Ulcerative Colitis: My Diet During a Flare Up

Ulcerative Colitis (UC) is a form of inflammatory bowel disease (IBD) which causes ulcers and inflammation to develop in the lining of the colon (large intestine/bowel) and rectum. These ulcers can bleed and produce mucus.

In UC inflammation can occur anywhere in the large bowel and rectum only.

The exact cause of UC is not fully understood. It is suggested to be due to a mixture of the immune system, genetics, variety of bacteria which is in everyone’s gut (gut microbiome) and environmental or lifestyle factors which contribute to UC.

The symptoms of Ulcerative Colitis varies from person to person and in their severity. Symptoms worsen during flare ups and include:

• Diarrhoea – frequent and often urgent bowel movements.
• Rectal bleeding – bleeding in the colon due to ulceration/inflammation which may be visible in stool or toilet paper.
• Fatigue – chronic inflammation, frequent bowel movements and nutritional deficiencies can lead to tiredness, weakness and lethargy.
• Abdominal (tummy) pain and cramping – discomfort in your stomach, including cramping and pain, particularly during bowel movements.
• Urgency and incomplete bowel movements - constant urgency for bowel movements and the feeling bowel movements are incomplete.
• Weight loss – a loss of appetite, intake of food due to fear of exacerbating symptoms may cause weight loss.
• Anaemia – iron deficiency causing pale skin, fatigue, and weakness.
• Fever – feeling ill and fatigued can occur during flare ups.
• Loss of appetite – abdominal pain and cramping can reduce the desire to eat.
• Joint pain – painful knees, elbows, and other joints.
• Dehydration – the loss of water and electrolytes due to diarrhoea. Signs include thirst, dry mouth, dark urine and dizziness.

The importance of nutrition in IBD is controversial. Many people with UC find what they eat affects their symptoms. Therefore, understanding diet and what works for you is extremely important, and although nutrition is not a cure of UC, it can help you manage the symptoms of UC.

During a flare up, the large colon is inflamed. Although the large colon is not a major player in the absorption of food, it plays a significant role in absorption of water, potassium vitamins & minerals, as well as being the site where “good” bacteria live and play a significant role in the breakdown of fibre. The combination of these crucial functions play a role in the symptoms and the management of these symptoms associated with UC.

Tips to manage your nutritional intake when experiencing a flare up

During a flare up, gut symptoms can be much worse and can greatly impact quality of life.

Understanding how different foods impact UC symptoms can support the relief of these symptoms.

Changing your dietary patterns can help reduce the symptoms associated with UC flare ups.

The following table summarises this.

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.

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 Ulcerative Colitis reducing their intake of insoluble fibre may reduce unpleasant symptoms of diarrhoea, abdominal pain, and flatulence.

Some sources of insoluble and soluble include:

Constipation

Some people with Ulcerative Colitis experience more constipation predominant symptoms during a flare up. If you are suffering with worsening constipation symptoms the following additional tips should help.

The following foods increase small bowel water content and so may help with laxation, aim to include fruit and vegetables from this list at both lunch and dinner every day.

Flaxseeds

There is some evidence that flaxseeds help with constipation and act like a natural laxative. The effect is likely gradual and it is recommended to take them daily for up to 12 weeks

Recommend to start with ½ tablespoon (6gms) and gradually increase to up to two x tablespoons over four weeks. They can be pre-soaked and added to breakfast cereals or smoothies or cooked with other meals containing liquid e.g., sauces or stews, sprinkled over your salad, yoghurt, porridge or stirred into soups. Please consume 150mls of water per tablespoon of flaxseeds to help them to move through your gut.

The following foods are good sources of soluble fibre:

If foods are not fully absorbed in the small intestine, they are partially digested by good bacteria in the colon, which produces gas (CO2). When an individual is not in a flare up due to the UC, this is a process which has positive health benefits. However, when the colon is inflamed, the gas produced causes abdominal pain and bloating, which are common symptoms during a UC flare up.

There are a range of foods which can exacerbate symptoms during a flare up, and more detail are provided on them below.

Certain types of carbohydrates

Carbohydrates are an important long-term energy source and are essential in a balanced diet. There are two main types of carbohydrates, simple carbohydrates (which include sugars in fruits, syrups, sweets and some vegetables) and complex carbohydrates (which include potatoes, most vegetables, cereals, pastas and breads).

Some simple and fibrous carbohydrates can exacerbate symptoms of UC as they cause the production of gas in the colon, which causes bloating and abdominal pain. Examples of these are shown below.

Therefore, during flare ups carbohydrates such as white rice, white bread, white pasta, and well-cooked / peeled vegetables are recommended as they are digested by the small intestine and will help manage the symptoms of UC.

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 UC, 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 UC, increased breakdown of proteins and malabsorption when UC 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.

Eating little and often can support you to keep getting sufficient nutrition whilst you are not hungry. Eating 3 snacks and 3 small meals throughout the day, spaced 2-3 hours apart can increase oral intake and prevent weight loss and malnutrition. These should be well-balanced and high in protein to support the increased protein requirements for active UC. Therefore, ensuring you choose high-protein options such as yoghurts, cheese, fish, chicken, eggs and tofu can help you achieve your dietary goals.

Furthermore, making the most of every mouthful is important. Fortifying oral intake with butter, full-fat milk and cream can support you getting enough nutrition whilst your appetite is low. This may be difficult during flare-ups, as food fortification with fats can make the symptoms associated with a UC flare-up worse. Focusing on complex carbohydrates, “healthy”, unsaturated fats such as avocados, nuts and olive oil, as well as eating more, smaller meals can support sufficient dietary intake whilst not exacerbating any UC symptoms.
This can be as follows:

7:00am – Breakfast

10:00 – snack

1:00 – lunch

16:00 – snack

19:00 – dinner

10:00 – snack

These should be well balanced and high in protein to support the increased protein requirements for active UC. Therefore, ensuring you choose high protein options such as yoghurts, cheese, fish, chicken, eggs and tofu can help you achieve your dietary goals.

Furthermore, making the most of every mouthful is important. Fortifying oral intake with butter, full-fat milk and cream can support you getting enough nutrition whilst appetite is low. This may be difficult during flare ups, as food fortification with fats can make the symptoms associated with a UC flare up worse. Focusing on complex carbohydrates and “healthy” unsaturated fats such as avocados, nut butters and olive oil, as well as eating more, smaller meals can support sufficient dietary intake whilst not exacerbating any UC symptoms.

A nutritional supplement may also be beneficial if you are struggling with appetite and oral intake. A dietitian will be able to provide advice if this is required.

Eating little and often can support you to keep getting sufficient nutrition whilst you are not hungry. Eating 3 snacks and 3 small meals throughout the day, spaced 2-3 hours apart can increase oral intake and prevent weight loss and malnutrition. These should be well-balanced and high in protein to support the increased protein requirements for active UC. Therefore, ensuring you choose high-protein options such as yoghurts, cheese, fish, chicken, eggs and tofu can help you achieve your dietary goals.

Fibre supports regular and healthy bowel movements. Fibre is a type of carbohydrate that comes from plant-based foods. The body does not fully absorb fibre, which means it is important in the formation of stool (poo).

There are two types of fibre:

• Soluble fibre, which absorbs water.
• Insoluble fibre, which does not absorb water.

Soluble fibre: Ensure to have a good daily intake of foods containing soluble fibre to increase stool weight (when taken in combination with foods that increase small bowel water content).

Ensure adequate fluid intake while increasing your fibre intake. Aim for 1.5-2 litres of fluid daily.

Increasing the portion of soluble fibre can support reducing constipation and diarrhoea. This is because soluble fibre is a gel like substance that makes stool softer, more easily passed and builds the stool, which will support more regular and easier bowel movements.

To support healthy bowel movements it is recommended to consume around 10g of sources of soluble fibre during a flare up. This includes white pasta, white rice, porridge oats, peeled fruit and vegetables with their seeds removed and golden linseeds.

During flare ups increasing carbohydrates such as white rice, white bread, white pasta, and well-cooked / peeled vegetables, tinned, stewed or peeled fruit are recommended as they are digested by the small intestine and will help manage the symptoms of UC.

Tips to manage diarrhoea symptoms

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.

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

Deficiencies of these micronutrients can result in a condition known as anaemia. This is linked to symptoms like fatigue, poor concentration, and dizziness. If deficiencies are not addressed, it can result in nerve damage and impaired immune function People living with an inflammatory bowel disease like Ulcerative Colitis 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 concentration, and dizziness. If deficiencies are not addressed, it can result in nerve damage and impaired 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 a and maximise your overall health.

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 Ulcerative Colitis are currently advised to take 1000 mg per day.

Vitamin D

Adults are recommended 10 μg per day for adults.

Food allergy is an abnormal immune reaction to the protein in food and can be diagnosed by a detailed clinical history.

Food allergy and intolerance

There is no clear link between Ulcerative Colitis 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

Some people with Ulcerative Colitis have temporary intolerance to dairy foods, especially during a flare up. If reducing your milk intake, it is important to ensure you still have plenty of calcium in your diet from other foods or use dairy free calcium fortified alternatives. 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.

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 Ulcerative Colitis. However, research has shown that high intakes may exacerbate UC 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