

Avoid:

• Whole wheat bread
• Whole wheat pasta
• Rye and rye products
• Barley
  
  

Fruits and vegetables

Fruits and vegetables have numerous health benefits, but can be problematic here since, like cereals, they are high in insoluble fiber.

However, it is not advisable to remove all fruit and vegetables from the diet. They can be processed in different ways to make them easier to digest. For example, steaming or boiling them in water can make them more easily digestible. Nonetheless, this process makes them susceptible to loss of important nutrients, especially vitamins and water-soluble enzymes. It is important to be aware of possible nutritional deficits.

Prefer:

• Apple puree
• Boiled vegetables 
• Peeled cucumbers
• Peppers 
• Bananas
• Melon
• Pumpkin

Avoid:

• Apples with peel
• Broccoli
• Kale
• Cauliflower
• Artichoke
• Cherries
• Peach
• Plum
  
  

Protein 

As far as protein is concerned, it should be selected on the basis of its fat content. Thus, protein with the lowest possible fat content should be chosen.

Prefer:

• Eggs
• Fish
• Seafood
• White meat
• Tofu and other soy products

Avoid:

• Red meat
• Sausages
• Deli products
  
  

Dairy Products

Sometimes dairy tolerance is not the greatest, so some substitutes are advised. 

Prefer:

• Vegetal drink
• Vegetal yoghurt
• Vegetal cheese
• Low fat fermented dairy products, like kefir

Avoid:

• Butter
• Dairy products (cream, bechamel)
• Margarine
  
  

Spices and Seasonings

Spicy foods can act as an aggressor to the gastrointestinal tract and aggravate symptoms. As such, excessively spicy seasonings should be avoided.

When it comes to the use of olive oil, it is recommended and should be preferred over the use of other fat sources (such as oils, butters, or margarines), due to their anti-inflammatory properties. 

Prefer:

• Turmeric
• Ginger
• Fresh Chives 
• Cumin
• Lemon zest
• Fresh herbs
• Mustard

Avoid:

• Allspice
• Black pepper
• Cayenne pepper
• Chili
• Jalapeños
• Garlic
• Onion 
• Paprika
• Wasabi
  
  

Beverages

The drinks of choice should be water or caffeine-free infusions. Carbonated, caffeinated, or alcoholic beverages should be avoided. 

Summary

It is important to analyze all the signs and symptoms that the client presents and develop a personalized nutritional plan. Always keep in mind the main goal: to maintain good nutrition and avoid malnutrition, as malnutrition can worsen Crohn's disease and lead to other health problems.

When it comes to the type of diet to recommend, there is no standardized nutritional treatment. There is a tendency to use a diet low in FODMAPs as one of the therapeutic approaches, however, this may not be suitable for all individuals. So, the approach should be made taking into account the various food groups mentioned above and with maximum attention to the client's body's tolerance and acceptability of the diet.

References

Examine, Crohn's Disease. https://examine.com/conditions/crohns-disease/ 

Watt, A. (2020, 20th November) Causes of Crohn’s Disease. Healthline. https://www.healthline.com/health/crohns-disease/causes 

Cherney, K (2022, 21st October) Crohn’s Disease Diet: Nutrition Guide. Healthline. https://www.healthline.com/health/crohns-disease/nutrition-guide 

Lichtenstein, G. R., Loftus, E. V., Isaacs, K. L., Regueiro, M. D., Gerson, L. B., & Sands, B. E. (2018). ACG Clinical Guideline: Management of Crohn's Disease in Adults. The American journal of gastroenterology, 113(4), 481–517. https://doi.org/10.1038/ajg.2018.27 

Crohn’s and Colitis UK, (2021, April) https://crohnsandcolitis.org.uk/info-support/information-about-crohns-and-colitis/all-information-about-crohns-and-colitis/understanding-crohns-and-colitis/crohns-disease 

Vrdoljak, J., Kumric, M., Vilovic, M., Martinovic, D., Tomic, I. J., Krnic, M., Ticinovic Kurir, T., & Bozic, J. (2022). Effects of Olive Oil and Its Components on Intestinal Inflammation and Inflammatory Bowel Disease. Nutrients, 14(4), 757. https://doi.org/10.3390/nu14040757