Nutrient deficiencies in IBD - why IBD type, location and disease state matters
Do you find yourself worried about nutrient deficiencies because of IBD?
Do not worry! You are not alone.
This blog is to give you a better understanding about how nutrients are absorbed and highlights the importance of the type of IBD you have when considering nutrient deficiency risk.
Nutrient deficiency risk with IBD
People with IBD are at a higher risk for micronutrient deficiencies (like iron, calcium and vitamin D) as a result of active bowel inflammation, food avoidance and medical or surgical treatments (1).
Deficiencies can lead to a range of issues such as bone disease, cognitive decline, anaemia, poor growth and potentially other complications like worsening disease course.
How does the type of IBD I have affect nutrient absorption?
In general, when we eat, most of the nutrients from our food are absorbed in our small intestine and different parts of our small intestine absorb different nutrients.
In people with Crohn’s disease in the small intestine, which ever part is affected, may be less able to absorb nutrients properly and this is known as nutrient malabsorption.
Although inflammation and irritation most commonly occurs in the lower section of the small intestine in Crohn’s disease (ileum), the inflammation can occur anywhere between the mouth and the anus. This is why its really important, whenever I am working with an IBD patient, that I know exactly where their inflammation is and whether they are in a flare or remission. If the intestinal lining is damaged, due to chronic inflammation or scarring, there is a greater risk of malabsorption in that area. Hence, patients with CD are at a greater risk of nutrient malabsorption than those with UC. This could eventually result in further issues such as dehydration or malnutrition if left untreated.
In ulcerative colitis, inflammation is limited to the colon or large intestine, which mainly absorbs water, hosts a large amount of our gut microbiota who make some nutrients, and to remove poo from our body. Hence, patients with UC are less likely to have nutrient deficiencies caused by malabsorption as the part of the intestines that absorbs nutrients in unaffected. However, this does not mean that it is not possible due to other causes, for example, food avoidance therefore lower nutrient intake, blood loss leading to iron deficiency, and vitamin D deficiency. In addition, different medications can interfere with the absorption of nutrients, particularly steroids. In addition, people who have had surgery to remove part of their small intestine or their colon, may also be at risk of nutrient deficiency.
Routine blood tests should be carried out to check for nutrient deficiencies and discussed with your IBD team, dietician or nutritionist.
Common nutritional difficulties and deficiencies in IBD (2)
Carbohydrate, protein and fat malabsorption or restriction could lead to insufficient calories and therefore weight loss.
Iron - reduced intake or increased blood loss can cause deficiency and lead to anaemia.
Folic acid - impact on absorption common with some medications. Potential absorption issues in Crohn’s.
Vitamins A, D, E and K - these are fat soluble vitamins and deficiencies are often associated with fat malabsorption and inflammation in the small intestine. Medications can also interfere with the absorption of these vitamins, especially vitamin D.
Zinc - can be due to chronic diarrhoea, jejunum removal or in prednisone use.
Potassium and sodium - this is common in a colectomy and those with a pouch as the colon or large intestine is responsible for processing fluids and electrolytes. There is an increased risk of potassium deficiency for those who take prednisone or experience diarrhoea and vomiting regularly.
Calcium - steroids interfere with the absorption of calcium, hence often people with IBD will be prescribed calcium support alongside steroids. Removal of dairy from the diet can also decrease calcium intake and this must be replaced from other sources.
Magnesium - deficiency is common in chronic diarrhoea and those with part of their ileum or jejunum removed.
Recommendations
It may be appropriate for some IBD patients to take a multi vitamin and mineral supplement daily. A chewable or liquid form may be more suitable and better for absorption. Adequate intake of calcium and vitamin D in particular is important for patients with IBD, especially if on a high dose or long-term steroids, or if avoiding dairy completely (1).
Seek help from an IBD specialist nutritionist or dietician to get guidance on what nutrients you may need support with.
What are the symptoms of nutrient malabsorption or nutrient deficiency?
Bloating
Gas
Belching
Abdominal cramping
Bulky/fatty stools
Chronic diarrhoea
Fatigue
Sudden weight loss
Other symptoms can also occur outside of the gut because every nutrient plays an important role in our body systems so if we don’t get enough of a certain nutrient that body system can start to malfunction and we can feel unwell.
In many cases these symptoms may not occur. Hence, routine blood tests for nutrient deficiencies are ideal.
What foods I should eat to correct deficiencies, or avoid them?
Eating a balanced diet is important to get as many nutrients as possible, avoid deficiency and promote absorption. A little and often approach is also useful if you are struggling with appetite and diarrhoea i.e. eat small amounts regularly through the day and hydrate!
If you find you are avoiding lots of foods or food groups because of your symptoms it would be a good idea to speak with an IBD specialist dietician or nutritionist who can support you to find foods that will least likely cause symptoms and fill any nutrient gaps you have to prevent deficiency.
Nutrient deficiencies can be treated by modifying the diet as well as taking supplements, which should always be discussed with your IBD team, dietician or nutritionist.
Take away points
People with CD are at a greater risk of nutrient deficiency than those with UC due to their disease location
Most nutrient absorption occurs in the small intestine
Medications can interfere with nutrient absorption
Food and food group avoidance can cause deficiencies
It is important to get routine nutrient deficiency tests as symptoms may not occur
Always consult your doctor and IBD team before starting any new supplement
If you would like help and support with your IBD and what dietary and lifestyle changes would be appropriate for you, please get in touch. You can book a free call, where I can get to know you, your journey, your struggles, your life, and we can chat about the best route forward for you. You can also ask any questions you have about working with me.
I have also written a free e-book to help you find a way forward for your everyday life with Inflammatory Bowel Disease. Whether you are right at the beginning of your journey with IBD or have been living with your condition for years and feel like you have tried almost everything, there are things you can do everyday, beyond the medication you are taking, to help you take back control.
References:
1. Crohnscolitisfoundation.org. 2017. Common Micronutrient Deficiencies in IBD. [online] Available at: <https://www.crohnscolitisfoundation.org/sites/default/files/legacy/science-and-professionals/nutrition-resource-/micronutrient-deficiency-fact.pdf>
2. ucsfhealth.org. 2022. Nutrition Tips for Inflammatory Bowel Disease. [online] Available at: <https://www.ucsfhealth.org/education/nutrition-tips-for-inflammatory-bowel-disease>