Tips on Staying Healthy

This handout was authored by OHIO GI specifically for our IBD patients to provide tips on how to stay healthy.

Staying Healthy with Ulcerative Colitis and Crohn’s Disease

Table of Contents

Preventing IBD Flare Ups

Dietary and Nutritional Strategies for IBD

Vaccinations for IBD Patients

Extra-Intestinal Manifestations of IBD

Other Staying Healthy Issues

Staying Healthy Tips for IBD Patients

PREVENTING IBD FLARE UPS

SOME POSSIBLE CAUSES OF IBD FLARE UPS:

• Stopping your IBD meds
• Gut infection
• Anti-inflammatory meds
• Diet?
• Antibiotics
• Stress?
• Seasonal flares
• Smoking
• Flares can occur without any identifiable factor.

WHAT CAN YOU DO TO TRY TO AVOID A FLARE UP?

1.) Take your Medications
Medications Can Keep You in Remission

• 89% of patients with ulcerative colitis who continue to take their medication (mesalamine) while they feel well maintain wellness compared with only 39% of patients who stop taking their medication.  This benefit is also seen for many Crohn’s disease medications.
• For many medications there is a relationship between dose of medication and response to it. Thus, reducing your dose without discussing with your doctor or forgetting to take doses may risk a flare.

Medical Treatment Promotes Mucosal Healing

• Even if you feel well, there may still be active inflammation on a microscopic level that can continue to heal by taking IBD meds. Healing as determined microscopically leads to fewer flare ups and less surgery for Ulcerative Colitis and Crohn’s disease.

Medications May Reduce Colon Cancer Risk

• Ulcerative colitis increases the risk of colorectal cancer. Research studies indicate a lower colon cancer risk if the disease is maintained in long term remission and also probably a direct cancer reduction effect of medications such as mesalamine.

Problems Taking Medications?

• If you forget to take them – let’s try to simplify the dosing schedule.
• If you feel well thus think you “don’t need meds” – this risks a flare up.
• Having possible medication side effects – let’s discuss and make some changes.
• Medications not working – let’s discuss and make some changes.
• If you cannot afford your medications – we can try to find free samples and sometimes pharmaceutical company assistance plans. In making medication recommendations, we try to take into consideration effectiveness, safety, and cost of prescriptions.

2.) Avoid Anti-inflammatory Medications (NSAID’s)

• Anti-inflammatory pain medications also known as nonsteroidal anti-inflammatory drugs (NSAID’s) are effective pain relievers and include medications such as ibuprofen, naproxen, aspirin and many others.
• They have been noted to occasionally precipitate a flare of IBD probably due to an effect on increasing permeability (leakiness) in the GI tract which promotes an inflammatory response. Celebrex, a selective “COX-2” anti-inflammatory, might have a lower risk of causing a flare.

3.) Caution with Antibiotics

• Humans normally live with an extensive bacterial population in our GI tract. Alteration of the healthy balance of bacteria may impact the immune system in the GI tract and promote inflammation.
• Use careful consideration as to the necessity of antibiotic use, when possible.

4.) Seasonal IBD Flares

• It is observed that some patients have flares during certain seasons. Whether this is related to environmental allergies or other mechanism is not known.

5.) Gut Infections

• Getting a virus or other infection in your GI tract stimulates the immune system and can activate inflammation.
• Prevention involves proper food handling and hand washing.

6.) Stress and IBD

• Do you think stress causes flares? Most patients (and their significant others) do.
• Correlation between stress and IBD flares is not well established in research studies, but… stress causes an increase in inflammatory mediators like tumor necrosis factor (TNF).
• Stress may also act to heighten symptoms of already active IBD.

7.) Do Not Smoke
Smoking and Crohn’s Disease

• 75% of people with Crohn’s smoke.
• Crohn’s disease is often more severe in smokers.
• Smoking reduces the response to treatments.
• Smoking increases recurrence after surgery for Crohn’s disease.
• Not smoking is critical to achieve and maintain health.

Smoking and Ulcerative Colitis

• Ulcerative colitis can actually develop or worsen after smoking cessation.
• The risks and consequences of smoking far outweigh any potential benefit.
• Smoking is not advised to treat or improve the health of patients with ulcerative colitis.

DIETARY AND NUTRITIONAL STRATEGIES FOR IBD

Overall Nutritional Concepts in IBD

• IBD and diarrhea can deplete essential fluids, nutrients and electrolytes, leading to dehydration, weight loss, malnutrition, and fatigue.
• Good nutrition plays an important role in staying healthy and coping with flare-ups of the disease. Weight loss and malnutrition can impair the body’s metabolic machinery needed to heal.
• No specific foods have clearly been identified to cause IBD flares but some foods have a stimulant effect on the GI tract and can accentuate symptoms.
• No one diet is right for all IBD patients.

“The Liberal Bland Diet”  –  For patients with active IBD and diarrhea.

• Eat: mildly seasoned foods that are low in fat and fiber, such as eggs and lean meat. Cooked and canned fruits and veggies are easier to digest.
• Avoid: spicy foods, caffeine, alcohol, raw vegetables and fruits, fast food, fried food, and milk if lactose intolerant.

“The Low Residue Diet” – For Crohn’s Disease with strictures (narrowing) of the bowel.

• Poorly digestible foods that do not liquefy during passage through the bowel can clog a narrowed area in the bowel. Chew everything thoroughly before swallowing.
• Eat: meat, fish, poultry, eggs, breads, and cooked or canned fruits and vegetables.
• Avoid: “chunky foods” such as raw fruits, corn, popcorn, nuts, seeds, raw vegetables, whole grains.

“The High Protein/High Calorie Diet” – To replenish protein and calories depleted through diarrhea and poor appetite and to prevent deficiencies.

• Eat: meat, soy, whole milk, grains, fruits and vegetables, milk shakes, protein/energy bars and drinks, and take a multivitamin. 
• Avoid: high-calorie foods with little nutritional value, such as sweets and desserts.

“The Lactose-Free Diet” – For patients who suffer from lactose intolerance.

• Less than 40% of people worldwide are able to digest milk after childhood due to reduction or loss of the enzyme (lactase) in the small intestine that breaks down milk sugar (lactose). This causes diarrhea and cramps but is not actually worsening or activating IBD.
• Lactose intolerance occurs in people with and without IBD.
• Eat: yogurt (except frozen), drink soy or lactaid milk, take calcium supplements.
• Avoid: milk (even skim), cheese, ice cream, frozen yogurt. You can enjoy some milk products in small amounts and/or by using over-the-counter lactase supplements (such as Lactaid Fast Act) taken with milk or milk containing foods/beverages.

VACCINATIONS FOR IBD PATIENTS

For IBD patients not on immune suppressing medications:

VACCINE                                                  FREQUENCY
Influenza                                                 Annually
Tetanus, Diphtheria, pertussis               Every 10yr
HPV (Women)                                        3 doses if <26 years old
Pneumococcal vaccine                            1-2 doses, may repeat at age 65.
Hepatitis A                                              Consider for all patients
Hepatitis B                                              Consider for all patients
Meningococcal                                        Give to at risk patients (college students etc.)
MMR                                                       Give if never received
Varicella                                                  Give if never received or never had chickenpox
Zoster                                                      Consider giving to prevent shingles

For IBD patients on immune suppressing medications:

VACCINE                                                  FREQUENCY
Influenza                                                 Annually
Tetanus, Diphtheria, pertussis               Every 10yr
HPV (Women)                                        3 doses if <26 years old
Pneumococcal vaccine                            1-2 doses
Hepatitis A                                              Consider for all patients
Hepatitis B                                              Consider for all patients
Meningococcal                                        Give to at risk patients (college etc.)
MMR                                                       CONTRAINDICATED
Varicella                                                  CONTRAINDICATED  

Consider giving before immune suppressed

Zoster                                                      CONTRAINDICATED

Consider giving before immune suppressed

Smallpox                                                 CONTRAINDICATED
Live Typhoid                                            CONTRAINDICATED

EXTRA-INTESTINAL MANIFESTATIONS OF IBD
Extra-intestinal manifestations of IBD are problems that occur outside of the digestive tract that are associated with having IBD.

1.) Arthritis

• Occurs in 15-30% of patients with IBD

Peripheral form (affects mainly the knees, hips, elbows).

• The most common type of joint involvement in IBD.
• Indicates active IBD – treating the IBD usually improves the joint aches.

Central form (affects the lower back).

• Also known as sacroileitis and ankylosing spondilitis.
• Back pain does not correlate with activity of IBD and is treated independently.

2.) Skin

• Occurs in 1-3% of patients with IBD
• Erythema nodosum – red raised painful areas usually on the skin of the lower leg.
• Pyoderma gangrenosum – sores/pustules/ulcers usually on lower leg.

3.) Oral Sores

• Sores (ulcers) can occur in the mouth, on the gums, and on the inner cheek as part of having IBD.

4.) Ocular (Eyes)

• Eye problems associated with IBD occur in 3-5% of patients.
• Inflammation in different parts of the eye causing redness, tenderness, itching, and blurred vision.

5.) Liver

• Occurs in 2-5% with IBD.
• Primary sclerosis cholangitis (PSC) from inflammation of the bile ducts.
• PSC can be present without symptoms and cause just elevations in liver blood tests. When it progresses it results in liver dysfunction and fatigue, itching, and jaundice, and eventually cirrhosis and possible cancer of the bile ducts.
• PSC also increases the risk of colon cancer.

6.) Kidney

• There is a higher incidence of kidney stones in patients with IBD, especially after an ileostomy and in Crohn’s disease after significant small bowel surgical resection.

7.) Osteoporosis

• Occurs in about 20% of patients with IBD
• Osteoporosis is thinning of the bones that increases the risk of bone fractures.

Osteoporosis Risk Factors:

• Low calcium and vitamin D intake.
• Low body weight for height.
• Limited exercise.
• Excessive use of caffeine and/or alcohol.
• Cigarette smoking.
• Medications (steroids).
• Inflammation (having IBD directly contributes to developing osteoporosis).

Steroid-Induced Osteoporosis

• All ages and both genders are at significantly increased risk of osteoporosis when treated with steroids (prednisone and others).
• Significant bone loss can occur after as little as 3 months of steroid use.
• 50% chance of developing osteoporosis if on steroids for 6 months or more.
• Higher dose and longer period of time on steroids increase risk of osteoporosis.
• Even low dose (2.5mg per day) increases fracture risk.

Preventing Osteoporosis in IBD

• Avoid/minimize steroid use when possible.
• Adequate daily calcium (1,000-1,500mg/day) and vitamin D (1,000-2,000 IU/day) intake.
• Get regular exercise.
• Do not smoke.
• Bone density (DEXA) scan to assess and follow up bone health.

8.) Anemia

• Occurs in about 16% of outpatients and 68% of hospitalized patients with IBD.
• Symptoms can include: fatigue, shortness of breath, headaches, and dizziness.
• Caused by: inadequate iron intake in the diet, bleeding (visible or microscopic bleeding), malabsorption of iron or vitamin B12.
• Treated by eating more iron containing foods (meat etc.), taking iron supplements, and sometimes intravenous iron infusions and blood transfusions.

9.) Blood Clots

• IBD can cause a hypercoagulable state  (a higher risk of developing blood clots).
• Blood clots can occur in the veins of the legs (deep vein thrombosis or DVT) and travel to the lungs (pulmonary embolus or PE) as well occur at other unusual sites in the body such as blood vessels supplying the gut, eyes, and other.
• Symptoms vary as to the site of blood clot (leg swelling, shortness of breath, etc.)

OTHER STAYING HEALTHY ISSUES

1.) Some Alternative and Herbal Products in IBD

• St John’s Wort – has worsened symptoms of IBD.
• Garlic – can stimulate immune system and potentially exacerbate IBD.
• Peppermint oil – can reduce spasm and pain.
• Aloe Vera – did not work in UC, has a laxative effect.
• Fish oil – shown only limited benefit.
• Echinacea – should not be given with immunosuppressants.
• Evening primrose oil – can cause nausea and gastric discomfort.
• Bovine colostrum – can cause nausea and gastric discomfort.
• Curcumin (the yellow pigment in tumeric) – may have beneficial anti-inflammatory properties.

2.) Probiotics for IBD

• Probiotics are live “good” bacteria given in a capsule or yogurt. They are generally considered to have little to no harmful effect.
• Probiotics are possibly helpful but no definitive recommendations can be made currently.
• Ongoing research should provide much needed information.

3.) Physical Activity and IBD

• A group of sedentary patients with inactive ulcerative colitis were studied and were instructed to walk 30 minutes three times per week. No flares developed. Patients noted a significant improvement in sense of well being.
• Especially for patients that feel well, regular exercise is part of a healthy lifestyle program.
• If IBD is significantly active, vigorous or prolonged aerobic exercise probably should be avoided or minimized.

4.) IBD and Cancer

• There is an increased risk of colon cancer in patients with ulcerative colitis and Crohn’s when it involves a significant length of the colon.• Surveillance colonoscopy with biopsies is done every 1-2 years after 8 years of having extensive ulcerative colitis or Crohn’s colitis. These examinations are done to obtain biopsies looking for precancerous changes even if the disease is in remission for a prolonged period.
• Mesalamine slightly reduces cancer rates in ulcerative colitis – don’t stop taking it!
• Human Papilloma Virus (HPV) and cervical cancer are more common in women on immune modulator therapy for IBD. Women less than 26 years old should consider vaccination before starting immune modulating therapies, if possible.

STAYING HEALTHY TIPS FOR IBD PATIENTS

• Find the right medications for you.
• Take your medications as prescribed.
• Talk to us if you are having any problems with or questions about your medications.• Try to avoid anti-inflammatory pain medications (ibuprofen etc). Acetaminophen (Tylenol) is generally OK to use.
• Let all your doctors know about any over-the-counter, herbal, and alternative products you take.
• Caution when using antibiotics.
• Eat healthy and well balanced foods.
• Do not smoke.
• Recognize the possible stress in your life. IBD can certainly add to your stress.
• Get regular exercise: it’s good for stress reduction too.
• Remember about bone health: adequate intake of calcium and vitamin D and get periodic bone density scans.
• Stay up to date on vaccinations. Discuss this with your primary care physician too.
• Discuss with us your possible increased risk of cancers and what we can try to do to prevent it.
• Be on the lookout for the extra-intestinal manifestations of IBD.
• Join the Crohn’s and Colitis Foundation of America (CCFA)

The CCFA supports research, has supports groups, supports education, and supports You!   (513)-772-3550