Sample Menu Items

Breakfast

• Decaffeinated coffee with cream and sugar
• Cup of juice, such as no-pulp orange juice, apple juice, or cranberry juice
• Cream of wheat
• Scrambled eggs
• Waffles, French toast, or pancakes
• White-bread toast with margarine and grape jelly (no seeds)
• Milk (if tolerable)

Lunch

• Baked chicken, white rice, canned carrots, or green beans
• Salad with baked chicken, American cheese, smooth salad dressing, white dinner roll
• Baked potato (no skin) with sour cream and butter or margarine
• Hamburger with white seedless bun, ketchup, and mayonnaise — lettuce if it doesn’t worsen your symptoms
• Cheeses (if tolerable)

Dinner

• Tender roast beef, white rice, cooked carrots or spinach, white dinner roll with margarine or butter
• Pasta with butter or olive oil, French bread, fruit cocktail
• Baked chicken, white rice or baked potato without skin, and cooked green beans
• Broiled fish, white rice, and canned green beans
• Cheese (if tolerable)

Food Guidelines

Remember: Eat small meals or snack every 3 to 4 hours. Stay hydrated. Drink small amounts of water throughout the day.

Foods to Avoid

• Seeds, nuts, or coconut, including those found in bread, cereal, desserts, and candy
• Whole-grain products, including whole-grain breads, cereals, crackers, pasta, rice, and kasha
• Raw or dried fruits, such as prunes, berries, raisins, figs, and pineapple
• Most raw vegetables
• Certain cooked vegetables, including peas, broccoli, winter squash, Brussels sprouts, cabbage, corn (and corn bread), onions, cauliflower, potatoes with skin, and baked beans
• Beans, lentils, or tofu
• Tough meats with gristle and smoked or cured deli meats
• Cheese with seeds, nuts, or fruit
• Crunchy peanut butter, jam, marmalade, or preserves
• Pickles, olives, relish, sauerkraut, and horseradish
• Popcorn
• Fruit juices with pulp or seeds, prune juice, or pear nectar

Medical Nutrition Therapy: Low Residue Diet

Purpose

1. Nutrition Indicators: Ulcerative Colitis (UC) and Crohn’s Disease (CD).
2. Criteria to Assign the Diet: Diets are altered from the norm and assigned based on each patient’s individual sensitivities, as some are more sensitive than others to different foods with high and medium residuals. The most effective way to decide what foods are “trigger foods” in this disease are for patients to keep a food journal to monitor intake and symptoms during and after meals. This can determine the amount of residue, fiber, and diary allowed in the diet.
3. Rationale for Diet: Some evidence suggests that a long-term low-residue diet can decrease the number of inflammatory outbreaks of those with Ulcerative Colitis or Crohn’s Disease, and perhaps even slow the effect and progression of the disease (Nelms). During outbreaks, it has been known to decrease symptoms while after outbreaks it possibly prolongs future outbreaks. The decrease in roughage moving throughout the intestine allows the gut heal.

Population

2. Overview: Ulcerative colitis and Crohn’s disease are inflammatory bowel diseases that are characterized by chronic inflammation of the digestive tract. The epidemiology as well as signs and symptoms have some overlap and therefore mistaking the diagnosis is plausible. Both diseases occur equally in both sexes and both have a high level of occurrence in North America, Northern Europe, and the UK. The peak onset of both diseases are also similar as UC typically begins between the ages of 20 and 30 years while Crohn’s disease most often begins in the teens and twenties (Nelms).
3. Disease Process: Ulcerative colitis is specifically inflammation of the colon, while Crohn’s disease encompasses the inflammation of any part and every part of the digestive tract but most commonly the ileum and colon. Ulcerative colitis is very specific in that it includes a constant inflammation of only the inner most lining of only the colon. Crohn’s disease is broader as it includes inflamed sections of the intestines at any layer of the bowel walls, and perfectly healthy parts can be present in between the inflamed areas (Nelms). Signs and symptoms of both UC and Crohn’s include diarrhea, abdominal pain, weight loss, fever, and blood or mucus in the stool. The way in which these diseases are diagnosed are very similar as well – including abdominal ultrasound, MRI, CT, antiglycan antibodies (ASCA) levels, and ferritin/transferrin levels (Best).
4. Biochemical and Nutrient Needs: Those with UC or Crohn’s disease are at an increased risk for malabsorption depending on how much of the bowel has been affected. The specific nutrients that need to be taken into account are also based upon which section(s) of the bowel has been altered. For example, damage to the jejunum may results in a decreased ability to absorb carbohydrates, protein, sodium, vitamin A, vitamin D, water soluble vitamins, and water while damage to the ileum may impact the body’s ability to reabsorb bile salts that must be recycled in order to aid in the breakdown of food (Nelms). Based on the area effected, anthropometrics, and chemical labs, one can assess the specific nutrient deficiencies and suggest supplements as necessary.

General Guidelines

3. Nutrition Rx: Medications often include corticosteroids which keep the immune system from fighting infection, as the symptoms of UC and Crohn’s Disease are caused by the immune system’s attack on the intestinal tract. This allows the inflammation to go down and normal function to continue. Mesalamine is also commonly prescribed as it relieves symptoms and inflammation, and has also been proven to be 45-55% effective in the sending UC and CD into remission. In severe cases, the gut is too damaged to continue use and it is therefore appropriate to remove and resect portions of the gut. This has been proven as an effective treatment (Mahan). One consequence of this, however, is the chance of developing Short Bowel Syndrome (SBS) in which the portion of gut removed is too large and malnutrition related to malabsorption occurs (Nelms).
4. Adequacy of Nutrition Rx: In mild to moderate cases, a low-fiber diet may be initiated in order to reduce the risk of further damage to the intestinal tract. In more severe cases, bowel resection and a modified consistency diet or even temporary TPN may be administered (Nelms). Corticosteroid use can also effect specific nutrient intake: calcium, vitamin D, magnesium, and Vitamin K. If used to long term, even more deficiencies become possible such as vitamin C, vitamin B12, folic acid, zinc, and selenium (Vavricka).
5. Goals: Both UC and Crohn’s disease are rarely cured, can sometimes require surgery, and include lifelong intermittent and repeated exacerbations (Nelms). Therefore, the goal is to decrease the strain on the gut via a low fiber, low residue, and/or low dairy diet especially during periods of exacerbations. Modifications in the diet can also prolong exacerbations if trigger foods are identified.
6. Does it Meet DRI: Low residue, low fiber, and/or low dairy diets have the ability to meet the DRIs in all categories with proper nutrition education. Based on weight fluctuations and lab values, supplements may be needed if the gut is not absorbing enough nutrients.

Education Material

4. Nutrition Therapy: “Low-residue” is actually starting to become outdated and is the term “Low-fiber” is not the preferred term of the Academy of Nutrition and Dietetics. The only reputable difference between the two terms is the elimination of milk in a low-residue diet, however milk has been found to be a medium residue food, and therefore it is simpler to identify patients as being on a low-fiber regimen and then specify whether the diet is lactose-free or if lactose is tolerated as in some cases, lactose-intolerances or lactose sensitivities coexists with Ulcerative Colitis and Crohn’s Disease (Cunningham).
5. Ideas for Compliance: Keeping a food journal is highly encouraged to help patients monitor foods that are causing symptoms. Nutrition education should be implemented on reading labels, altering menus, and tracking symptoms. Also, education on increasing caloric intake to match needs and increasing specific micronutrient needs that are lacking in that individual may be necessary.

Sample Menu

5. Foods Recommended: Low fiber grains, skinless poultry and tender meats (not fried), canned or soft fruits without seeds, well-cooked vegetables (excluding beans and legumes), and dairy products as tolerated.
6. Foods to Avoid: Nuts, seeds, whole-grain products, raw or dried fruits, raw vegetables, certain cooked vegetables (peas, broccoli, squash, cabbage, corn, onions, cauliflower, the skins of potatoes), beans, lentils, tofu, tough meats, crunchy peanut butter, jam or marmalade with seeds, pickles, sauerkraut, popcorn, fruit juices with pulp.
7. Example of a meal plan

Breakfast

• Decaffeinated coffee with cream and sugar
• Cup of juice, such as no-pulp orange juice, apple juice, or cranberry juice
• Cream of wheat
• Scrambled eggs
• Waffles, French toast, or pancakes
• White-bread toast with margarine and grape jelly (no seeds)
• Milk (if tolerable)

Lunch                           

• Baked chicken, white rice, canned carrots, or green beans
• Salad with baked chicken, American cheese, smooth salad dressing, white dinner roll
• Baked potato (no skin) with sour cream and butter or margarine
• Hamburger with white seedless bun, ketchup, and mayonnaise — lettuce if it doesn’t worsen your symptoms
• Cheeses (if tolerable)

Dinner

• Tender roast beef, white rice, cooked carrots or spinach, white dinner roll with margarine or butter
• Pasta with butter or olive oil, French bread, fruit cocktail
• Baked chicken, white rice or baked potato without skin, and cooked green beans
• Broiled fish, white rice, and canned green beans
• Cheese (if tolerable)

Websites

6. Organizations with Websites

• Crohn’s and Colitis Foundation of America: http://www.ccfa.org/

1. Government Websites

7. References
8. Journal articles references

Best WR, Becktel JM, Singleton JW, Kern F Jr. Development of a Crohn’s disease activity

Index (1976). National Cooperative Crohn’s Disease Study. Gastroenterology 1976;

70: 439–44.

Cunningham, E. (2012) Are low-residue diets still applicable? Journal of the Academy of

Nutrition and Dietetics, 112(6), 960.  doi: 10.1016

Mahan, L. K., Stump, E., & Raymond, J.L. (2012). Krause’s Food and the Nutrition Care Process. 12^th edition. Elsevier/Saunders, St. Louis, MO; 2012

Nelms, K. Sucher, K. Lacey, S. Roth (2011). Nutrition Therapy and Pathophysiology.

Vavricka, S., Schoepfer, A., Scharl, M., & Rogler, G. (2014). Steroid Use in Crohn’s Disease.

Drugs, 74(3), 313-324.

Diet Instruction: Self-Made Case Study

Description of Patient and Diagnosis

Patient Summary: Jessica Crowns was diagnosed with mild Crohn’s disease 1 week ago.

History:
Onset of disease: Dx. Crohn’s disease 1 week ago
Medical history: Diagnostics revealed that damage was present in the latter half of the ileum and a small portion of the colon. Jessica has been taking corticosteroids. Most recent Dx. Suggests immunosuppressing medications have allowed Jessica’s gut to heal.
Family history: What? Inflammatory bowel disease. Who? Maternal Aunt.

About:
Age: 16
5’ 2” 102 pounds (UBW 107 pounds)

Bio: Jessica is a sophomore in high school and is very active – she participates in cross country and track, and works at the local Boys and Girls club. Jessica states that in the last few weeks she has had very little energy and little appetite due to stomach pains. Jessica had lost 5 pounds in the 3 weeks prior to diagnosis, and missed school several times this past week from excessive bowel movements and diarrhea.

Complaints of stomach pain, tiredness, frequent bowel movements, diarrhea.

Dx: Barium X-rays reveals that Jessica had some abnormalities in her lower small intestine. An endoscopy revealed that Jessica has mild Crohn’s disease in the ileum and beginning portion of the colon.

Necessary Lab Values: CDAI of 190

Tx: Corticosteroid 1/day until symptoms subside.

Medical Nutrition Therapy Goal: Diet should be altered as necessary to provide patient with comfort as the gut heals, as well as decrease likelihood of worsening symptoms. Proper weight gain should be a priority.

Etiology

Inflammatory bowel disease is defined as chronic inflammation of all or parts of the gastrointestinal tract. The pain caused by this disease, as well as other signs and symptoms, can have a huge impact on a person’s life. The two most commonly found diseases under this category are ulcerative colitis (UC) and Crohn’s Disease. Jessica is a 16-year old who was just diagnosed with Crohn’s Disease. Crohn’s disease is the inflammation of sections of the intestine – usually the latter half of the ileum and the beginning of the colon. It can also effect the thickness of the entirety of the GI tract. This damage leads to malabsorption, malnutrition, abdominal fistulas and abscesses, intestinal obstruction, bacterial overgrowth, gallstones, kidney stones, urinary tract infections, thromboembolic complications, perianal disease, and neoplasia (Nelms).

The etiology of this disease is unknown but the following factors are linked to CD: smoking, infectious agents, intestinal flora, genetics, and an abnormal inflammatory response in the small intestine. The peak onset of Crohn’s disease is in the teens and twenties. Signs and symptoms include diarrhea, abdominal pain, weight loss, fever, urgent need to move bowels, constipation, and blood or mucus in the stool (Nelms).

Diagnostic Measures

Diagnostic techniques include abdominal ultrasound, MRI, CT, antiglycan antibodies (ASCA) levels, and ferritin/transferrin levels. Colonoscopies and endoscopies are also used to look at the gut in order to determine the current severity of the disease (Crohn’s and Colitis Foundation). Crohn’s Disease Activity Index (CDAI) is used to give a numerical value to the severity of a patient’s current disease state. The scale is broken up into different stages of mild to moderate disease (CDAI 150 – 220), moderate to severe disease (CDAI 220-450), severe-fulminant disease (CDAI >450). Remission is also a stage in which the individual is asymptomatic due to medical intervention or surgical resection. Those with mild to moderate disease are at low risk of dehydration, toxicity, high fevers, abdominal tenderness, painful mass, obstruction, or more than a 10% weight loss (Best). Jessica falls into the category of mild to moderate with a CDAI of 190.

Treatment

Medical/Surgical/Psychological: Jessica has been prescribed to take Corticosteroids. These keep the immune system from fighting infection. Crohn’s disease is a disease in which the immune system attacks the intestinal tract, therefore the use of corticosteroids decreases the severity of symptoms by suppressing the body’s immune system which is attacking the GI lining. This results in the inflammation going down and normal function continues. Corticosteroids are not to be used long term or there is a possibility that the body will become dependent, so use is to be stopped or decreased once the body has gone into remission (Vavricka). Based on this severity, treatment options can range from simply diet alterations to medicinal interventions such as corticosteroids to the surgical removal of portions of the GI tract. In mild to moderate cases, a low-fiber diet may be initiated in order to reduce the risk of further damage to the intestinal tract. In more severe cases, bowel resection and a modified consistency diet or even temporary TPN may be administered (Nelms).

Medical Nutrition Therapy: Both UC and Crohn’s disease are rarely cured, can sometimes require surgery, and include lifelong intermittent and repeated exacerbations (Nelms). According to Nelms, there is research that suggests that a long-term low-residue diet can decrease the number of inflammatory outbreaks, or even slow the effect of the disease. However, this information is outdated and is no longer supported by the Nutrition Care Process created by the Academy of Nutrition and Dietetics (Cunningham). It is now referred to as simply a low-fiber diet. This is due to the inconsistency of the term “low-residue” as the only reputable difference between low-residue and low-fiber is the elimination of milk. However, milk is actually a medium residue food. Overall, the Academy of Nutrition and Dietetics’ Nutrition Care Manual does not support the “low-residue” diet, but supports low-fiber diets for those with bowel resection, ileostomy, Crohn’s disease, and ulcerative colitis (Cunningham).

Research has been unsuccessful at determining what specific foods are the culprit for everyone with this condition. Bottom line: there’s no one diet to alleviate Crohn’s disease. Yet, important steps in treatment for Crohn’s include keeping a detailed food diary, avoiding foods that cause symptoms and consulting with a registered dietitian experienced in digestive health.

Nutrient Needs

Nutrient deficiency is a common concern as the inflammation and damage to the internal wall of this condition interferes with nutrient absorption. As a result, people with Crohn’s disease need a nutrient-rich diet with adequate calories, protein and healthy fats. For Jessica, the primary goal is for her to return to her usual body weight by finding foods that are irritating her gut lining, and eliminating those foods short term. When symptoms subside, these foods can then be consumed in moderation with an awareness of symptoms worsening. Multivitamins may also be needed. Corticosteroid use can also effect specific nutrient intake: calcium, vitamin D, magnesium, and Vitamin K. If used to long term, even more deficiencies become possible such as vitamin C, vitamin B12, folic acid, zinc, and selenium (Vavricka).
Jessica is going to be put on a diet of 1,900-2,200 kcal diet until her weight returns to normal. The focus will be on taking in nutrient dense foods as absorption may also be currently compromised. When symptoms subside, Jessica may return to a predominantly normal diet that eliminates or reduces the frequency of foods that were determined as irritants for her specifically. This will be done through her keeping a journal. Lactose-intolerance will be tested, and lactaid tablets may be administered if needed.

Prognosis

There is no cure. Treatment with anti-inflammatory steroids and proper diet can suppress symptoms and prolong the time between episodes. Some may experience inflammation and irritation often while some can go decades with suppressed symptoms. The severity range varies widely. Some experience one episode while others experience frequent spurts with minimal suppression in between. In severe cases, surgery can be done to remove the most damaged areas of the bowel (Mahan). Death is very rarely a result of Crohn’s disease with technology, so there is a normal life expectancy.

References

Best WR, Becktel JM, Singleton JW, Kern F Jr. Development of a Crohn’s disease activity

Index (1976). National Cooperative Crohn’s Disease Study. Gastroenterology 1976; 70:

439–44.

Christian, G.M., Alford, B., Shanklin, C.W., & DiMarco, N. (2013) Milk and milk products in

low-residue diets: Current hospital practices do not match dietitians’ beliefs. J Am Diet

Assoc. 91:341-342

Crohn’s and Colitis Foundation of America (2015). What is Crohn’s Disease? Retrieved

February 16, 2015 from http://www.ccfa.org/what-are-crohns-and-colitis/what-is-crohns-

disease/

Cunningham, E. (2012) Are low-residue diets still applicable? Journal of the Academy of

Nutrition and Dietetics, 112(6), 960.  doi: 10.1016

Mahan, L. K., Stump, E., & Raymond, J.L. (2012). Krause’s Food and the Nutrition Care

Process. 12^th edition. Elsevier/Saunders, St. Louis, MO; 2012

Nelms, K. Sucher, K. Lacey, S. Roth (2011). Nutrition Therapy and Pathophysiology.

Vavricka, S., Schoepfer, A., Scharl, M., & Rogler, G. (2014). Steroid Use in Crohn’s Disease.

Drugs, 74(3), 313-324.