Crohn's Disease and Nutrition: Complete Guide

Understanding Crohn's Disease and Nutritional Challenges

Crohn's disease is a chronic inflammation that can affect any part of the digestive system from mouth to anus, but most commonly affects the end of the small intestine (terminal ileum) and the beginning of the colon. It is characterized by inflammation extending through the entire intestinal wall, leading to complications such as strictures, fistulas, and malabsorption.

Nutritional challenges in Crohn's disease are multiple: malabsorption especially of fats and fat-soluble vitamins, increased calorie and protein needs due to inflammation, loss of appetite and nausea, intestinal strictures that limit tolerated food types, and side effects of medications on nutrition.

Malabsorption: The Greatest Challenge

Crohn's disease, especially when involving the small intestine, causes malabsorption of many nutrients.

Most Affected Elements

Fats: Inflammation reduces production of bile salts and enzymes, leading to fat malabsorption and steatorrhea (fatty stools).

Vitamin B12: Absorbed exclusively in the terminal ileum. Involvement or resection of this area leads to inevitable deficiency.

Fat-Soluble Vitamins (A, D, E, K): Fat malabsorption means malabsorption of these vitamins.

Iron: Chronic inflammation and intestinal bleeding cause anemia, not to mention malabsorption.

Zinc and Magnesium: Lost in chronic diarrhea and poorly absorbed with inflammation.

Calcium: Vitamin D malabsorption and dairy avoidance increase the risk of calcium deficiency and osteoporosis.

Managing Malabsorption

• Regular testing of vitamin and mineral levels every 6-12 months
• Correcting deficiencies with high-dose supplements as needed
• Using enhanced absorption forms (e.g., methylcobalamin instead of cyanocobalamin for B12)
• Intramuscular injection when oral absorption fails (especially B12 and iron)
• Increasing caloric intake by 20-30% to compensate for losses

Nutrition During Acute Flares

During flares, the priority is to reduce the burden on inflamed intestines, prevent malnutrition, and control symptoms.

Nutrition Principles During Flares

Low-Fiber, Low-Residue Diet: Essential especially if there are strictures. Avoid raw vegetables, fruits with skins, whole grains, seeds, and nuts.

Easily Digestible Foods: White rice, boiled potatoes, boiled chicken, white fish, boiled eggs, very ripe bananas.

Fat Reduction: If there is steatorrhea, reduce fats to 40-50 grams daily and focus on medium-chain triglycerides (MCT oil) which are absorbed directly.

Small Frequent Meals: 6-8 small meals are better than 3 large ones to ensure adequate calories without exhausting the intestines.

Intensive Hydration: 2-3 liters of fluids daily. Oral rehydration solutions are useful for replacing salts.

Safe Foods During Flares

Proteins: Boiled or grilled chicken (skinless), turkey, white fish (tilapia, sole, haddock), boiled eggs, soft tofu.

Starches: White rice, white pasta, boiled or mashed potatoes (without skin), toasted white bread.

Fruits: Very ripe bananas, cooked and peeled apples, fruit compote, strained juices.

Vegetables: Well-cooked carrots, peeled and cooked zucchini, mashed pumpkin, butternut squash.

Fats: MCT oil, small amounts of olive oil, mashed avocado (small amounts).

Exclusive Enteral Nutrition (EEN)

Exclusive enteral nutrition is a therapeutic protocol based entirely on balanced liquid formulas for 6-8 weeks, without any solid food.

Mechanism of Action

EEN gives the intestines complete rest, reduces exposure to food antigens, improves nutrition, and modulates the intestinal microbiome. Studies have shown efficacy similar to corticosteroids in achieving remission, especially in children.

Types of Formulas

Polymeric: Contains whole proteins, easier in taste and tolerance, suitable for most patients.

Elemental: Contains free amino acids, pre-digested, for severe cases or multiple sensitivities. Taste is more difficult.

Semi-elemental: Contains short peptides, middle ground between the two.

Practical Application

• Patient usually needs 6-8 bottles daily to meet requirements
• Can vary between different flavors
• Chilling improves taste
• If drinking is difficult, nasogastric tube feeding is possible
• After 6-8 weeks, gradual reintroduction of solid food

Efficacy

Remission rate with EEN reaches 60-80% in children, and about 50-60% in adults. The major advantage is mucosal healing without corticosteroid side effects.

Crohn's Disease Exclusion Diet (CDED)

CDED is a relatively recent strategy combining partial enteral nutrition (50% of calories from liquid formula) with carefully selected solid foods.

CDED Principles

The diet excludes foods that may negatively affect the microbiome or increase inflammation: processed products, emulsifiers, trans fats, refined sugars, processed meats, and gluten.

Focuses on: chicken, turkey, and fish, eggs, potatoes, rice, bananas, strawberries, apples, carrots, sweet potatoes, and olive and canola oils.

Phases

Phase One (weeks 0-6): Strict CDED + 50% of calories from liquid formula. Very limited food list.

Phase Two (weeks 7-12): Gradual expansion of list while maintaining 25% of calories from formula.

Phase Three (maintenance): Continuing CDED principles with greater flexibility.

Scientific Evidence

Recent studies have shown that CDED is effective in achieving and maintaining remission in Crohn's disease, with the advantage of being easier to adhere to than complete EEN.

Nutrition During Remission

The goal is to maintain healthy weight, improve nutritional density, support intestinal healing, and prolong remission.

Reintroducing Foods

Begin reintroducing foods gradually, one every 3-4 days. Record tolerance and symptoms. Start with soluble fiber before insoluble fiber.

Suggested Order: Cooked and peeled vegetables → soft fruits → refined grains → fatty fish → ground nuts → well-cooked legumes → whole grains → raw vegetables.

Anti-Inflammatory Diet

Focus on foods that reduce inflammation and support healing:

Omega-3: Salmon, mackerel, sardines - 2-3 times weekly. Ground chia and flax seeds.

Turmeric: Adding turmeric powder to food with black pepper to improve absorption.

Extra Virgin Olive Oil: Primary fat source, rich in anti-inflammatory oleocanthal.

Berries and Anthocyanin-Rich Fruits: Blueberries, strawberries, cherries.

Colorful Vegetables: Carrots, sweet potatoes, pumpkin, cooked spinach.

Supporting the Microbiome

Microbiome health is very important in Crohn's disease:

• Probiotics: Well-fermented yogurt (if lactose tolerant), kefir, naturally fermented pickles.
• Prebiotics: Ripe bananas, cooked oats, cooled and reheated potatoes (resistant starch).
• Dietary Diversity: Target 30 different types of plant foods weekly (as tolerated).

Essential Dietary Supplements

Basic Supplements

Vitamin D: Most Crohn's patients are deficient. Target 40-60 ng/mL. Dose usually 2000-5000 IU daily or more depending on level.

Vitamin B12: Very necessary especially with ileal involvement or resection. 1000 mcg daily orally, or monthly injections of 1000 mcg.

Iron: Anemia is common. Use iron bisglycinate (25 mg elemental) daily, gentler on the stomach. In severe cases, intravenous iron is better.

Folic Acid: 400-800 mcg daily, especially with medications like sulfasalazine and methotrexate.

Calcium: 1200-1500 mg daily (from food and supplements), important for preventing osteoporosis.

Omega-3: 2-4 grams daily of EPA/DHA. Reduces inflammation and supports gut health.

Zinc: 15-30 mg daily. Important for wound healing and immunity.

Magnesium: 300-400 mg daily. Lost with chronic diarrhea.

Supportive Supplements

Curcumin: 1-3 grams daily of enhanced-absorption extract. Studies have shown benefit in maintaining remission.

Probiotics: Specific strains may benefit. Saccharomyces boulardii is especially helpful with diarrhea.

Glutamine: 10-15 grams daily. Supports healing of intestinal lining.

Vitamins A, E, K: According to their blood levels, especially with fat malabsorption.

Managing Strictures and Obstructions

Strictures (intestinal narrowing) are a common challenge in Crohn's disease, requiring special dietary caution.

Low-Residue Diet

Essential with strictures to prevent obstruction:

• Completely avoid: rough fiber, peels, seeds, whole nuts, popcorn, whole corn
• Peel all fruits and vegetables
• Cook vegetables well until very soft
• Chew well and slowly
• Eat small frequent meals

Obstruction Signs

Seek medical care immediately if these appear: severe and increasing abdominal pain, severe bloating, complete stoppage of stool and gas passage, repeated nausea and vomiting.

Trigger Foods in Crohn's Disease

Triggers are very individual, but these are common:

• Dairy Products: Lactose intolerance is common
• Gluten: Some benefit from avoiding it even without celiac disease
• Spicy Foods: May irritate intestines
• Alcohol and Caffeine: Intestinal stimulants
• Processed Foods: Emulsifiers and additives may harm the microbiome
• Saturated Fats: Red meats, fried foods
• Refined Sugars: Feed harmful bacteria
• Artificial Sweeteners: May negatively affect the microbiome

Nutrition and Surgery

Resection of intestinal segments may be necessary in some cases.

Pre-Surgery

Improving nutritional status before surgery improves outcomes: increase calories and protein, correct vitamin deficiencies, maintain good hydration.

Post-Surgery

Phase One (liquids): Water, clear broth, light tea.

Phase Two (full liquids): Milk (if tolerated), liquid formulas, strained juices.

Phase Three (soft foods): Mashed potatoes, pureed chicken, well-cooked rice.

Phase Four (gradual return): Introduce foods slowly and carefully.

After Ileal Resection

Resection of more than 20 cm of ileum requires:

• Lifelong vitamin B12 injections (monthly)
• Bile salt supplements if more than 100 cm resected
• Low-fat diet if there is steatorrhea
• Increased fluids to compensate for losses

Practical Tips for Daily Life

Managing Loss of Appetite

• Small frequent meals are easier than large meals
• Calorie-dense foods (nut butters, avocado, oils)
• High-calorie liquid formulas as snacks
• Eat in a pleasant and comfortable environment

Managing Diarrhea

• Reduce diarrhea-causing foods (fats, caffeine, sorbitol)
• Increase thickening foods (bananas, rice, cooked apples)
• Hydrate well with oral rehydration solutions
• Consult doctor if diarrhea persists

Weight Gain

Many Crohn's patients suffer from underweight:

• Target 500-1000 extra calories daily
• Focus on protein: 1.5-2 grams/kg body weight
• High-calorie snacks between meals
• Protein supplements and high-calorie drinks
• Light resistance exercises to build muscle

When to Consult the Medical Team

Consult a gastroenterologist and dietitian in these cases:

• Unintended weight loss of 5% or more
• Inability to meet nutritional needs from food
• Vitamin or mineral deficiencies proven by tests
• Worsening symptoms despite treatment adherence
• Considering following a special diet (EEN, CDED, SCD)
• Before and after any surgical procedure
• Children and adolescents - to ensure normal growth

Conclusion

Crohn's disease poses complex nutritional challenges requiring an individualized comprehensive approach. Nutrition is not merely supportive treatment, but an essential part of the treatment strategy. Through deep understanding of disease location, disease severity, personal triggers, and malabsorption management, quality of life can be significantly improved.

Exclusive enteral nutrition and CDED diet represent important developments in treating Crohn's disease nutritionally, and may be an alternative or complement to pharmacological treatment. Close work with a specialized medical team including a gastroenterologist and a dietitian experienced in inflammatory bowel diseases is the foundation for success.

Suffering from Crohn's Disease and Need Specialized Nutritional Support?

Dr. Mai Obeid, clinical dietitian, provides personalized consultations for Crohn's disease and inflammatory bowel disease patients.

For Appointments and Inquiries:

WhatsApp: +961 81 337 132