Does Standard Advice Apply to the Post-Surgical IBD Population?

Article reprint courtesy of The Phoenix (link to www.phoenixuoaa.org) magazine, America’s leading ostomy publication. Use code SAVE20 to save 20% on a digital subscription.

By Amalia Karlin, MS, RDN

The latest research in Inflammatory Bowel Disease has found that there are dietary factors that can increase and decrease the risk of developing IBD amongst the general population. These factors are being integrated into dietary interventions used in combination with pharmaceuticals to manage symptoms and induce remission in individuals with Crohn’s Disease and Ulcerative Colitis. 

The question is, how do these factors hold up in a population with IBD who have undergone surgical intervention? How do these dietary recommendations apply to individuals who have had gastrointestinal resections or undergone a total colectomy resulting in an ostomy? Because of the lack of nutrition research amongst the post-surgical IBD population, it is important to examine the current recommended interventions to determine their practicality in individuals with an ostomy.

Dietary Fiber

Bacterial fermentation of fiber in the large intestine has the ability to create short chain fatty acids (SCFAs) that are protective against IBD. Energy can also be derived from these SCFAs and supply the body with additional calories. High fiber diets amongst Crohn’s disease patients may even reduce flare risk. 

Does the research about fiber apply to individuals without a large intestine? Is there a benefit to prioritizing whole food fiber sources, like fruits, vegetables, and whole grains, when these food groups are feared by ostomates due to the risk of intestinal blockage? In addition, dietary fiber increases overall fluid requirements in a population already at risk for dehydration and malnutrition. Fiber increases fluid losses by soaking up fluid in the bowel, pulling in additional fluids from the bowel wall, and ultimately exiting the body dragging along electrolytes and even some nutrients along with it.

Practical Application: Fiber, when you isolate the nutrient on its own, may not be beneficial to individuals without a colon. A low fiber diet may be the solution to managing hydration and easing fears that an intestinal blockage will not be imminent. Some great alternatives that are low in fiber and high in bioavailable nutrients include organ meats, fatty fish, boneless canned fish, and eggs.

If there is an interest in eating fiber containing foods, peeling, deseeding, cooking, and changing the texture of these foods are great ways to enjoy them with a reduced risk of blockages. Fiber containing foods can also bring enjoyment and variety to the diet for those that enjoy eating them. Just remember when choosing high fiber foods to increase fluid intake, particularly from a good quality oral rehydration solution. 

Inflammatory Fats

There are four main types of dietary fats: saturated fat, trans fat, monounsaturated fat, and polyunsaturated fat. Saturated fats are naturally occurring in animal products, like beef, pork, poultry, butter, cheese, and palm and coconut oils. Trans fats are naturally occurring in some animal products, but mostly consumed in the form of partially hydrogenated oils used in the production of ultra-processed foods. There is an association between saturated and trans fats and the risk of flares in individuals with Crohn’s Disease (CD) and Ulcerative Colitis (UC).

Dietary fat can also be a great source of energy for individuals with an ostomy. It is an efficient way to consume calories without introducing too much volume. In a population already limiting fiber, dietary fat can help remedy challenges feeling satiated at mealtimes. This begs the question, which sources of saturated fats should be reduced? Which types of dietary fats should be increased? 

Practical Application: In both the CD and UC population it is beneficial to reduce the consumption of saturated fats that have been highly processed, like deli meats, sausages, and baked goods. These sources of saturated fats are proinflammatory. In an environment already predisposed to inflammation, especially in UC, the key is to replace sources of pro-inflammatory fats with sources of anti-inflammatory ones. Omega-3 fatty acids are a type of monounsaturated fatty acid known for their anti-inflammatory benefits. Good sources of Omega-3’s include fatty fish, walnut butter, ground flax, olive oil, and soy. Omega-3 is even found in small amounts in avocado.

For individuals with Ulcerative Colitis, who still have some segment of colon remaining, it may be beneficial to also reduce consumption of dietary fats that contain a specific fatty acid, called myristic acid. Myristic acid is found in high fat dairy, palm oil, coconut oil, and grain-fed animals. Shifting focus to sources of dietary fats lower in myristic acid is beneficial to reducing flare risk. Sources of dietary fat low in myristic acid include, grass-fed animal proteins, low-fat dairy, and olive oil.

Processed Foods

Specific ingredients found in processed foods can increase the risk of developing IBD and increase flare risk. These ingredients include maltodextrin, artificial sweeteners, titanium dioxide, carrageenan, and emulsifiers like polysorbate-80. 

It is common amongst the post-operative IBD population to include a variety of processed foods during the early stages of adjusting to an ostomy. In fact, a lot of the above ingredients are actually found in hospital foods served to patients while they are still admitted. For example, maltodextrins and carrageenans are common additives found in pudding cups. Titanium dioxide is a common ingredient found in coffee creamers. Artificial sweeteners are found in diet jellies and desserts. Patients often leave the hospital and follow a similar diet at home to that which they were served in the hospital because they consider those foods to be safe. Many individuals with ostomies don’t stray from the post-op diet for months due to the lack of nutrition support and education post discharge.

Practical Application: The reality is that food additives are often found in processed foods that many individuals with ostomies consider “safe foods”. It is important to note that there is a continuum of types of processed foods. Some are more processed than others, often referred to as ultra-processed. Simple foods like packaged plain yogurt and tuna fish are still considered processed, but contain a lot less additives than ultra-processed foods, like chips, ice cream, deli meats, and many breakfast cereals. 

The focus should be shifted toward adding in whole foods with minimal processing. Once an individual has grown accustomed to including more nutrient dense foods, the focus can be shifted to reducing intake of ultra-processed foods. Establishing routine intake of quality sources of proteins, carbohydrates, and fats will liberalize the diet and create opportunities to reduce sources of undesirable additives.

Final Thoughts

Nutrition guidelines for the IBD population will continue to be updated as more research is published. Less research however, is looking at the benefits of these guidelines to the post-surgical IBD population specifically. For this reason, providers should revise guidelines appropriately for their post-surgical IBD patients in order to maximize the potential of the remaining bowel, improve absorption capacity, prevent complications, and improve overall quality of life.

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