Crohn's disease: My Diet During a Flare Up

Crohn’s disease is a type of inflammatory bowel disease (IBD). Crohn’s disease is a lifelong condition that can cause inflammation of any part of the gut from the mouth to the anus (bottom). All layers of the lining of the bowel may be inflamed and it most commonly affects the small and large bowel.

Crohn’s disease impacts the bowel in cycles. When symptoms are stable with no active disease this is known as remission. When symptoms flare up and there is active disease this is known as a Crohn’s Disease flare up.

The cause of Crohn’s disease is not fully understood. Several factors are involved including genetics (you are more likely to live with Crohn’s disease if you have a family member who has the condition), an over-active immune system and environmental triggers e.g. smoking. No known cure is currently available. However, remission can be achieved and managed through medication and diet. In some cases, surgery may be required.

• Diarrhoea sometimes with blood or mucus.
• Fever.
• Abdominal pain (cramps).
• Blood in the stools.
• Weight loss.
• Pain in the abdomen (tummy area).
• Lack of energy / tiredness

Some people may experience:

• Swollen joints
• Mouth ulcers
• Inflamed eyes or rashes on their body

A common condition associated with Crohn’s disease is malnutrition. This is where there is a lack of the important nutrients like energy and protein to keep our bodies functioning effectively. This is especially common during a flare up where inflammation of your gut reduces its ability to absorb these nutrients. Additionally, symptoms like diarrhoea, abdominal pain, tiredness, cramping, and loss of appetite, can reduce the amount of food we eat, which reduces the amount of important nutrients obtained from your diet.

This can result in:

• Weight loss (including loss of muscle
• Vitamin and mineral deficiencies
• Muscle wasting
• Weakness, tiredness, and poor concentration
• Poor wound healing resulting in increased surgical complication risk.

This means that it is important to be well nourished during a flare up to ensure your body is well fuelled to promote healing and reduce the impact of inflammation on your gut.

It is strongly recommended during a flare up to eat well to replace lost nutrients. If you find that you can eat a normal diet without any ill effects, then continue to do so.

You may find that some foods seem to make your symptoms 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.

Here are some tips to manage your nutritional intake

Where the bowel is under immense stress during a flare-up, your dietitian may recommend undertaking an exclusively enteral nutrition (EEN) diet for a period (usually 10 days to 8 weeks). This enables your bowel to rest and heal from inflammation by ensuring that nutrients are easy to absorb. This reduces the work done by the bowel to digest foods. You will be monitored and reviewed throughout this diet and offered information on the most appropriate liquid feed to provide essential nutrients to promote your health.

Aim to eat every 2-3 hours - this can be a small meal or snack. You should have around 3 small meals and 2-3 snacks. It’s important to choose high-energy, high-protein options as these requirements increase due to the inflammation occurring in the bowel.

During a flare-up, it can be difficult to eat enough to meet your increased protein requirements, especially with a poor appetite. However, adding high-energy foods to meals and snacks can increase your energy and protein intake without increasing the amount you eat. This can a done by adding whole milk, skimmed milk powder, butter, cream, and cheese to meals.

If you are unable to eat enough, additional nutritional supplements may be beneficial. These can be taken alongside your usual diet to help you achieve your increased energy and protein requirements. Your dietitian will provide more advice if these supplements are required.

Tips to manage symptoms

When appetite is low, is it important to have a high protein intake. This is because protein is essential to repair the body tissue, improve immune function and support muscle growth. For people with CD, it is recommended they eat at least 1.2g of protein per KG of body weight. For example, someone who is 80kg would need at least 96g of protein each day. This is higher than in remission due to the medications which treat active CD, increased breakdown of proteins and malabsorption when CD is active.

This could come from a range of sources, such as tofu, lean meats (chicken and turkey), eggs and dairy products (cheese, yoghurt etc). These sources are particularly good in flare ups as they do not exacerbate symptoms.

The role of dietary fibre

There are two types of fibre that can be found in your diet:

Insoluble fibre

Insoluble fibre is not easily digested by gut bacteria, nor does it dissolve in water. It rather soaks up water like a sponge and forms the bulk of stools. It helps stools to move quicker through the bowel.

Soluble fibre

Soluble fibre can be broken down by gut bacteria and forms a gel-like substance when it absorbs water. Intake of soluble can aid symptoms like diarrhoea (to slow down bowel movements) or constipation (to soften stools when consumed in even balance with water).

In some people who live with Crohn’s disease reducing their intake of insoluble fibre may reduce unpleasant symptoms of diarrhoea, abdominal pain, and flatulence.

Some sources of insoluble and soluble fibre

The way food is prepared may also reduce the impact fibre may have on your bowel. For example, tinned fruits and vegetables that have a lower fibre content, are suitable way to obtain need vitamins and minerals without increasing the risk of bowel obstructions. Furthermore, chopping, dicing, blending, or slightly overcooking fruits or vegetables breaks down the fibres and makes it easier to digest.

For further information see the bowel strictures and diet page.

Before undergoing any dietary changes, speak to your dietitian to provide you with guidance on how to do this appropriately.

Common nutritional problems and deficiencies

More than 50% of those living with an inflammatory bowel disease like Crohn’s disease are at increased risk of impaired bone health (osteoporosis) and various vitamin and mineral deficiencies. This is related to reduced food intake, inflammation causing malabsorption, and the use of certain medications like steroids used to manage the condition. Being deficient in certain vitamins and minerals can have negative effects on your overall health and cause long term issues like nerve damage and heart issues if left untreated. During a flare up, it is important to work alongside your dietitian and doctor to manage your vitamin and mineral levels to prevent deficiencies and maximise your overall health.

Common nutritional deficiencies

Having foods and drinks rich in vitamin C like orange juice, fresh fruits or vegetables with meals containing plant iron sources can be a great way to enhance your iron absorption.

There are certain compounds and minerals found in foods that reduce iron absorption like:

To increase the absorption of iron from your meals avoid:

• Mixing these foods.
• Consider drinking / eating sources of these compounds about 30 minutes after meals.

Iron 

Men need 8.7mg of iron and women need 14.8mg every day but these requirements may be increased during active disease.

Calcium

People with Crohn’s disease are currently advised to take 1000 mg per day.

Vitamin D

It is recommended during winter months for adults to take a daily vitamin D 10µg supplement. Some foods contain some vitamin D but not enough to meet your daily requirements. Before taking any supplements speak to your Doctor or Dietitian for more information.

Food allergy and intolerance

There is no clear link between Crohn’s Disease and specific food allergy or intolerance. However, some people find that their symptoms are triggered or made worse by certain foods. 

Avoiding food unnecessarily can lead to nutritional deficiencies, so always speak to your dietitian to help you check if your symptoms are related to specific foods and ensure your diet remains balanced. 

Lactose Intolerance

Many people with Crohn’s disease have a limited ability to digest the milk sugar lactose and so may need to follow a low lactose diet. If reducing your milk intake, it is important to ensure you still have plenty of calcium in your diet from other foods. Check with your dietitian if you require more advice on this.

When identifying certain suspected “trigger” foods (foods that are thought to increase your symptoms) it can be helpful to remove the suspected food from your diet and monitor your symptoms for a period and see if they reduce and then slowly reintroduce the food as tolerated. This is known as a food exclusion or elimination diet. This should be done with the supervision and advice of your dietitian and should not be done for an extended period as it may result in an inadequate diet. Alongside this completing a food and symptom diary can help you track your intake and foods that may show trends of causing unpleasant symptoms. 

After this a structured reintroduction diet can be followed with the guidance of a dietitian to help you do this appropriately and to maintain a balanced diet. This can help to maintain remission and manage your symptoms effectively. An example of a food re-introduction diet is the low fibre fat limited exclusion diet (LOFFLEX).  

A LOFFLEX diet is used to reduce the difficulty and time-consuming nature of food reintroduction and identification of problem foods. LOFFLEX stands for Low Fat/Fibre Limited Exclusion Diet. It is found that foods high in fat and fibre tend to cause unpleasant symptoms in those living with Crohn’s disease. For more information about re-introduction diets please consult your dietitian.

These types of foods are formulations of ingredients, typically created by series of industrial techniques and processes often including additives, preservatives and emulsifiers typically used to lengthen their shelf life, improve the flavour, texture, or even colour of foods.  

Many of these foods contain high amounts of salt, sugar, and saturated fats to improve flavour meaning that their regular consumption can poorly impact our health if consumed long term. Research has shown that regular intake of ultra processed foods such as crisps, biscuits, sugary cereals, instant meals (e.g., packet noodles and instant soups), fizzy drinks, sweetened yoghurts, and energy drinks are linked to conditions like heart disease and type 2 diabetes.  

There is no evidence to suggest ultra-processed foods cause Crohn’s Disease. However, research has shown that high intakes may exacerbate Crohn’s Disease symptoms because they have a negative impact on our gut bacteria and can activate inflammation in the gut. The following list of food additives have been cited in the literature to specifically link to gut inflammation should ideally be limited in the diet.

General information about IBD - Crohn's and Colitis UK  

Diet and IBD - Crohn's and Colitis UK

Osteoporosis and diet - BDA  

Crohn's disease - NHS UK

Tel Number: 0203 447 9289 

Fax: 020 7380 9811