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Principles of a Short Bowel Syndrome Diet

A summary of research

Graphic titled My Short Bowel Syndrome Plate. Image is two pie charts displayed on plates showing the recommended daily percentages. In the center the description for the pie charts. Hydration - Drink a small amount with meals. Sip throughout the day. Carbohydrate - Refined flours and grains. Avoid whole grains and sugars. ORS is best absorbed. Fats - Focus on essential fats. Watch for signs of malabsorption. Protein - Eat a quality protein source with every meal and snack. Soluble fiber - Be selective with fruits and vegetables and grains. Stay away from insoluble fibers. Replenish lost electrolytes as needed. The pie chart on the left is for patients with a colon and has a larger segement for complex carbs. The chart on the right is for those without a colon and complex carbs and proteins are equal. There is also a food group for salt. Above each plate is a cup labeled hydration. The cup for without colon is larger.

With short bowel syndrome, only a tiny fraction of the small intestine remains to digest and absorb food. Every bite of food matters.

Following the proper diet can help improve nutrition, decrease stool output, and promote intestinal adaptation. There are several principles that experts agree can help.

This article summarizes the most frequently cited scientific articles about diet recommendations for short bowel syndrome. I am not a doctor, dietitian, or researcher, nor do I hold any medical license. I am not prescribing a diet for you to follow. My sole purpose is to summarize the available research and resources. I hope this information can springboard conversations with your medical team.

Principle 1: There is no single short gut diet.

Even though experts agree on many basic principles, every patient is different. Medical history and anatomy change the way each body handles food. The foods you can eat may change depending on where you are in your short gut journey. Each person needs to figure out how to apply the principles to their own situation. Your food pyramid may be taller or shorter, bigger or smaller, thinner or fatter. You'll learn what works best for you through trial and error.

Principle 2: Many typical rules don't apply.

Let's clarify that right up front. The standard rules for healthy eating were written for people with a functioning, healthy digestive system. When most of that system is missing, the standard rulebook is no longer helpful. We're in MacGyver territory here. Scientific laws still apply, but you have to change things to work with the tools that you have on hand. Some of the guidelines you are about to read might not shock a kindergarten teacher or health-conscious neighbor. Rest assured, these principles are science-based and healthy. They are just made for different bodies.

Principle 3: Reduce the intestine's workload.

Suppose a factory lost 90% of its workforce. The remaining 10% would have to change their processes to keep operating. They might work overtime, outsource tasks, or reduce their product line.

The same principles apply to eating with a shortened gut. New habits can help the intestine meet a greater demand. Instead of three large meals, several small meals or snacks spaced throughout the day can increase the total nutrients absorbed. (This is also the goal of tube feeding.)

You can also help your gut by giving it food that will be less effort to process. A simple way to do this is to chew food thoroughly before swallowing. Chewing is, after all, the first step in the digestive process.

Your doctor might prescribe a formula made of proteins already broken down for easy digestion. The words "peptide" and "elemental" describe these formulas. You can also choose whole foods that are easier for your body to digest. We'll tell you more about how below.

a graphic titled Short Bowel Syndrome Food Pyramid. The food groups are as follows, beginning at the base. Group 1. Starches - colon: 50-60% of diet; no colon: less than 50% of diet. white bread, pasta,rice, potatoes, low sugar cereal. Avoid or limit - simple carbohydrates, sugars, sweets, sugary cereals, whole grains. Group 2. fats, especially essential fats, colon: less than 30% of diet; no colon: 30-40%. high EFA vegetable oils (sunflower,soy, walnut, etc.), margarine,fish and fish oil, avocado, may. Some MCT and coconut is ok. Avoid or limit fried foods, animal fats, saturated fats. Overall fats with a colon and history of kidney stones. Group 3. Proteins. eat with every meal and snack. lean meats, fish, eggs are best. nut butters, tofu, milk alternatives, dairy in small amounts if tolerated. Avoid or limit most milk and dairy, nuts, seeds, sweetened nut butters and drinks. Group 4. Soluble fiber. no colon: only as tolerated. eat a variety! oatmeal, oat bran, green beans, carrots, unsweetened peeled apples & pears, green banana, sstrawberries, blueberries, beans, sweet potato, citrus & citrus rinds, squash⁴, guar gum, pectin. Avoid or limit insoluble fiber (whole grains, corn , dried fruit, other berries, leaf veggies, celery, cauliflower, brassica, coconut, skins, peels, stems, seeds, kernels, etc.) Group 5. Salts. no colon: increase intake. oral rehydration drinks (ORS), low sugar sports drinks, broths, salty snacks, added salts and electrolytes. Footnotes: 1. Sugars including lactose and fructose, & also sugar alcohols draw water from the GI tract causing fluid loss. Sugar alcohols are sucralose, sorbitol, mannitol, xyliton, maltitol, isomalt, erythritol, lactitol, HSH. 2. The lactose in milk products and dairy is a sugar and causes fluid loss when consumed in large quantities. Small amounts may be tolerated if divided throughout the day. 3. Oxalate in foods like green beans, leafy greens, root vegetables, caffeine, soy, nuts, potato skins, wheat, berries, etc. can cause kidney stones for those with an intact colon. Further, malabsorbed fat binds calcium leaving oxalates. An oxalate restricted diet is only recommended for those with a history of kidney stones and an intact colon. 4. Some believe that a limiting foods high in FODMAP would decrease fermentation and SIBO. A modified FODMAP diet may reduce gas, bloating, and excess stool. Further research is needed.

Principle 4: Focus on easy-to-absorb calories in carbs

While a typical food pyramid recommends building on a base of fruits and vegetables, a short gut diet has starches at its base. The goal is to get the most calories possible with the least amount of work for the intestine. The gut can easily convert complex carbohydrates like white bread, rice, potatoes, and pasta into calories, making them a key part of the short gut diet. Refined, low-fiber grains instead of whole grains are preferred because they are more readily digested.

If bacterial overgrowth is a problem, reducing certain carbs that feed bad bacteria can help. Of course, giving up carbs means giving up easy calories.

Some sources also recommend a low-FODMOP diet to help with symptoms of gassiness and high stool output. Again, there is a trade-off of losing high-calorie food options.

Work with a dietitian and/or doctor before eliminating foods from your diet. People with short gut should try to keep as many foods in their diet as possible.

Principle 5: Stay away from sugars and sugar substitutes

While starches are recommended, sugary sweets are not. Sugar pulls water into the GI tract. This excess water causes increased diarrhea and dehydration. To combat these symptoms, avoid simple sugars in any form. Simple sugars include corn syrup, fructose from fruit, and lactose from dairy.

Some people tolerate small amounts of fruit or dairy, and research shows that some people may tolerate small amounts of lactose. Since dairy and fruit have possible health benefits, some people find it worth eating small amounts. However, tolerance is often very low, and caution is warranted.

Many sugar substitutes and sweeteners are more difficult for the body to absorb than sugar and can cause even more severe symptoms than sugar itself. Watch out for xylitol, sortibol, and mannitol that can cause dumping.

Principle 6: Don't go lean on fats

Fat is another excellent calorie source, and getting enough essential fatty acids (EFA's) is, well, essential. EFA's support our bodies' development and health. Essential fats also act as carriers for vitamins in the gut.

However, fat is difficult for the gut to absorb, especially without complete anatomy, and unabsorbed fat can take the nutrients it carries with it in stool. Unabsorbed fat can bind to calcium in the colon and lead to kidney stones. Patients with a colon, especially those with a history of kidney stones, may need to limit their fat intake.

Fats are a staple of the short gut diet. Still, unless you have a jejunostomy or ileostomy, fat intake should be balanced with the drawbacks of fat malabsorption.

A balanced diet includes essential fats in the form of vegetable oils, margarine, mayo, dressings, etc. MCT oils (coconut and palm oil) can also be used, as they are easier to digest and absorb than essential fats. However, they lack the health benefits of EFA's and can cause diarrhea. They should add to, not replace, essential fats.

Principle 7: Prioritize proteins

Proteins are the building blocks of life. Thankfully, they are also fairly straightforward in the short gut diet. Include a high-quality protein source with every meal. Meat, fish, poultry, eggs, and dairy are all excellent sources.

Principle 8: When eating fiber, choose soluble over insoluble

While fruits and vegetables are the foundation of the traditional food pyramid, short bowel syndrome gives them a much smaller role. A high fiber content helps digestion in healthy guts but can make food move too quickly to be absorbed in short gut.

Insoluble fiber isn't absorbed at all. Leafy greens, vegetables in the broccoli and beet family, whole grains, nuts, and the peels, seeds, and skins of fruits and vegetables pass through the intestine without being digested. Insoluble fiber pulls water into the bowel, making stooling worse.

Soluble fiber, however, makes a gel with water, thickening stool for some people. It can help promote healthy bacteria in the gut. It can also ferment and produce short-chain fatty acids in the colon, which provides extra calories for people with colon. Soluble fiber may even help with intestinal adaptation.

Oatmeal, nut butters, and the soft parts of many fruits and vegetables are good sources of soluble fiber. Your doctor can help you decide whether to add fiber to your diet and, if so, how to do so safely.

Remember that unabsorbed fat in the colon can increase the risk of kidney stones. If you have a colon, you may need to be cautious of high-oxalate vegetables like green beans that can contribute to kidney stones.

Principle 9: Love your salt shaker

Too much salt is bad for you, but if you constantly lose sodium in your stool, you may be deficient and need more salt than is normally recommended. Avoiding salt is one of those standard recommendations that can be inappropriate and even harmful for short gut patients. Your body needs salt, especially if you have an ostomy or high stool losses. Many people with short gut need to eat a lot of salt to maintain normal sodium levels. So if you tend to run low on sodium, help yourself to some pretzels, crackers, chips, or other salty snacks. Wash it all down with an electrolyte-rich oral rehydration drink. Wield that salt shaker with pride!

Principle 10: Take your vitamins

There are certain nutrients that are only absorbed in certain parts of the intestine. Depending on what parts of intestine you lost, you may struggle to absorb certain nutrients. It may not be possible for you to get enough of these vitamins or minerals through food or standard doses of supplements. Your doctor can run blood tests to help you identify deficiencies and recommend what supplements to take. In some cases, doses may be much higher than normally recommended to absorb what your body needs. It is possible to take too much of certain supplements, however, so it's important to work with your doctor to find the correct dose. You may also need to consider delivery routes like sublinguals, patches or injections that don't rely on the intestine you are missing.

Principle 11: Do hydration right

Between high-volume stool losses and limited ability to absorb fluids, dehydration is a constant battle in short bowel syndrome.

Staying hydrated is of the utmost importance. You have to pay attention to be sure you are drinking enough. What you drink matters, too.

As mentioned above, you lose more than just water in stool. Hydration means getting enough fluid and electrolytes. Drinking water alone, even by the bucketful, will not provide the rehydration someone with short bowel syndrome needs.

Water is not the best choice for dehydration. Oral rehydration solutions (ORS) closely match the balance of the body's own fluids. This similar concentration, or osmolarity, is easiest for the cells to absorb. Fluids have a higher concentration of sugar or salt draw fluid into the intestine, causing diarrhea. Water or other drinks with a lower concentration have less negative impact, but are also less efficient at rehydrating the body and restoring electrolytes. Because efficiency matters in short gut, oral rehydration solutions are the best choice for hydration.

Commercial ORS include Ceralyte, DripDrop, Liquid IV, Hydralyte, Equalyte, Pedialyte, Rehydralyte, and Thioral. There are other recipes online for homemade ORS. Be careful of sports drinks, soda, and tea that may be high in sugar.

Some closing thoughts

Food is interwoven into almost every aspect of our lives, so living with a condition that affects your ability to eat can have a significant impact on your overall quality of life. It helps to approach diet with some quality of life goals in mind.

In making diet choices, we seek to accomplish these goals:

  1. Maximize nutrition and health
  2. Decrease stool outputs to improve overall quality of life by reducing bathroom stops, discomfort, and dehydratio.
  3. Reduce complications such as bacterial overgrowth, d-lactic acidosis, kidney stones, etc.
  4. Keep as large of a variety of foods in the diet as possible.
  5. Find enjoyment in food and the social opportunities that accompany eating.

There will be times when these goals compete with each other. Sometimes tradeoffs will be made to meet one goal at the cost of another. These choices will vary with different people and different circumstances.

There is no one right answer or one right diet. However, diet also doesn't have to be a guessing game. Once you understand the goals and principles, you can better understand what is happening as you work with your doctor to try different foods and work out the best diet for you or your family member.

References

  1. Byrne, T. et al; Beyond the Prescription: Optimizing the Diet of Patients with SBS; NCP 15:306-311, 2000 e+Epi">https://www.researchandmarkets.com/reports/5345917/short-bowel-syndrome-epidemiology-forecast
  2. Iyer, K., et al; AGA Clinical Practice Update on Management of Short Bowel Syndrome: Expert Review, Gastroenterology,DOI: https://doi.org/10.1016/j.cgh.2022.05.032, 2022
  3. Matarese LE. Nutrition and fluid optimization for patients with short bowel syndrome. JPEN J Parenter Enteral Nutr. 2013 Mar;37(2):161-70. doi: 10.1177/0148607112469818. Epub 2012 Dec 21. PMID: 23264168.
  4. Medico, T., et. al "A Kids Guide to Short Bowel Syndrome". 2020.
  5. Parrish, Carol R. The Clinician's Toolkit for the Adult Short Bowel Patient Part I: Nutrition and Hydration Therapy. Practical Gastroenterology (2022).https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2022/06/June-2022-Parrish-SBS-Nutrition-and-Hydration.pdf
  6. Parrish, C., Nutrition Therapy for Short Bowel Syndrome in the Adult Patient. Practical Gastroenterology, 2014 https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2014/06/Parrish-October-14.pdf
  7. Parrish, C., ORS: The Solutions to Optimize Hydration in Short Bowel Syndrome. Practical Gastroenterology, 2020 https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2020/03/ORS-Parrish-March-2020.pdf




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