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ILEOANAL POUCH & DIET
Karen Jackson
Dietitian RD, BSc Hons, Sports Nutrition Specialist PG Cert
Oxford University Hospitals NHS Trust
May 2014
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Function of the colon
• Re-absorbs electrolytes e.g. salt (sodium)• Re-absorb water• Forms stool• Fermentation• Synthesize & absorb vitamins
( Vit K, B12, thiamine)
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Post op Guidelines• Improve nutritional status• Light, soft & low fibre• Adequate fluid & salt intake• Regular eating pattern• Re-introduce fibrous foods after 4 wks
in small quantities & well chewed• “Restore eating confidence”
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What should you eat to maintain a healthy body?
• In most cases - a healthy balanced diet
• CHO (55%)
• Fat (30%)
• Protein (15%)
• 5 food groups
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5 Food Groups
1. Fruit & Vegetables
2. Breads, cereals, rice, pasta & potatoes
3. Meat, fish & alternatives
4. Milk & dairy products
5. Fats & sugars
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1. Fruit and Vegetables• Excellent source of many vitamins, minerals &
antioxidants• Aim for as much variety as possible• Aim for 5 or more serves every day – determine
individual tolerance
1 serve =1 medium sized fruit (eg apple, banana, peach, orange)
=2 small fruit eg satsuma, plums=2 tablespoons vegetables=1 small glass fruit juice= 1 small bowl of salad
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Low Fibre High fibre Fresh tinned or stewed:
Apples, cherries, grapes, melon, banana, plums, pears, peaches, plums
(avoiding pips, skin & pith)
Carrot,beetroot,courgette lettuce, spinach, squash, pepper, swede, broccoli or cauliflower florets, skinned cucumber & tomato, turnip
Berry fruits, dried fruit, unripe bananas, kiwi fruit, grapefruit, rhubarb, mango, oranges
Beans & pulses, chick peas, split peas
Brussel sprouts, peas, mushrooms, cabbage, garlic, green beans, okra, onions, leeks & sweetcorn
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2. Bread & Cereals
• Starchy foods provide us with energy
• Excellent source of fibre & B vits
• Cheap & easy to prepare
• Base each meal around
• Opt for lower fibre choices if required– eg sweet potatoes, pasta, noodles, scones,
baguettes, crackers, cous cous, rice krispies, corn flakes
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3. Meat, fish & alternatives
• Protein is essential for growth & repair• Excellent sources of B vits, iron & zinc• Try to have lean & low fat versions
where possible: eg lean meat, poultry, fresh fish, oily fish, eggs, soya products, pulses, nuts
• 1 – 2 serves day (approx. 45g/11/2 oz)
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4. Milk & Dairy foods
• Most abundant supply of calcium – major “at risk” nutrient
• Good sources protein & energy
• Low fat versions have the same amount of calcium
• 3 serves day = 1 glass (250ml) milk
1 pot yoghurt
1 matchbox (30g/1 oz) cheese
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5. Fats & Sugars
• Limit animal fats
• Restrict fats/sugar if excess weight is a problem
• Practice good oral hygiene
• Beware of hidden fats & sugars
• Become a label reader
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Fluid Intake
• Very important (rehydrate well)
• Thirst is not a good indicator of your hydration status (too late)
• Aim 8 - 10 of cups of fluid per day
• High pouch output looses water, salt & potassium
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Types of fluid
• Rehydration drinks (sports drinks with added salt, dioralyte, WHO)
• Keep tea & coffee to
<4 cups/day
• Limit fruit juice & sugary/fizzy drinks
• Encourage water
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Special dietary considerations
• Calcium intake
• Vitamins & minerals
• Hydration
• High energy
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The Dysfunctional Pouch• erratic eating habits • high caffeine intake• high alcohol intake• high fibre diet• high fat intake• poor fluid intake• sorbital intake• irritable bowel syndrome• food intolerance• pouchitis• probiotics
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Probiotics• “Friendly bacteria” in the digestive tract• Pouchitis associated with lack of “good
bugs” (Lactobacilli + Bifidobacteria)• Patients with chronic pouchitis
remained in remission after taking high dose probiotics (Gionchetti et al., (2000);
Mimura et al., (2004) )• Yoghurt, Yakult, Actimel, capsules,
powders (VSL#3)
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Probiotics• Vary in their efficacy• A small increase in bloating or
flatulence when first commenced is normal
• Try to take both Bifidus & Lactobacillus and with food preferably
• Trial for several weeks - 3 months
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Foods that thicken output
• rice & rice cakes• pasta (fresh) & white bread • mashed potato• apple sauce• smooth peanut butter• marshmallows & jelly cubes• banana (ripe)
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Increase wind & odour• broccoli, sprouts, cabbage• onion, garlic, leeks, asparagus• beans• spicy foods • carbonated drinks• beer• eggs• differing individual tolerability
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Increase pouch output• pulses & leafy vegetables• high fibre fruit & veg• wholegrain cereals• nuts & sweetcorn• alcohol, fruit juice &
caffeinated beverages• chocolate• fatty foods• food intolerance
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When to use the Exclusion Diet?
• Final dietary step, –when all initial modifications have
failed to improve symptoms• Only reliable method of investigating food
intolerance• Threshold effect/dose response• Challenge beliefs• Motivated / appropriate client• Support / extra financial burden• Recipes / meal planning / access for
support
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Foods that are likely to cause symptoms
• Wheat, rye, oats, barley, corn, potatoes, cows milk, sheeps milk, goats milk, corn oil, veg oil, onions, sweetcorn, garlic, leeks, citrus fruits, tea, coffee inc decaff, squash, sparkling mineral water & processed foods
• Foods allowed Rice,Tapioca,Sago, Millet, Buckwheat,Quinoa,Arrowroot, gram flour, soya milk, herbal tea
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Exclusion Diet cont’d:
• State Registered Dietitian who is experienced / interested in food intolerance
• 2-3 week period on baseline diet• If symptoms improve proceed to reintroduction of
foods• Careful food reintroduction is crucial & support
required ++• Follow up
–At start of diet–During exclusion phase–Regularly during reintroduction phase
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Optimizing Pouch Function 1
• Don’t skip meals, eat small meals regularly
• Include foods that thicken output
• Avoid eating & drinking at same time
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Optimizing Pouch Function 2
• Healthy eating, freshly cooked CHO
• Fruit & veg to tolerance
• Consistent fluid intake throughout the day
• Probiotics
• Limit foods that cause irritation e.g. spicy
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Optimizing Pouch Function 3
• Limit food that increases output• Limit foods that cause gas• Chew food well• If active overnight aim to finish
eating early in evening• Formal assessment from dietitian -
in exceptional cases - exclusion diet
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Good nutrition and healthy eating
make a difference!
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References• Gionchetti P, Rizzello F, Venturi A, et al. Oral
bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebo-controlled trial. Gastroenterology (2000) 119:305–9
• Mimural T, Rizzello F, Helfwig U, Poggioli G, Schreiber S, Talbot IC, Nicholls RJ, Gionchetti P, Campieri M, Kamm MA. “Once daily high dose probiotic therapy (VSL#3) for maintaining remission in recurrent or refractory pouchitis”. Gut (2004) 53:108-114 doi:10.1136/gut.53.1.108