Let's Talk About Crohn's Disease and Diet

Eating is one of life’s greatest pleasures. But eating when you’ve got Crohn’s disease is a double-edged sword. On the one hand, it can make symptoms worse, especially during a flare. On the plus side, the right meal plan can help medications work more effectively, minimize GI issues, heal your digestive tract, and boost your immunity. There’s no one-size-fits-all plan, but there are basic rules that can help you make smart food choices if you have Crohn’s. Here’s what to know.

What Is Crohn’s Disease Again?

Let’s review: Crohn’s disease causes inflammation of the digestive or gastrointestinal (GI) tract and can impact everything from your mouth (in the form of canker sores) to your anus. It’s most likely to strike in the small or large intestine, though, and is referred to as an Inflammatory Bowel Disease (IBD) for the havoc it can wreak.

Crohn’s is triggered by the immune system’s white blood cells attacking your body’s healthy tissue. That produces inflammation, causing ulceration and tissue swelling that limits the intestine’s ability to process food, absorb nutrition, and eliminate waste. The result: Abdominal pain, diarrhea, and weight loss.

Crohn’s is an equal opportunity employer, affecting the same number of men and women. While it can occur at any age, it happens most frequently between the ages of 15 and 30, and again in your 50s and 60s.

How Crohn’s Disease Affects Nutrition

A little backstory: Your small and large intestines each have a specific task to do. Foods and beverages travel through the small intestine first, where vitamins, minerals, and other nutrients are absorbed. When what’s left arrives in the large intestine, also known as the colon, it sucks up the excess water and salt from the waste material before converting it to stool.

When you have Crohn’s disease, however, these organs stop doing their job. The inflamed small intestine isn’t able to fully digest food, so you lose out on both macronutrients like proteins, carbs, and fats (all sources of energy), and micronutrients, which are the vitamins and minerals your body needs. As a result, incompletely digested food then travels on to the colon, causing diarrhea. If your colon is also affected by Crohn’s disease, it struggles to absorb water, and that excess liquid joins the diarrhea and creates the urgent need to go to the bathroom.

All of which is to say, even if you’re eating healthy, during a Crohn’s flare, many of those good nutrients go to waste—literally. Add to that the fact that your body needs more calories than usual during a flare, and you’ve got a recipe for malnutrition. People at greatest risk are those who:

• have severe or chronic diarrhea, which robs the body of water, nutrients, and electrolytes
• have numerous bowel movements, which can cause them to cut back on eating to avoid trips to the bathroom
• have nausea or abdominal pain, which can reduce their appetite
• have had surgical removal of parts of the small intestine, which can interfere with absorption
• have ileostomies (abdominal wall openings made via surgery), that can lead to nutrient losses and dehydration

Basically, it’s a messy situation that calls for professional help. A knowledgeable dietitian (your GI doc can recommend one) can tailor nutrition recommendations to your needs. You should also be tested often—via bloodwork—for vitamin and mineral deficiencies and drink plenty of water. The good news: With the help of a Crohn’s specialist, it’s possible to devise a diet that minimizes some of the worst aspects of the disease while helping you build a nutritional reservoir to carry you through the rough patches. Start with these strategies for how to eat during a remission or flare.

What to Eat During Remission

There is no single diet plan for Crohn’s disease because the illness and symptoms manifest in so many different ways. In general though, you'll want to avoid processed foods that can trigger gut inflammation, and primarily follow a Mediterranean Diet of whole grains, vegetables, fruits, healthy fats, lean meats, fish, beans, and eggs. Nourishing your body during the good times means you’ll be in better shape to handle the flares and surgical procedures, if necessary. When you’re in remission, focus on eating these nutrient-packed options:

• Fiber-rich foods: It’s a myth that Crohn’s patients should skip fiber. Fiber is loaded with prebiotics, which may improve the balance of good bacteria in your gut. Plus, studies show that eating fiber when you’re not in a flare can help keep you in remission longer. Include whole grain breads and pasta, as well as oat bran, beans, barley, and nuts. Check labels to see that whole grains are the first ingredient listed with at least three grams of fiber per serving.

• Protein: Focus on lean meats (and eat only a little red meat), fish, eggs, nuts, nut butters, and tofu. Avoid processed and high-fat meats, sausages, bacon, hot dogs, bologna, and cold cuts.

• Fruits and vegetables: Go whole hog on as many of these as you like. Aim for at least five and up to nine servings—a half cup cooked or a whole cup raw—daily. Try to eat a rainbow of colors for the best balance of nutrients.

• Calcium-rich foods: These include broccoli, kale, collard greens, oranges, white beans, and almonds, as well as milk, yogurt, and cheese. If you are lactose intolerant, like a lot of people with Crohn’s, choose lactose-free dairy options such as fortified almond and rice milk, or take a lactase enzyme supplement before eating dairy.

What to Eat During a Flare

Like so much else with Crohn’s disease, experiencing a flare is highly individual. Some people may find a few dietary adjustments are all that’s needed, while others will have symptoms that prevent them from eating a normal diet for days or even weeks at a time. It takes a little detective work to discover your triggers: Use a notebook to track everything you eat, how you feel afterwards, whether or not symptoms follow, and the overall status of your disease at the time.

In general, you’ll probably want to avoid:

• Spicy foods
• Greasy and fried foods
• Butter, margarine, mayonnaise, oils
• Gas-producing foods (beans, cabbage, broccoli, carbonated drinks)
• Lactose-rich foods (dairy)
• Foods with sugar (pastries, candy, juices), artificial sweetener, and sugar alcohols (found in sugar-free gum, candy, ice cream)
• Caffeine
• Alcohol
• Insoluble (difficult to digest) fiber, including fruits with skin and seeds, raw green vegetables, whole nuts, and whole grains

Some fiber may be OK during a flare, just be sure to peel, de-seed, and cook it first. A Granny Smith is a no go, for instance, but applesauce is probably alright.

Bottom line: Eat like a picky kid during a flare—bland and boring are your best friends. Try these options:

• Refined grains: white rice, noodles and pasta; oatmeal; white, potato, sourdough or gluten-free breads

• Lean protein: skinless, white-meat chicken or turkey; pork; eggs; fish; tofu

• Low-fiber fruits: bananas, cantaloupe, honeydew, peeled ripe peaches, and cooked fruits, such as applesauce

• Well-cooked, skinless, seedless, non-cruciferous produce: carrots, squash, asparagus tips, potatoes

• Oral nutrition supplements: Drinking Boost, Ensure, or Orgain daily during a flare is a great way to ensure you’re meeting your nutritional needs and getting enough calories. They’re easier on your digestive system and may even protect or improve your small intestine’s ability to absorb nutrients.

You also may be able to tolerate yogurt, smoothies, protein shakes, canned fruit without added sugar, and pureed vegetable soups. Don’t be afraid to experiment—just take it slow by trying a little at a time and waiting a day or two to see if symptoms develop before you have more or try something else new.

What Vitamins and Mineral Supplements Should I Take?

Crohn’s raises your risk for nutritional deficiencies because your body doesn’t digest food properly, meaning important nutrients may be expelled rather than put to good use. Flares, severe symptoms, surgeries, and other complications add to the difficulty of getting proper nutrition. Not helping matters, some medications you need to take can inhibit nutrient absorption, including prednisone, sulfasalazine, and methotrexate. Your doctor will do bloodwork and may prescribe supplements to help alleviate these deficiencies and prevent you from becoming malnourished.

Common deficiencies seen in Crohn’s patients are:

• Vitamin B12
• Vitamin D
• Iron
• Calcium
• Vitamin A
• Vitamin K
• Vitamin E
• Folate
• Magnesium
• Zinc
• Potassium

Anemia—a condition in which you lack the healthy red blood cells needed to carry oxygen to the body’s tissues—is a common issue when iron levels are low.

It’s important to not take any supplements without the approval of your doctor, since some may contain ingredients like lactose, artificial colors, sugar alcohols or preservatives that can aggravate your Crohn’s disease symptoms.

Meal Strategies With Crohn’s

When you’ve got Crohn’s, the traditional three-meals-a-day pattern is not necessarily the best. You may not be able to eat enough to carry you from, say, breakfast to lunch, and even if you can, large meals can tax your already sensitive digestive system. Try these strategies:

• Go small. Eat smaller meals about four to six times daily. Grazing helps intestines better absorb nutrients.
• Drink a lot. Aim for 64 ounces of water a day, but at the right time. Stick to about a half a cup of liquid at meals, then wait at least 20 minutes after eating before drinking more. Sip, don’t guzzle. You’ll know you’re getting enough liquid if your urine is clear to light yellow.
• Avoid chewing gum between meals. You’ll ingest excess air, leading to gas.
• Cook foods simply. Choose steaming, boiling, poaching or grilling.

Special IBD Diets

Diets that aim to exclude certain types of foods are controversial within the medical community because they risk nutritional deficiencies and weight loss—the last things many Crohn’s patients need—and are limited in research showing their success. They can also be challenging to stick to when you may already be stressed. The upside: One of them may help if you’re game to try.

• Carbohydrate exclusion diet: Grains, fiber, and some sugars are either limited or totally excluded. You also have to pass on potatoes, okra, and corn. The theory is that hard-to-digest complex carbs can promote the growth of harmful gut bacteria, so cutting them out reduces bad bacteria and gives the intestines a chance to heal.

• Semi-vegetarian diet: In this primarily plant-based diet, participants are allowed fish once a week and meat once every two weeks. These foods are allowed anytime: Fruit, vegetables, eggs, yogurt, legumes, brown rice, miso, and pickled vegetables. Some research suggests a semi-vegetarian diet may help treat inflammation and reduce symptoms by improving the balance of beneficial gut bacteria.

• Low-fiber diet: This plan eliminates green leafy vegetables, nuts, seeds, popcorn, whole grains, and raw fruits with peels. It may help reduce both cramping and bowel movements and can also benefit patients with a stricture or bowel obstruction, or after surgery when your gut needs time to heal.

• Low-FODMAP diet: FODMAP is an acronym for a group of carbs and sugar alcohols (fermentable, oligosaccharides, disaccharides, monosaccharides, and polyols) that are poorly absorbed by the body and notorious for triggering gas, cramping, and bowel urgency. The diet eliminates certain vegetables, fruits, beans, lentils, wheat, dairy products with lactose, high fructose corn syrup, and artificial sweeteners, and is only meant for short-term use.

• Gluten-free diet: Eliminating gluten—a protein found in wheat, barley, and rye—may help with symptoms, but there is no evidence it reduces inflammation. In one study, more than 65 percent of IBD participants who tried a gluten-free diet reported an improvement in symptoms, and 38 percent claimed fewer or less severe flares. Another upside? Less fatigue.

• Liquid diet: In certain instances, enteral nutrition, or consuming nutrients in liquid form, can be really helpful as it gives your intestines a much-needed rest from digesting whole foods. Beverages like Ensure, Boost, and Orgain contain all the proteins, carbohydrates, fats, minerals, and vitamins you need if you are unable to eat solid foods. Liquid diets are sometimes used for people with short bowel syndrome from multiple surgeries, or in the case of an extremely severe flare.