THEORETICAL STUDIES

doi: 10.1111/j.1471-6712.2011.00890.x

Nutritional care in inammatory bowel disease a literature review

den PhD, RN (Professor) Kari Skrautvol CCRN, RN (Cand.polit, Associate Professor) and Dagnn Na
Faculty of Nursing, Oslo University College, Oslo, Norway

Scand J Caring Sci; 2011; 25; 818827 Nutritional care in inammatory bowel disease a literature review Aim and method: During recent years, an increasing number of young adults have developed inammatory bowel disease (IBD). The caring perspective on IBD is now changing to adapt to the development of the illness and prescribing new health promotion methods of care, with a focus on nutrition, education and patient supervision. IBD, immunology and nutrition are the main focus in the selected articles, with presentation of possible connections to contribute to broader understanding of the illness. This present article is part of an empirical research project and is providing an overview of the current research knowledge in this eld. The article is based on an extensive, systematic survey of literature comprising 28 review and original articles from June 2008 to July 2009. The important topics are emphasized and described. Results: Two areas of knowledge are considered instrumental in inter-disciplinary health-promoting work with IBD patients: a focus on gut immunology and stress, nutritional care and diet. Healing damage to the gut wall by introducing an individually prescribed diet may take time,

but will reduce internal stress on the body. Documentation shows that use of probiotics, fatty acids and antioxidants has been effective in a number of clinical scenarios relating to IBD. Individually prescribed nutrition, primarily through the diet, may be decisive in terms of a sustainable improvement in outcomes for patients with IBD. Conclusions: Addressing the educational challenges in caring to cure suffering from IBD is crucial. Emergency medical treatment helps patients during the acute phase of the disease. Once the acute phase is passed, the recommendation is a focus on investigating the environmental factors that could act as triggers for IBD in humans. Diet is the most important environmental factor in terms of the gut. Proper nutrition and micronutrients assist the body by subtly strengthening its capacity for self-healing and regeneration. Education, conrmation, and a reection into ones illness, create insight and a basis for coping. Keywords: caring, diet, health promotion, inammatory bowel disease, nutrition, interdisciplinary, rehabilitation, literature review. Submitted 14 May 2010, Accepted 27 March 2011

Introduction
Inammatory bowel disease (IBD) is on the rise in Western countries and in this article refers to two known chronic diseases, Crohns disease (CD) and ulcerative colitis (UC). The incidence of the disorder in Norway is among the highest worldwide and has increased in the postwar period (1, 2). Statistics Norway (2009) states that in 2008, 2590 patients were discharged from Norwegian hospitals following overnight stays with the diagnosis of CD and UC. There has been an increase of 11.5% more outpatient

Correspondence to: Kari Skrautvol, Faculty of Nursing, Oslo University College, Postbox 4 St Olavs Plass, Oslo 0130, Norway. E-mail: kari.skrautvol@su.hio.no

consultations across all age groups, with 16 330 patients in 2006 and rising to 18 778 patients in 2008. The number of patients particularly those of reproductive age (1845 years) has increased by 14.5% over the past 3 years (3). In developed countries during the past 20 years, CD has generally overtaken UC in incidence rates. In developing countries in which IBD is emerging, UC is more common than CD (4). Recent population studies indicate IBD is as common in Australia and New Zealand as other parts of the world and prevalence of developing the disease is increasing in Asia (5). Care and treatment of chronic IBD have now changed following the development of the disorder with more recent medical treatment methods and with greater focus on nutrition, education and guidance (6, 7). We need to know more about the syndrome and not only to focus on treatment by immunosuppression (8). It is felt that by avoiding or being cautious about eating certain foods, the

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Nutritional care in IBD bodys tolerance may increase and possibly have an inhibitory effect on inammation. The theme is of increasing general interest both nationally and internationally. The purpose of this article is to answer the question as to whether dietary advice and a change in diet improve health, result in less pain and reduce the likelihood of relapse. The following research questions were posed: What published scientic research is available in respect of chronic IBD, diet and guidance in the young adults? The theoretical perspective in this interdisciplinary study is grounded in caring science. Caring includes a deep respect for the dignity of human being and being genuinely present for the suffering human being (9, 10). Caring preserves and enables health and well-being. The body has an inner driving force between regeneration and degeneration to support health promotion and includes physical, mental and emotional dimensions in the body. These three dimensions are striving towards balance, and illness or disease tends to cause unbalance between these levels in the body, but always in interplay with our surroundings (11). When counselling patients in health-promotive actions, showing a tune of conrmation in the guiding is important. Conrmation releases energy and creates trust and respect (12). Both conrmation and acknowledgement are important aspects in the process to cope in IBD, especially in periods when the disease relapses. The patient is undergoing a period of very challenging and stressful time, and when health care professionals interact, the patient nds better ways of solving problems, seems more attentive and present. This article has focus on the physical and biological aspects in the body and immune system promoting nutrition as an important part of the healing process of the gut. The main purpose of this article is to provide an overview of the current research knowledge in this eld.

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Method
This literature review is an essential step in the identication of evidence-based caring (13). The concept of caring is used to create knowledge for health care professionals. Qualitative evidence review involves an inductive, iterative and emergent process (14). The article is based on a systematic literature search in medical and health-related databases from June 2008 to July 2009, with an arbitrary selection of research and review articles based on the rst authors experience within the eld. Other sources are from the authors own literature archive. The evidence presented in articles with regard to immunology of the gut between stress and curing of advanced gastrointestinal disease represents a mature eld of research. It can be viewed as more solid than the results obtained regarding nutrition and dietary advice in IBD. An emerging area of research with nutrition in IBD is coming with obvious limitations and in measuring outcome of caring treatment.

Data bases used in search are Cinahl, Cochrane Library, Medline, Norart, Svemed+, PubMed and Wiley InterScience. The following search words were used: IBD, CD, UC. These were combined with nutrition or diet (column 3) and counselling or educational intervention (column 4). Criteria for search are subject heading, keywords and English abstract in review and research articles regarding adult population 19 years44+ in the period June 1999 until July 2009 (Table 1). In the table, we can see the hits of the search (results for IBD/CD/UC), with Cinahl 132, Cochrane Library 27, Medline 108/173/128, Norart 5, Svemed+ 28/2/58, PubMed 121/49/56 and Wiley InterScience 349. The new concept IBD includes both CD and UC, and this is the reason for the unexpected few hits on some of the databases. When we combine the search words above with nutrition or diet, the hits are signicantly reduced to only seven articles in Cinahl and 18 articles in Medline. In Cinahl database, one could nd 12 articles on nutrition in Crohns disease and seven articles in Medline. In the same way, the search above combined with counselling has very few hits (02). One should note that the search in combination with advanced nursing practice or quality of care produces four hits in Wiley InterScience database. All texts were thereafter evaluated based on the clarity of their presentation in connection to the aim of the study and to reach new insight and knowledge with respect to nutrition. In the results section, the primary material is from 28 research and review articles. This includes 17 medical articles and 11 articles with nutrition and dietary advice (please refer to Tables 2 and 3 in result section). We noted that articles concerning biomedical research on drugs and their efcacy are not included, nor are articles on this populations quality of life included in this article, but articles regarding quality of care are included. Insomuch as UC and CD are described as autoimmune diseases, there are numerous articles concerning understanding of immunology and research within genetics. IBD, immunology and nutrition are the main focus in the selected articles, with presentation of possible connections to contribute to broader understanding of the illness. This article is part of a research project: Development of Nutritional Program for counselling patients with chronic IBD at Oslo University College, in cooperation with the Norwegian Association against Digestive Diseases. Data analysis started with reading the articles chosen for inclusion. Because of the fact that internet bases overlap with regard to medicine and nutrition science references, it was important to decide which discipline each article belonged to. Both the heading of the article, the authors discipline and the abstract, helped in this reading process. The theoretical perspective is an important understanding in this inductive process to create new connections in a new area of knowledge building in interdisciplinary

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den K. Skrautvol, D. Na
Table 1 Results from database search in the period 19992009 with keywords

Keyword Database Cinahl Cochrane Database for Systematic Review Medline Norart Svemed+ PubMed Wiley InterScience
a

Inammatory bowel diseases, Crohn disease, ulcerative colitis

Inammatory bowel diseases, Crohn disease, ulcerative colitis and nutrition/diet

Inammatory bowel diseases, Crohn disease, ulcerative colitis and counselling/educational intervention

132 27

7/12/9 0

1 0

108/173/128 5 28/2/58 121/49/56 349

18/7 0 3/3/0 8/4/4 18

1 0 0 2 4a

Advanced nursing practice or Quality of care. Criteria for search: Subject heading, keywords, English abstract. Type of articles: Review article and Research article. Age: 1944+. Period 10 years or June 1999July 2009.

Author(s) Colombel et al. (15) Garn and Renz (16) Falk et al. (17) Berstad and Brandtzg (18) Hugot et al. (19) Saebo et al. (20) Berstad (21) Fish and Kugathasan (22) Van Kruiningen and Colombel (23) Engkilde et al. (24) Bakke-McKellep et al. (26) Brown and Mayer (27) Rutgeerts et al. (28) Schlmerich (8) Pyerin-Biroulet et al. (29) Henriksen and Moum (31) Henriksen et al. (32)

Published 2008 2007 1998 2000 2003 2005 2005 2004 2008 2007 2007 2007 2008 2006 2007 2007 2007

Context/sample Adults Adults Adults Adults Adults Adults Adults Adolescent Adult Age 699 year Atlantic salmon sh Adult Adult Adult Adult Adult Age <40>

Research method Systematic literature research Systematic literature research Systematic literature research Literature research Literature research Statistical comparison analysis Literature research Epidemiology, comp. study Literature research Statistical comparison analysis Experimental diets, statistical analysis Systematic literature research Literature research Systematic literature research Systematic literature research Literature research Clinical prospective study

Table 2 Medicine references used in systematic review

research (13, 14). The concepts in the main heading in the result section are core concepts from the reading of articles. Validity of the content and the meaning of the subject are based on the authors profession and experiences in the eld. Regarding this article, the rst author is registered nurse, specialist nurse in critical care in hospitals and has longstanding qualitative research competence both in caring science and in public health. Nutrition and dietary advice is a common knowledge bridge between clinical specialist nurse, medical doctor and dieticians. The second author

has long experience in caring science and qualitative research.

Results
Description of the material
In Tables 2 (medicine context) and 3 (nutrition and dietary advice), articles are listed according to rst author, year published, context/sample and type of review or research method.

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Nutritional care in IBD

Table 3 Nutrition and caring advice in systematic review

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Author(s) Geerling et al. (33) Lucendo and De Rezende (36) Goh and OMorain (37) OSullivan and OMorain (38) Pappa et al. (39) Jrgensen et al. (40) Bengmark (41) Baroja et al. (42) MacDermott (44) Ferguson et al. (45) Beattie et al. (46)

Published 1999 2009 2003 2006 2006 2007 2007 2007 2007 2007 2006

Context/sample Adult Adult Adult Adult Adolescent Adult Adult Adult Adult Adolescent/ Adult Adolescent/ Young adult

Research method Systematic literature research Literature research Systematic literature research Best practice research Systematic literature research Literature research Systematic literature research Statistical experimental study Literature research Systematic literature research Best practice research

In the medical articles, the context in which young people >19 years are included, there are articles with quantitative research from the whole lifespan. This is clinical prospective studies, statistical comparison analysis and epidemiological study. Review articles are both systematic literature research and literature research based on clinical expertise and evidence. In Table 3 with nutrition and dietary advice, the authors are clinical experts in the eld of nutrition. Research articles from caring science and patient experiences are the main topic in the further research production from the authors. There are few randomized-controlled studies in the area of nutrition at this time because the knowledge regarding specic diets is still under development. In this research, it is important to control all consumption of food and drinks over a longer period of time. From 2006 and 2007, there is a shift with more articles in the area of nutrition and dietary advice. On review of the articles, two fundamental themes came to light, which are presented here.

Immunology of the gut between stress and curing of advanced gastrointestinal disease
Environmental factors more than genetic changes in gut epithelium are responsible for that the number of persons affected by IBD in the USA and Western Europe has increased over a short historical period (15). Changes in diet and food preparation may have an inuence on microora. The hygiene hypothesis suggests that there is a link between lack of stimulation of the immune system from environmental microorganisms and antigens during childhood, which may predispose to IBD (16). Historically, a greater number of patients with UC were seen between 1950 and 1980, but this trend has stabilized. In contrast, we saw an increase in acute appendicitis between 1980 and the turn of the century. Experience suggests that acute appendicitis protects against UC, but may be a risk factor for CD. We are now seeing an increase in CD over UC, which gives us reason to ask why?

The resent change in perspective on research and knowledge development regarding the importance of the microbial ora of the gut suggests new strategies to improve the conditions for the microbial ora to use the microbes to promote health (17). The gastrointestinal tract, skin and lungs are crucial immunological organs. There is a growing understanding that the composition of gut ora and the presence of dysbiosis may be signicant in terms of development of chronic illness. Development of the immune system is affected when our consumption of food and drink consists of soft drinks with a high sugar content, as well as deep frozen or microwave-cooked food with a low content of microorganisms (18). Modern food processing, involving freezing and refrigeration, prevents the growth of many types of bacteria, but may be a favourable environment for the growth of gram-negative bacteria such as Yersinia and Listeria. The question is also whether certain species of these two bacteria may provoke immune reactions in sufferers of CD (19, 20). In IBD, atus may be present that has become toxic and that breaks down the mucosa so that it no longer manages to maintain its bacterial ora (21). This suggests a link between how food is prepared, bacterial ora in the gut and how we retain prebiotic and probiotic microbes. Researchers into IBD are currently investigating whether environmental factors exist, which trigger inammation in individuals with a genetic prole that predisposes them to IBD. The focus is now on nutrition particularly in patients with CD. Malnutrition or undernourishment is less common in UC than CD. Although nutrition and probiotic treatment appear attractive, pharmacological preparations remain the most important treatment of IBD (22). This begs the question whether UC and CD are different diseases or part of a continuum (15). The suggestion, based on microscopic examination of CD lesions, is that lymphangitis plays an important role in the pathology of CD and where greater attention should be focused on the lymphatic endothelium. CD often occurs during the phase in the lives of young people when they are at increased risk of a

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den K. Skrautvol, D. Na There is currently insufcient knowledge about the benets of vitamin supplements, but researchers envisage that this may bring knowledge of disease processes in a new direction (29). The researchers Valeur and Berstad (30) suggest failure in butyrate metabolism as a possible trigger of IBD. These are short fatty acids, largely formed in the caecum. This production probably creates an acid barrier, which is crucial for countering the growth of pathogenic bacteria. Gut ora in the large bowel has signicant health-related potential, and much remains unknown. The fatty acids are signicant for nourishment of the colonic epithelium. More clinical studies are required to conrm the signicance of short-chain fatty acids in the development of IBD and intestinal cancer. Patients with chronic IBD are at increased risk of developing colorectal cancer (31). Cancer develops in areas of active or previously active inammation. This is currently prevented by close follow-up of the disease and with anti-inammatory drugs where necessary. The preventive effect of drug treatment in reducing the risk of cancer in persons with IBD remains unclear. There may be much to gain by keeping gut inammation at the lowest possible level by health-promoting measures. The IBSEN study in Norway has followed a total of 843 patients with IBD over 5 years (32). After 5 years, 200 patients with CD were selected for further analysis. Development of strictures was observed in 64% of patients when CD was localized to the lower part of the small bowel. The potential for penetration was the same throughout the entire gastrointestinal tract. Fifty-six per cent of the patients underwent surgery involving partial bowel resection. Fifty-four per cent of the patients used medication after 5 years, while 36% took no medication. Four different curves were identied for the development of symptoms over 5 years. Forty-four per cent showed reduction in serious symptoms and 29% cyclic symptoms with good and bad periods. Many of those who underwent surgery had serious or chronic symptoms (32). This indicates that preventive measures are important, where possible, to avoid surgery. When compiling the analysis from the individual articles referred to above one can conclude that there is a suggested link between genetic susceptibility, the gut microbes on which we depend, stimulation of the immune system, dysbiosis of the gut, development of inammation, lymphangitis and the degree of damage to mucosa and gut epithelium. More recent knowledge focuses on solutions aimed at suppressing inammation and repairing damage at a cellular level.

number of infectious diseases such as tonsillitis, infectious mononucleosis, appendicitis and Hodgkins disease (23). One Danish study (24) analysed the link between contact allergy (CA) and IBD. This demonstrates the link between the skin and gastrointestinal tract and the way in which the body attempts to protect internal organs. In linking the data register between the two disorders for the period 1985 to 2003, the researchers found an inverse link between CA and CD. This link may be associated with a common genetic factor or common environmental factors. Another possibility is that the development of CA affects the immune system such that the risk of developing CD is reduced. Paratuberculosis bacteria are found in parts of the gut in patients with CD. Research groups are endeavouring to establish the possibility of a link between paratuberculosis bacteria in animals such as cattle and goats and CD in humans. In heat treatment of milk, the bacteria must not be harmful to humans (25). In sh farming, experience has been that sh feed can cause inammation of the digestive system. Where the sh feed contains cabbage, beans and soya, a toxic reaction may occur resulting in the sh developing inammation of the terminal digestive tract and diarrhoea. The gastrointestinal tract of sh is not unlike our own, and vegetable matter may contribute to inammatory disorders. As long as the diet is varied, the likelihood of developing a chronic inammatory condition will be reduced (26). The development of biological medicine, alongside traditional treatment with aminosalicylates, cortisone and antibiotics, may result in signicant improvement in a small number of selected patients with IBD. Currently, there is insufcient knowledge about long-term treatment with biological medicines (27), but the treatment is effective in being able to heal gut epithelium and mucosa (28). Treatment with Remicade or Humira has signicantly improved the health of many patients, with fewer hospital admissions and less need for surgery. However, the side effects can reduce the patients motivation to continue the treatment. Much has been carried out to reduce the side effects from cortisone treatment by limiting its use to the acute phase. Researchers are now focusing on gastrointestinal disorders via an approach that looks beyond the immunosuppressive paradigm. Looking at the interaction that occurs between bacteria and the epithelial layer in the gut may result in new approaches to treatment (8). Chronic stress metabolism can be measured via the amino acid homocysteine, which plays an important role in cellular stress, inammatory processes and microbial interaction. Plasma levels of homocysteine in the blood are determined by nutritional status in respect of folate, vitamin B6 and B12. Too much of this metabolite has an inuence on the development of IBD. Where the level of folate and important B-vitamins are increased, homocysteine levels are reduced and development of the disease is prevented.

Nutrition and dietary advice in IBD

There is scientic evidence that nutrition can play an important role in the development of illness and in the

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Nutritional care in IBD treatment of IBD, and there is a need to study which nutritional factors have a health-promoting effect. Several studies have reported nutritional and functional failure in patients with IBD particularly those with CD (33). There is a clear indication that environmental factors such as nutrition play a role in the aetiology of IBD, together with urbanization (34). The question is whether nutrition in itself is an aetiological factor for developing IBD (35). IBD is associated with frequent nutritional deciencies, the pattern and severity of which depends on the extent, duration and activity of the inammation (36). Thus far, there is no systematic evidence that specic factors in the components of food contribute to the pathogenesis of IBD; however, what our diet consists of over time may be signicant. New feeding habits involve a high consumption of sugar and rened carbohydrates. Since the 1970s, various studies have indicated the high consumption levels of these products in patients with IBD, to the extent that they are now considered a risk factor for CD and UC (33, 36). Poor nutrition is linked to disease activity and the extent of the disease, particularly in CD. Lack of protein is a common nding among patients with IBD. There may be reduced hepatic protein synthesis, malabsorption and anorexia. Serum albumin appears to be a more signicant marker of disease activity than nutritional status. This shows that analysis of nutritional status is complex; it consists of numerous factors, and it can be difcult to discriminate between disease-induced and nutritionally induced changes in nutritional parameters, particularly in CD (33). Besides medication, nutrition has maintained its central role in the treatment of IBD in adults. The aim with dietary supplements is to correct poor nutrition in relation to caloric intake or specic macro- or micronutrients. Lack of calcium, vitamin D, folate, vitamin B6, vitamin B12 and zinc has particular clinical signicance. With long-term use of corticosteroids, many clinicians use enteral nutrition as the primary treatment of CD in the acute phase. There is support for a gradual return to normal diet after a period of exclusion, reintroduction of foodstuffs or other dietary regimes together with enteral nutrition, to increase the degree of remission (37). Patients with IBD often report concern that foods they eat may exacerbate their symptoms and many adapt their diet in the hope of controlling the symptoms or preventing relapse. This is a concern when patients reduce much or completely avoid important sources of nutrition that may increase the risk of malnutrition. The most common behaviour is avoidance of milk and dairy products. This change in diet results in reduced calcium intake, but no clear impact on the number of relapses. The key is to ensure sufcient intake of calcium and vitamin D, with supplements where necessary (38). Vitamin D affects both hormone and calcium balance and is essential for bone mineralization throughout life. New studies show a higher

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prevalence of hypovitaminosis D in adult patients with IBD: one of the factors caused by malabsorption and gastrointestinal loss from an inamed bowel (39). Epidemiological data support the hypothesis of the effects of vitamin D on autoimmune diseases such as IBD. There is evidence that daily D-vitamin intake can be increased signicantly without the development of hypercalcemia, particularly during the winter months (40). Research work is now focused more on biological control of IBD. In developed countries, many people cope badly with irregular eating habits and stress. One extreme example is astronauts who, after their space travel, return to earth having lost much of their normal gut ora. It has been shown that the layer of mucous that coats the mucosa in healthy people is important in terms of maintaining health generally and particularly in respect of the gastrointestinal tract. Modern foodstuffs such as dairy products and species of grain that contain gluten (wheat, rye and barley) will cause damage to mucosa particularly in autistic individuals. A series of pharmaceutical preparations have the same effect on mucosa and their function. This can be prevented by the addition of probiotics and synbiotics (41). Probiotic yoghurt has long been known as a good nutritional product with anti-inammatory effects. This has been shown in experimental studies between research centres in Canada and Finland, where probiotic yoghurt was used for 30 days in outpatient follow-up of 20 patients with IBD, compared with 20 healthy patients with no known intestinal problems (42). Yoghourt is a fermented milk product containing B-vitamins, lactose, proteins, fat and minerals and is better tolerated than normal milk products in patients with IBD. Another alternative is lactic acid bacteria if patients have to be cautious about using milk products. Functional foodstuffs have begun arriving on the market, e.g. yoghurt with added lactic acid bacteria and bread enriched with bre and B-vitamins. Breakfast cereals were the rst foodstuffs to be enriched and that can be considered early functional foodstuffs (43). There is still signicant research to do to document whether functional foodstuffs can improve gut health. One good alternative is to focus on vitamins, minerals, fatty acids and trace elements, which are important micronutrients. Lack of several micronutrients is probably a contributing factor to poor gut health. Conventional medicine gives recognition to the most powerful treatment methods, because they are easier to measure under controlled scientic trials. Dietary elements have been discovered, in particular vitamins and fatty acids, which can function as hormones by entering the cell nucleus and affecting it (29). Nutritional biology will ensure that dietary therapy has a signicantly higher prole in the future. A practical approach with less use of medication, together with greater focus on hypersensitivity to foods and drinks that stimulate the gastrointestinal tract, may be an

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den K. Skrautvol, D. Na just to avoid those foods they themselves feel they are intolerant to. In Norway, we have a high carbohydrate diet with high consumption of grains and sugar. Today, a carbohydrate intake comprising 5560% of total energy intake is recommended, while sugars should not exceed 10% of the diet. The question is whether this percentage is too high, and should be reduced for patients with IBD. In recent years, special attention has been paid to fat and the lipid components of the diet as triggers of IBD. Lately, the discussion regarding the importance of essential fatty acids, in particular the relation between the fatty acids omega 3 and omega 6, where omega 6 activates inammation while omega 3 restrain the inammation, has been resumed (43). This balance is better maintained if the consumption of grain and oils saturated by omega 6 acids is reduced and that of fat sh, nuts, seeds and vegetables is increased. Malnutrition creates chronic stress metabolism, and therefore, nutrition therapy should play a fundamental role in the clinical care of all patients suffering from IBD. Chronic stress metabolism may also have psychological causes. Suppressive factors in ones private life or work life may also contribute to developing chronic IBD. Chronic psychological problems, experienced by the body as psychological environmental toxins, may lie behind the diagnoses of UC and CD. A person may have been in a situation over time from which it has been impossible to escape or to overcome. Our defence apparatus attempts to redress this balance, but is weakened by disease and age. In many ways the gut is the bodys emotional spinal cord, i.e. how we deal with things may be signicant in terms of gut health. What is crucial in understanding IBD is looking at causal development in a circular process instead of linear single factors that cause a disease. The explanation lies in an interaction between genetics, environmental factors and the immune response of the individual (36). We see that individuals with IBD have a reduced biological ability to down-regulate the guts normal inammatory reactions. The start of the disorder may be triggered by various individual factors. We may see that the person has been in a harmful or exposed situation, where something has acted as a trigger such that the immune system, the nervous system and the blood supply to the gut become unbalanced. Patients with IBD eventually develop problems with chronic inammation, constipation/diarrhoea and fermentation problems in the gut. Use of biological medicine has changed our treatment of IBD. Such patients will be able to eat a normal diet if they react positively to the treatment. The important question is whether this should be tried by patients who wish to follow a more natural route by examining their own responses following intake of food. This is real caring for own body, to listen and to conrm important symptoms from the patients and look to complementary interventions to pain

alternative pathway. There are numerous foodstuffs and drinks that can induce Irritable bowel syndrome (IBS) symptoms in patients with IBD (44). Knowing the nature of the symptoms involved in IBD in the individual patient and developing a therapy which takes into consideration individuals food tolerance based on their genetic prole has been the subject of signicant research interest (45). They say: While pharmacogenetics is increasingly being used to predict and optimize clinical response to therapy, nutrigenetics may have even greater potential. In many cases, IBD can be controlled by prescribing an elemental diet, which appears to act through modulating cytokine response and changing the microbiota (op.cit p.70). This means that developing a diet for all patients with IBD is not the way to go, but that one via an individual elimination diet could give specic recommendations for the individual. Diagnosis and treatment require an inter-disciplinary approach, and hospitals should merge their expertise from their own centres in treating this patient population, particularly young adults in whom growth development and nutrition are key factors (46). When compiling the analysis from the individual articles referred to above, one can conclude that vitamin and mineral supplements, fatty acids, antioxidants and probiotics are important micronutrients for metabolism of energy. Identifying those foods that reduce pain and inammation can be achieved by looking at intake of various foodstuffs over time, eliminating them and nding substitute foods thus improving the health.

Discussion
According to caring science, keeping pain to oneself can increase the suffering to an unbearable level and reduce the patients perceptions of quality of care (9, 47). If there is something in the diet that triggers increased inammatory activity and abdominal pain, patients with the disorders are advised to refrain from eating the specic foodstuffs during acute periods. Many patients experience improvement on elimination diets, where specic foodstuffs are removed from the diet. Some IBD patients with IBS symptoms will improve on a milk-free diet, and others will respond well to a wheat- or glutenfree diet. Patients with coeliac disease have similar consequences: daily concerns about gluten, constant preparation, being different, emotional pressure and body sensations because of coeliac disease. Women and men have a different social situation in relation to preparing food, making decisions about purchases, buying food products and preparing meals. The clinical implications of these ndings are that health care professionals need to develop information to close family members of the patient and take in to account that many women more than men are close to food preparations (48).The best advice for most patients is to eat a well-balanced diet and

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Nutritional care in IBD killers (11, 12). Changing lifestyle during daily food intake can be an important intervention for IBD sufferers as for persons with coeliac disease (48). There may be a difference between men and women, because such measures make more demands on the person responsible for food preparation. Biological medication does a great deal for patients who have been chronically unwell and for whom stula formation is a factor. The offer of a programme of dietary guidance should be included in meetings with IBD patients in hospital and outpatient clinics, for those that feel they may benet from this. Changing lifestyle needs time and space. In developing quality of care, education plays a very important role in the formation of patients expectations from the health care system (47, 48). The interdisciplinary team with physicians and health care professionals have to change their roles from expertise to include respect for dignity and improve care with mindfulness for the vulnerable patients own experience with illness and health. Patients want to take more responsibility for their own lifestyle in visits to their doctor. They need knowledgeable communicating partners who manage to listen to their experiences to physical, emotional and mental symptoms. Analysis of environmental factors, with individual follow-up of patients, is recommended as a future therapy option for patients with IBD. Nutritional guidelines may contribute to fewer patients suffering relapse and to improved general health. The question is whether researchers should develop the intervention programme rst or whether patients should be given the opportunity to create individual diet plans and tailored care until further notice, which is something cancer patients are offered.

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studies, focusing on changes in nutrition in connection with IBD, available. A prerequisite for research on this topic is to have theoretical knowledge on nutrition. This knowledge should be combined with practical experience from a number of patients to produce empirical evidence. The intention is to publish such empirical research based on the theoretical foundation presented in this article as a follow-up. How the individual patient is composing his/ hers daily meals has impact on the development of the disease and experienced quality of life. To secure the public health, research independent of food industry and pharmaceutical industry should be prioritized. As individual patients experiences are accumulated and present clear patterns, this base of experiences can be systemized and be established as evident valid knowledge for clinical practical use. Only by performing clinical studies of health prots caused by changes in nutrition, the hypothesis can be developed into conrmed evidence.

Conclusion
We see that disease occurs when environmental stressors exceed the bodys ability to cope with them. The gastrointestinal tract is the organ that comes into direct contact with the food we eat on a daily basis. Dietary content is the most important environmental factor for the gut. Daily intake of the same food not properly digested or where particles leak through the gut leads to an immune response. These continual effects may lead to autoimmune diseases. The foods that individual patients do not tolerate well should be documented. Depending on their response, individuals should either be cautious with these foods or completely remove them from the diet for a shorter or longer period. What is important is nding good substitute foods to underpin dietary diversity. The challenge is dealing with malnutrition or poor nutrition, particularly in patients with CD. This may be the reason why doctors are cautious about recommending changes in diet. Better measuring methods are now being developed for specic needs in terms of vitamin and mineral content and for better tests of various inammatory markers. Primary message of the literature: 1 Inammatory bowel disease is an interplay between the persons constitution, immunology and the environment. 2 Establishment of an offer of dietary guidance as a health rehabilitation option in IBD. 3 Nutrition has anti-inammatory effects on IBD, if the foods are tolerated. 4 Where sufferers make their own food, this leads to increased awareness of how to return to health.

Methodological considerations and limitations

The search is limited to a 10-year period from 1999 to 2009. These 10 years were chosen because the scientical results regarding changes of microbial population in the gut as potential cause of chronic disease emerged. The body of literature that has been reviewed is presented in a largely descriptive way. Science so far is dominated of deductive studies mainly focusing on single components in nutrition as potential cause for IBD in conjunction by genetical predisposition and a hyperactive immune system. The nutrition is composed of a number of single components, but the total diet can also inuence the body in general. To study the connections between the nutritional elements both on macro- on microlevels might reveal new knowledge on the nutritions impact during chronic inammations in general. There is a clear requirement for more innovative practical research on qualitative patient experience regarding IBD and other sufferings caused by IBD over long time. A qualitative synthesis of the literature was made because there are too few qualitative and quantitative

Acknowledgement
We thank Eckbos Legates for publishing support.

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den K. Skrautvol, D. Na

Author contribution
Kari Skrautvol is the main author of the systematic liter den is research ature review article. Professor Dagnn Na guide and has given expert advice during the writing process. Both authors are trained in qualitative research methods.

Ethical approval
The article is part of a research project: Development of Nutritional Program for counselling patients with chronic IBD at Oslo University College, in cooperation with the Norwegian Association against Digestive Diseases (Landsforeningen mot Fordyelsessykdommer LMF). Regional Committees for Medical and Health Research Ethics (REK) have approved the project 30.4.09, with reference number S-08085a.

Funding
The author has this research project as a part of her position as associate professor at Oslo University College. Eckbos Legate has given economical publishing support to this research project in 2009.

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