The inadequate nutritional status frequently encountered in colitis patients, which is characterized by underweight, negative nitrogen balance, decreased serum albumin, reduced serum concentration of vital substances (micronutrients), has an extremely negative impact on the patients’ well-being as well as on the course of the disease. In children, malnutrition delays length growth and puberty. Consequently, nutritional therapy or preoperative treatment of ulcerative colitis must consist of a high-energy diet containing sufficient amounts of all important nutrients and vital substances (macro- and micronutrients). The aim of nutritional therapy is to improve the general condition, alleviate the symptoms and prevent complications.The treatment is in the foreground until the episodes of ulcerative colitis – although leaving behind morphological changes in the intestinal mucosa – heal and the signs of inflammation subside. In the case of fulminant colitis – toxic megacolon – or the development of malignant tumors in the colon or rectum, surgical removal of the colon is usually required.Nutrition to meet the needs also plays an essential role for the period after surgery, since a poor nutritional status can significantly delay the postoperative course. In order to be protected from pronounced clinical deficiency symptoms, colitis patients should – depending on their needs – increase their dietary intake of critical vital substances (micronutrients), including fat- and water-soluble vitamins, calcium, magnesium, iron, zinc, selenium, essential fatty acids, proteins and dietary fiber, or be substituted with these. Patients at increased risk of deficiency who have very low serum levels of vitamin B12, iron and zinc, for example, must be substituted parenterally with these vital substances (micronutrients). Because vitamin D is often ingested in insufficient amounts in the diet – low consumption of fish, such as eel and herring – and exposure to sunlight is low, especially during the winter months, vitamin D requirements are also increased in colitis patients. Vitamin D supplementation is recommended Notably, regular as well as generous intake of vitamins A, E, zinc, and omega-3 fatty acids in colitis patients can reduce the inflammatory process, protect the intestinal wall from ulcers, relieve symptoms, and promote mucosal regeneration [5.4].
Dietary recommendations in secondary disaccharidase deficiency
Ulcerative colitis is often associated with secondary lactase deficiency because of the primary inflammatory disease of the intestinal wall. Depending on the severity of the damage to the intestinal villi, the activity of lactase is decreased In this case, the lactose supplied by milk and milk products cannot be broken down and subsequently not absorbed. In this case, lactose should be largely avoided at the beginning of the dietary treatment of ulcerative colitis in order to avoid typical symptoms of lactose intolerance – flatulence and cramp-like complaints (meteorism) as well as diarrhea. Consequently, low-lactose milk and dairy products should be included in the diet to ensure the absorption of the valuable nutrients and vital substances (macro- and micronutrients) of milk – including vitamins A, D, E, K, calcium and biologically high-quality protein. As the intestinal villi regenerate during dietary therapy, the activity of the enzyme lactase normalizes, and milk and dairy products are again tolerated normally [4.2].
Importance of calcium and vitamin D
If colitis patients eat a predominantly low-fiber diet, calcium deficiencies can rapidly develop the unabsorbed fatty acids combine with calcium to form insoluble calcium soaps. Finally, the absorption of calcium is inhibited and there is an increased risk of calcium deficiency Due to a low consumption of dietary fiber, the conversion of primary bile acids into secondary bile acids is promoted in the colon, resulting in a low micellar concentration. As a result, accumulating fatty acids can no longer be reabsorbed, which – depending on the extent of the fat reabsorption disorder. As a result, oxalic acid can no longer be bound by calcium to calcium oxalate. The free oxalic acid ingested from food is increasingly absorbed and excreted in the urine (hyperoxaluria).In addition, the increased occurrence of oxalic acid increases the risk of kidney and urinary stone formation (urolithiasis). Accordingly, ulcerative colitis patients should avoid foods containing oxalic acid, such as beet, parsley, rhubarb, spinach, chard and nuts. A low-fat diet and additional administration of calcium ensures the binding of calcium with oxalic acid and in this way prevents hyperoxaluria and consequent stone formation. Patients with inflammatory bowel disease are often found to have decreased bone density due to steroid therapy. Lack of physical activity, inadequate dietary intake of calcium and vitamin D, and the more or less pronounced absorption disorders may also be responsible for low bone density. Meeting the increased need for calcium and vitamin D is therefore essential in inflammatory bowel disease. Calcium and vitamin D substitutions promote bone health and prevent deficiency [4.2].
Importance of iron
If chronic oozing bleeding occurs inside the intestine in ulcerative colitis as a result of gastrointestinal symptoms, such as the formation of ulcers, strictures, fistulas, or abscesses, the severe or prolonged bleeding results in high iron losses. If patients also lose a lot of blood due to frequent bloody diarrhea, the iron deficiencies are exacerbated. The risk of iron deficiency increases considerably under these circumstances [4.2]. Iron should therefore be supplied orally. The trace element is particularly essential for oxygen transport in the human organism.
Importance of antioxidants
To fight off bacteria and germs in the area of damaged colonic mucosa, white blood cells synthesize free oxygen radicals in high amounts. Free radicals multiply in the body in the form of chain reactions, snatching an electron from the molecule under attack and thereby turning it into a free radical itself. The increased formation of radicals – especially in the colonic mucosa – is known as oxidative stress.Oxidative stress is associated with damage to the body’s proteins, enzymes, amino acids, carbohydrates in the cytoplasm as well as cell membranes. In addition, DNA (genetic material), the cell nucleus and mitochondria are attacked. Fatty acids are converted into toxic compounds (lipid peroxidation) [4.1. ].Impairments of the cell nucleus DNA can lead to gene mutations that impair individual cellular functions. As a consequence, there is an increased risk that cancer cells – colon adenoma and colon carcinoma, respectively – may develop [4.1. ].Furthermore, oxidative stress reduces the concentration of antioxidants, which can effectively detoxify free radicals or prevent or inhibit their formation and thus enable the survival of mucosa cells. Without antioxidant protective factors such as vitamins B2, B3, E, D, C, selenium, zinc, manganese and copper as well as secondary plant compounds – such as carotenoids and polyphenols – the harmful oxygen radicals cannot be intercepted.The high level of oxygen free radicals ultimately maintains or promotes the inflammatory reactions of chronic inflammatory bowel disease. High dietary intake of antioxidants or substitutions can inhibit the proliferation of harmful radicals in the colon, reduce its concentration, and decrease the inflammatory responses of the colonic mucosa
Importance of omega-3 fatty acids and gamma-linolenic acid
In ulcerative colitis, elevated concentrations of the inflammatory mediators leukotriene B4, prostaglandin E2, and thromboxane A2 can be found in the mucosa and in the irrigation fluid of the rectum [4.2]. In addition, high concentrations of arachidonic acid can be found in the intestinal mucosa, which promotes the formation of the inflammatory mediators.Evening primrose oil contains abundant gamma-linolenic acid. During drug treatment with evening primrose oil, a high supply of gamma-linolenic acid causes a decrease in the synthesis of the inflammatory mediator prostaglandin E2 and an increased formation of prostaglandins E1. Series 1 prostaglandins, in turn, inhibit the release of arachidonic acid from cell membranesAs a result of the effect of the valuable gamma-linolenic acid, the concentrations of inflammatory mediators in the colonic mucosa are reduced, which promotes the regeneration of the mucosa.For drug therapy, in addition to evening primrose oil, patients are also administered fish oil, which is rich in omega-3 fatty acids – especially eicosapentaenoic acid – in the form of gelatin capsules. Eicosapentaenoic acid (EPA) has an anti-inflammatory effect in that increased intake leads to increased synthesis of the anti-inflammatory prostaglandin I3 and a significant reduction in the formation of leukotriene B4. Thus, omega-3 fatty acids are of considerable importance for the mucosal regeneration of the intestinal wall.An administration of 5 grams of omega-3 fatty acids per day leads to a reduction in the extent as well as the severity of colonic inflammation and relief of symptoms in ulcerative colitis by influencing inflammatory mediators. In addition, essential fatty acids – omega-3 fatty acids, such as alpha-linolenic acid, EPA as well as DHA,and omega -6 compounds, such as linoleic acid, gamma-linolenic acid and arachidonic acid – are particularly needed to meet the increased caloric needs of colitis sufferers.
Importance of low-molecular-weight protein
Because of the frequent undersupply of protein-due in part to high intestinal protein loss and hypalbulinemia-ulcerative colitis sufferers have an increased need for high-quality protein. In particular, low-molecular-weight protein – high-quality, complete, short-chain protein from milk, soy, potato, or egg – should be supplied because its utilization is nearly 100%. This is due to the absorption of this protein, which requires only a greatly reduced effort by the human digestive tract. Even considerably weakened patients can make the effort of protein resorption. Enzymatic breakdown of the high molecular weight dietary protein produces small amino acid chains – oligopeptides, which are broken down and metabolized almost as quickly as glucose.Common long-chain dietary proteins – meat, for example – on the other hand, are broken down and absorbed at only 40-70%. In some colitis patients, common dietary proteins can trigger allergic reactions and should be reduced in the dietary regimen for this reason.Patients with ulcerative colitis should consume about 100-125 grams of low molecular weight protein per day to increase resistance to disease-causing agents, such as bacteria and germs. The additional intake of the high molecular weight protein in protein deficient people has a positive effect on body weight, total serum protein, serum albumin as well as on the level of gamma globulins. It also supports immune system function, blood circulation, and the absorption and utilization of nutrients and vital substances (macro- and micronutrients).Low molecular weight protein provides the amino acid glutamine. This substrate plays an essential role in the energy metabolism of the small intestinal mucosa, as it is an important source of energy for intestinal cells. Glutamine counteracts mucosal damage of the intestine and is needed for the healing process of the colon wall. Adequate and regular consumption of dietary fiber – protective effects.
- Inhibition of the development of colon tumors – carcinogenesis – by binding carcinogens as well as by the short-chain fatty acids formed during bacterial degradation – in particular, butyric acid exhibits anticarcinogenic effects. By increasing stool weight, dietary fiber dilutes the concentration of all carcinogens. Since the transit time of stool is shortened by acceleration of intestinal peristalsis in a high-fiber diet, the contact time of carcinogens with the intestinal wall is also reduced. Patients on high-fiber diets show an approximately 40% reduced risk of colorectal cancer, with mortality decreasing as fiber intake increases.
- Cardioprotective effects – fiber grants protection against cardiovascular disease. Just under 30 grams of fiber a day is enough to reduce the risk of heart attack by almost half.
- Lowering LDL cholesterol levels by up to 25%.
- Improvement of carbohydrate tolerance – due to the low glycemic index of fiber-rich foods. Also in diabetics, it comes as a result of high fiber intake to improve carbohydrate tolerance.
- Immunomodulating properties – especially hemicellulose and pectins.If colitis patients pay attention to a regular fiber intake – about 30 grams a day – the immune competence can be significantly improved by increasing the non-specific as well as specific defense mechanisms.
- Increased excretion of fat as well as toxic substances with the stool – dietary fiber binds fatty acids and toxic pollutants as well as heavy metals. For example, pectin binds with lead and mercury, increasing the excretion of heavy metals and protecting the body of colitis patients, already weakened by inflammatory reactions, from oxidative damage
Due to the versatile mechanisms of action of fiber, patients with ulcerative colitis should definitely increase their fiber intake and in parallel ensure adequate fluid intake. Dietary fiber requires fluid to swell. Low fluid intake reduces their swelling capacity, which may cause constipation
Importance of phytochemicals
If colitis sufferers pay attention to an adequate intake of bioactive substances, such as carotenoids, saponins, polyphenols, and sulfides, the development of colon cancer may be inhibited.
- Carotenoids – for example, in apricots, broccoli, peas and kale – are able to inhibit phase 1 enzymes responsible for carcinogenesis.
- Saponins – found primarily in beans, green beans, chickpeas, as well as soybeans – bind primary bile acids, helping to reduce the formation of secondary bile acids. In high concentrations, secondary bile acids can act as tumor promoters. Primary bile acids bound by saponins are increasingly excreted in the stool. The body’s own cholesterol is then used for the new formation of bile acids, which lowers the cholesterol level in the blood. By saponins insolubly bind cholesterol in the intestine, the cholesterol level is also lowered
- Flavonoids belonging to the polyphenols – primarily found in citrus fruits, red grapes, cherries, berries as well as plums – have structural similarities to nucleotides and can therefore mask DNA binding sites for active carcinogens. They also have the ability to prevent the growth of DNA-damaged cells. Furthermore, flavonoids have a positive effect on the vital substance status. They increase the effect of vitamin C and coenzyme Q10 by a factor of ten, have a stabilizing influence on the plasma level of vitamin C and delay the consumption of vitamin E [5.1]. Phenolic acids – especially found in various cabbages, coffee, radishes and whole wheat grains – have a strong antioxidant effect and can therefore inactivate numerous cancer-promoting substances from the environment, such as nitrosamines and mycotoxins.
- Sulfides – abundant in garlic, onions, chives, asparagus and shallots – exhibit similar anti-cancer effects as carotenoids, saponins and polyphenols. They also have an immunomodulatory effect, activating natural killer cells as well as cell-killing T lymphocytes to halt carcinogenesis
Importance of growth factors
Growth factors – grow factors – are fat or protein molecules that exhibit protective effects on the intestinal mucosa. Among the most important growth factors are epidermal growth factor, neurotensin, and insulin-like-growth factor [4.2. ].These are able to stimulate new cell formation as well as growth in the colonic mucosa, which significantly improves nutrient and vital substance absorption in ulcerative colitis patients. In addition, as a result of cell proliferation, the barrier function of the colon mucosa, which is often reduced in colitis patients, can be optimized, so that the uptake of bacteria, germs and endotoxins or a transfer of antigens from the intestines into the lymph and portal blood is largely prevented [4. 2. ].Colitis patients should consequently be fed with supplemental administrations of growth factors to improve nutritional and general status by increasing nutrient and vital substance absorption, maintain the mucosal barrier of the colon, and reduce inflammatory symptoms of the intestinal wall
Nutritional therapy in mild disease-maintenance of remission
If no particular complications are present, a light, whole-food diet is used to maintain the symptom-free or symptom-free period [4.2].In this case, those foods, preparation methods and dishes must be avoided that experience has shown to trigger the typical complaints. Food sensitivities can aggravate inflammatory bowel disease.In principle, food intolerances are more common in patients with inflammatory bowel disease than in healthy individuals. According to clinical studies, long symptom-free intervals and low relapse rates occurred after elimination of such foods that aggravate the symptoms of ulcerative colitis. In particular, wheat products, milk and dairy products, citrus fruits, yeast, corn, bananas, tomatoes, wine, and eggs were eliminated, since these foods most frequently trigger symptoms [4.1. ].People with colitis should regularly consume foods rich in fiber, such as whole grains, rice, wheat bran, oat bran, fruits, vegetables, and legumes, on a long-term basis. High fiber consumption ensures a high supply of short-chain fatty acids in the colon. By promoting the metabolic activity and growth rate of the intestinal flora, acetate, propionate and butyrate can optimize the mucosal barrier of the colon, which is often lowered in colitis patients. Short-chain, low-molecular-weight fatty acids are thus able to reduce the severity of chronic intestinal inflammation and the number as well as the severity of relapses. Above all, n-butyrate, as an essential energy-providing substrate of the colonic mucosa, has a positive effect on the course of the disease ulcerative colitis.According to studies, the dietary fiber ispaghula in particular leads to an alleviation of the typical symptoms – diarrhea, bloating, mucosal secretion – in inactive ulcerative colitis.Water-soluble dietary fibers, such as pectins and plant gums found in fruits, are essential for the restoration of intestinal function. Compared to insoluble fiber, they have an even higher water-binding capacity. By prolonging intestinal transit, reducing stool frequency, increasing water retention, and increasing stool weight, soluble fibers counteract diarrhea and thus high fluid as well as electrolyte losses. It is recommended to avoid refined carbohydrates to a large extent. They promote bacterial overgrowth, aggravate damage to the colonic mucosa, and exacerbate absorption disorders and vital substance deficiencies [4.1. ].Ultimately, a high-fiber, sugar-free diet can positively influence the course of the disease. In addition, the rate of required surgical interventions is significantly reduced
Nutritional therapy in acute relapse, general malnutrition or specific substrate deficiencies, and after extensive bowel resection
Artificial enteral nutrition
In severe courses of ulcerative colitis with severe nutrient and vital substance utilization disorders, intestinal fistulas, and general malnutrition or specific substrate deficiencies, it is advisable to provide artificial enteral nutrition in the form of a chemically defined formula diet to the patient to preserve bowel function. In contrast, a poorly soluble diet during an acute episode additionally irritates the inflammatory colonic mucosa, increasing the severity of the episode and prolonging its duration.Formula diets – elemental or peptide diets – are administered in ready-to-use liquid form – in some cases via a nasogastric tube. They consist of a fully balanced mixture of mono- or low-molecular nutrients and vital substances (macro- and micronutrients) that can be absorbed without enzymatic cleavage, such as amino acids, oligopeptides, mono-, di- and oligosaccharides, triacylglycerides, vitamins, electrolytes and trace elements. The composition of the ingredients must be individually adjusted.In contrast to nutrient-defined diets – with 20 to 35% fat -, chemically defined formula diets contain only a maximum of 1.5% of the energy as fat. Thus, the growth of fungal microorganisms such as mycoplasmas and mycobacteria, is inhibited inside the intestine. A high fat content, on the other hand, promotes their growth as well as the formation of antigens that can damage the intestinal mucosa both morphologically and functionally. A high-fat diet, especially high in linoleic acid, increases the conversion to arachidonic acid.Arachidonic acid belongs to the omega-6 compounds and in high concentration inside the intestine promotes the occurrence of lipid peroxidations as well as the formation of inflammatory mediators – especially leukotriene B4 [4.2. ].Chemically defined formula diets therefore have a positive effect on the intestinal mucosa. They decrease the permeability of the intestinal mucosa as well as the excretion of white blood cells with the stool. In addition, they improve the nutritional status, as they adequately cover the increased caloric and vital substance requirements of the patients.As in Crohn’s disease, in 50-90% a temporary reduction of the disease symptoms (remission) can be achieved through exclusive nutrition with an elemental diet.However, as the relapse rate is very high at around 50%, surgical interventions to restore intestinal function should be sought. In this case, artificial enteral nutrition before surgery improves the general condition in malnourished patients and reduces the rate of postoperative complications. Meeting energy, nutrient, and vital substance (macro- and micronutrient) requirements is of considerable importance, especially in children with ulcerative colitis. Artificial enteral nutrition is well suited for the treatment of short stature. Enteral nutrition is preferable to parenteral nutrition because of its low monitoring requirements, lower complication rate, and lower cost. Parenteral nutrition also carries an increased risk of central venous catheter infections, with bacteria entering the patient’s bloodstream through the catheter (catheter sepsis). In addition, occlusion of the subclavian vein by a blood clot may occur as a result of parenteral nutrition
Total parenteral nutrition-oral nutritional abstinence
If enteral nutrition is not possible or if the course of ulcerative colitis is extremely severe – bleeding not responding to therapy, threatening toxic megacolon – the patient must be fed via venous access (parenteral). In about 60% of cases, a temporary reduction in the symptoms of the disease (remission) can be achieved in this way. However, about 40% of patients in remission who receive total parenteral nutrition relapse within one year. Total parenteral nutrition improves the nutritional status of malnourished colitis patients, which is particularly important for patients who are about to undergo surgery. In addition, parenteral nutrition reduces the rate of complications that can occur during surgery. Artificial enteral or total parenteral nutrition – inhibitory effects on chronic inflammation.
- Improvement of nutritional status with a positive effect on the course of the disease.
- Quantitative and qualitative changes in the intestinal flora
- Reduction of the load of the intestine with antigens, such as bacteria, germs as well as endotoxins.
- Normalization of the impaired barrier function of the intestinal mucosa by reducing the permeability of the intestinal mucosa.
- Positive effects of “immobilization” of the intestine
Side effects of medication
In addition to malabsorption, medications commonly used in ulcerative colitis- treatment to reduce inflammation or to heal inflammatory bowel wall changes-can also promote the development of nutrient and vital substance deficiencies
- Synthetically produced steroids-corticosteroids, such as fludrocortisone, prednisone, prednisolone, and methylprednisolone-impede the absorption of calcium, phosphorus, and zinc; increase renal excretion of vitamins C, B6, potassium, sodium, calcium, magnesium, as well as phosphorus; and increase the requirement for vitamins D, E, as well as folic acid. Since corticosteroids as immunosuppressants have an inhibitory effect on the immune system, long-term use significantly impairs the immune system – increased susceptibility to infections. In addition, there may be an increase in blood pressure, water retention, muscle wasting, an increased tendency to bruising, acne and mood swings
- The substance sulfasalazine or salazosulfapyridine – is administered for months and years in both ulcerative colitis and Crohn’s disease. Only through the cleavage of salazosulfapyridine by the colon bacteria, the actual active substance, mesalazine (5ASA) is released.Salazosulfapyridine, in particular, inhibits vitamin B9 absorption and thus may contribute to the development of folic acid deficiency
- Salicylates, such as mesalazine, decrease serum levels of folic acid as well as iron. Furthermore, salicylates decrease the absorption of vitamin C and impede its uptake into leukocytes (white blood cells). Consequently, the vitamin C level in plasma as well as in platelets (blood platelets) is lowered and the renal excretion of vitamin C increased
Methotrexate is one of the immunosuppressive agents. In addition to the absorption of folic acid, it blocks the absorption of vitamin B12 and increases zinc requirements Colestyramine binds bile acid and is used to treat diarrhea. This drug contributes to deficiencies of all vital nutrients (micronutrients) by impairing the absorption of vitamins A, beta-carotene, D, E, K, B9, and iron. Colestyramine also inhibits intestinal absorption of thyroid hormones [5.5].
Ulcerative colitis – vital substance deficiency (micronutrients)
| Vital substance | Deficiency symptoms |
| Vitamin A |
Increased risk of
Deficiency symptoms in children
|
| Beta-carotene |
|
| Vitamin D | Loss of minerals frombones-spine, pelvis, extremities-leads to
Symptoms of osteomalacia
Deficiency symptoms in children
Symptoms of rickets
|
| Vitamin E |
Deficiency symptoms in children
|
| Vitamin K | Blood coagulation disorders leading to
Decreased activity of osteoblasts leads to.
|
| B group vitamins,such as vitamin B1, B2, B3,B5, B6. | Disorders in the central and peripheralNervous system lead to.
Deficiency symptoms in children
|
| Folic acid | Mucosal changes in the mouth,intestine and urogenital tract lead to
Blood count disorders
Impaired formation of white blood cells leads to the
Elevated homocysteine levels increase the risk for
Neurological and psychiatric disorders, such as.
Deficiency symptoms in children Disturbances in DNA synthesis -limited replication- andreduced cell proliferationincrease the risk for
|
| Vitamin B12 |
Blood count
Gastrointestinal tract
Neurological disorders
Psychiatric disorders
|
| Vitamin C |
Weakness of blood vessels leads to
Carnitine deficit leads to
Deficiency symptoms in children
Increased risk of vitamin C deficiency disease- Möller-Barlow disease in infancywith symptoms such as.
|
| Calcium | Demineralization of the skeletal system increases the risk of
Increased risk of
Deficiency symptoms in children
Symptoms of rickets
Additional vitamin D deficiency leads to
|
| Magnesium | Increased excitability of muscles and nervesleads to
Increased risk of
Deficiency symptoms in children
|
| Sodium |
|
| Potassium |
|
| Chloride |
|
| Phosphorus |
Disease of the nerves, which transport informationbetween the central nervous system and theMuscles leads to.
Deficiency symptoms in children
Symptoms of rickets
|
| Iron |
Symptoms of deficiency in children
|
| Zinc | Instead of zinc, the toxic cadmium is integrated into the biological processes, resulting in
leads.
Metabolic disorders, such as.
Deficiency symptoms in children Low zinc concentrations in plasma and white blood cells cause
|
| Selenium |
Increased risk of
Deficiency symptoms in children
|
| Copper |
Copper metabolic disorders
Deficiency symptoms in children
|
| Manganese | More than 60 enzymes-including decarboxylases,aminopeptidases, hydrolases, and kinases-are activated by manganese or containthe trace element as a component.Manganese deficiency results in decreasedactivity of the enzymes, leading to
can lead to. |
| Molybdenum |
|
| Essential fatty acids- omega-3 and 6 compounds. |
Deficiency symptoms in children
|
| High qualityProtein |
|
| Amino acids, such as glutamine,leucine, isoleucine, valine, tyrosine,histidine,carnitine |
|
| Secondary plant compounds,such as carotenoids, saponins,sulfides, polyphenols. |
Insufficient protection against
Free radicals lead to
Increased risk of
|
| Dietary fiber | Increased risk of
|
