Ulcerative Colitis: My Diet during remission

UC is a form of irritable bowel disease (IBD) which causes ulcers (open sores) and inflammation to develop in the lining of the colon (large intestine/bowel) and rectum. These ulcers can bleed and produce pus.

The positioning of UC differs from Crohn’s disease. In UC inflammation can occur anywhere in the large colon only.

he symptoms of Ulcerative Colitis vary from person to person and their severity. They are generally worse in active UC. In remission the gut is healing, however, symptoms do still arise and the following symptoms are commonly found: 

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

The importance of nutrition in IBD is controversial. Patients 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 for UC, it can help your management for UC. 

During remission, people can go weeks or months or even years without any symptoms. Despite having no symptoms, diet is still important to get sufficient nutrients and energy to prevent malnutrition, allow your body to heal, and fight off infections. 

Although the large colon is not a major player in the absorption of food, it plays a significant role in the 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 plays a role in the symptoms and the management of these symptoms associated with UC.

Here are some tips for eating healthily during remission

Healthy eating is all about enjoying a variety of foods!

During remission, the symptoms of UC are partially, or completely gone. This is an important time to build healthy dietary habits and ensure you are sufficiently nourished. Goals may include regaining weight, eating more nutritious foods, and building up fibre intake. A dietitian can support you in identifying these goals. 

The eat well plate provides an excellent guide on how to develop a healthy, balanced diet. The principles of the healthy eating guide are as follows: 

• 5 portions of fruit and vegetables/day.
• Starchy carbohydrates (including bread, pasta and rice).
• Protein sources, including 2X portions of fish/week (one of these being oily fish e.g. salmon/mackerel/sardines). It is important to note legumes such as chickpeas, lentils and beans are a good source of nutritious proteins. 
• Dairy or dairy alternative products.
• Some unsaturated fats, olive oils and avocados are great healthy fat sources. 
• 6-8 cups of water/day. 

Protein

Protein is essential to repair the body tissue, improve immune function and support muscle growth. In remission, protein is not in as high demand as it is during the active state of the disease. Therefore, it is recommended we have around 1g/kg of body weight each day. For example, if you are 80kg, it is recommended you eat 80g of protein. 

Sources of protein include tofu, chicken, turkey, eggs, legumes (beans/lentils), pulses and red meats such as beef. Beans and pulses sources are great protein sources which have a low impact on the environment and support regular gut function as they contain fibre. However, increasing fibre should be done slowly (more information in the fibre section below). 

Furthermore, evidence suggests we should not eat red meat and processed protein sources more than twice a week (150g). This is because in excess they can increase the risk of colon cancer, therefore should be consumed in moderation.

Note: some plant-based protein sources may be ultra processed to imitate animal products e.g., plant-based sausages and burgers. This means they have high amounts of saturated fats, sugar and salt. It's important to eat these in moderation.

Carbohydrate

Carbohydrates are an important energy source and are essential in a balanced diet. They include bread, pasta, rice, fruits and vegetables. During remission, it is encouraged to eat healthy portions of carbohydrates with no restrictions. 

It is recommended we eat around of 30g fibre each day. The average person in the UK only consumes ~18g. Fibre can support healthy bowel movements, improves the diversity of “good” bacteria in the gut and supports immunity. 

However, after long periods of eating a low fibre diet, which is common during flare-ups to reduce symptoms, it is important to build up fibre intake slowly. This is because too much fibre at once upsets our stomach and can cause bloating and gas, which can cause abdominal pain, gas and bloating. Therefore, a gradual increase in fibre is recommended. 

Sources of fibre include: 

• Wholemeal bread
• Wholemeal pasta
• Broccoli
• Nuts, such as almonds and peanuts
• Peas
• Legumes e.g. kidney beans and chickpeas.

Fruit and Vegetables

These provide much needed vitamins, minerals, energy, and fibre to help keep your body functioning as usual. You may find that fibre from some raw fruits and vegetables may worsen your symptoms, so it may help to try cooked or tinned vegetables as these might be easier to digest. If you have a stricture (a narrowing in the bowel) this can help reduce the likelihood of blockages and their associated symptoms.

Examples include

Please note that some of these food items contain high levels of insoluble fibre which can worsen symptoms if you have a narrowing in your bowel (stricture). Please see the Diet and Stricture page for more information.

Fat

Fat is an important energy source and supports fat-soluble vitamin absorption (Vitamin A, D, E and K), hormone production and protecting internal organs.

It is recommended that fat does not constitute more than 30% of your daily intake and saturated fat intake is no higher than 30g/day for men and 20g/day for women.

Therefore, it is recommended to reduce fat. Methods such as choosing lean meats, such as chicken and turkey, cutting fat from meat, and grilling/baking foods rather than frying foods can support reducing fat intake.

Calcium rich foods

Dairy foods contain important vitamins and minerals such as calcium. Many people living with UC do not get the 1,000mg/day of calcium that is recommended. Calcium plays an important role in supporting bone health, reducing the risk of osteoporosis (brittle bones), bone fractures and the maintenance of strong teeth. It is important to note when taking corticosteroids you may need an additional calcium supplement as they reduce the body’s ability to absorb calcium.

Dairy is an important source of calcium. However, during flare-ups people may temporarily become intolerant to lactose, which means someone can develop loose stools, abdominal pain and bloating due to gasses produced in the stomach by undigested lactose. Therefore, people may rely on lactose-free sources of calcium (such as fortified plant milks and lactose-free alternatives).

After a flare-up, tolerance to lactose should gradually improve. However, it is important to remember to slowly build up your tolerance of lactose-containing products and ensure you get sufficient calcium from other sources to maintain good bone health.

Vitamin D

Another important factor to maintain healthy bones is vitamin D. Furthermore, it supports the immune system and heart health. It is recommended we have 10 micrograms of vitamin D each day. 

Sunlight is the main source of vitamin D, however in the UK, the sun is only strong enough between April and September for our bodies to absorb vitamin D. Therefore, for the rest of the year it is important we get sufficient vitamin D from food sources, such as eggs, oily fish, cod liver oil and fortified foods.

It is important to note if you are taking immunosuppressant drugs, such as Azathioprine, 6-mercaptopurine and Methotrexate your skin is more sensitive to the sun. Therefore, it is important to wear sun cream to prevent any damage from happening. 

Vitamin D deficiency is common, especially in winter and therefore it is important to follow your Doctors or Dietitian’s advice with regards to taking a vitamin D supplement.

Iron

Due to poor absorption, poor intake, medications, blood loss in flair-up, inflammation and/or blood loss in your stool, people with UC are at risk of having low iron levels, also known as anaemia. This can cause low energy, weakness, reduced exercise, brain fog, light-headedness, short breath and pale skin. Therefore, it is important to incorporate iron into your diet from sources such as red meat, fish, chicken and eggs. Sources from animals are better absorbed than vegetables, however dark green vegetables, broccoli, courgette, dried fruit and fortified breakfast cereals can be sufficient sources of iron. It is recommended men & post-menopausal women require 8.7mg of iron/day and women require 14.8g of iron/day.

Other tips to increase iron absorption include consuming coffee/tea 30 minutes before or after meals and avoid bran in meals as they contain phytates which prevent iron absorption. Furthermore, you should avoid eating dairy with meals as calcium can block iron absorption. On the other hand, ensuring not to overcook or boil vegetables can increase the amount of vitamin C they retain. Vitamin C has been found to increase the absorption of iron from vegetables and therefore it is helpful to retain it.

Iron-rich sources:

Vitamin B12

Vitamin B12 is an essential chemical to prevent anaemia. Good dietary sources of B12 come from meat, fish, eggs and dairy products. This can be difficult for vegans who need to eat fortified cereals and meal-alternative items or supplements to support sufficient B12 intake. 

Folate

Folate is an essential chemical reaction in the body to prevent anaemia. It is found in green leafy vegetables (such as cabbage and spinach), fruit, nuts and fortified cereals.  

Folate requirements are higher during pregnancy to support the development of a baby’s spine. Therefore, folate supplementation is recommended when you are planning for pregnancy or in the early stages of pregnancy and it is important to contact a doctor or dietitian about this. 

Medications can also reduce your rate of folate, including aminosalicylate sulfasalazine and methotrexate. Therefore, if you are taking these medications ask your dietitian for advice on how to ensure you eat enough folate or your doctor for a supplement of folate.

Probiotics

Contain live “good” bacteria which can keep the bad bacteria under control and supports immunity, digestion of fibre and bowel movements. Strong formulations of biotics from dietary supplements Therefore, they can prevent and improve bloating, constipation and abdominal pain in people living with UC. Furthermore, there is evidence that some probiotics alongside medications can help support the induction of remission in mildly active UC.

Probiotics can be obtained naturally from fermented foods, such sauerkraut, kimchi and keffir yoghurts.

Please speak to your Doctor or Dietitian for more information about use of probiotic supplements.

Prebiotic foods

Support the growth of good bacteria in the gut health. They include foods such as: Jerusalem artichoke, chicory root, red onions, spinach, broccoli, asparagus, seaweed, leeks, garlic, dandelion greens, olives, apples (stewed) and green banana.

Ultra processed foods

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.

The following websites provide more useful information about UC:

• Irritable bowel syndrome (IBS) - NHS

  NHS England – IBD page provides a good source of information about dietary symptoms and treatment options 

• Guts UK - committed to fighting all digestive diseases

  Guts UK – website provides factsheets about a range of conditions related to gut health, including UC.

• Crohn's & Colitis UK

  Crohn’s and Colitis UK - the charity provides vital information, practical advice, and emotional support to individuals living with these chronic conditions, as well as their families and caregiver.

Address: 

Department of Nutrition and Dietetics, 3rd Floor East, 250 Euston Road, London, NW1 2PG 

Switchboard: 0845 155 5000 

Extension: 9289 

Fax: 020 7380 9811