Anaemia in IBD

If you have Crohn’s disease or ulcerative colitis, your risk of developing anaemia is increased. Anaemia develops you do not have enough red blood cells in your blood, or when they do not work properly.

Common types of anaemia experienced by people with IBD

Why are iron, vitamin B12 and folate important?

Iron helps to create red blood cells that carries oxygen around your body, folate helps make new red blood cells, and vitamin B12 helps to keep your blood and nerve cells healthy. Up to a quarter of people with IBD have iron deficiency anaemia.

Common causes of anaemia in people with IBD

• Chronic Inflammation
• Blood loss from ulcerated and inflamed bowel
• Decreased absorption of iron, vitamin B12 and folate in the gut caused by inflammation
• Surgery at the end of your small bowel (terminal ileum) where vitamin B12 is absorbed
• Not eating enough foods rich in iron, folate or vitamin B12 (see section below)
• Certain prescribed medications can decrease the absorption of iron and B12, and change the metabolism of folate

Signs and symptoms of anaemia

How is anaemia managed in people with IBD?

Anaemia should always be managed by your doctor or gastroenterologist. It is important for your doctor to first review whether your anaemia is being caused by your IBD and to review all your medications.

If your iron is low, your doctor may recommend oral or intravenous iron supplementation. It is important to discuss the most suitable form of iron replacement with your doctor as oral iron supplements may cause nausea, abdominal pain, constipation, darker stools and for some may make inflammation worse.

If your vitamin B12 is low, your doctor may recommend intramuscular injection of vitamin B12. B12 sprays and oral tablets are not always effective.

Folate deficiency is common if you are taking sulfasalazine and methotrexate medication. An oral folic acid supplement is usually required and will be prescribed by your doctor.

Can dietary strategies help with anaemia?

Your doctor may also suggest you speak to an IBD Dietitian to ensure you are eating enough iron, vitamin B12 and folate. An IBD Dietitian can assess your current diet and advise you on how to include more iron, vitamin B12-rich and folate-rich foods in your diet. An IBD Dietitian can also advise on which foods can interfere with iron absorption.

How much iron, vitamin B12 and folate do I need?

Folate

Folate is present in fruits and vegetables, legumes, wholegrains and fortified cereals.

Iron

Iron naturally occurs in animal and plant-based foods. Iron-rich foods include from animal sources (red meats, chicken, eggs, sardines) and plant-based sources (lentils, legumes, wholegrains, tofu, green leafy vegetables). Animal sources contain haem-iron which is more efficiently absorbed than plant-based sources of iron (non-haem iron).

Iron rich foods	Serving size
High iron foods
Kangaroo fillet or mince	100g
Beef steak	125g
Lamb, lean	150g
Green lentils	1 cup
Kidney beans, canned	1 cup
Weetbix	30g
Medium iron foods
Sardines, tinned	110g
Tuna, tinned	180g
Eggs	2 medium
Chickpeas, canned	2/3 cup
Wholemeal pasta, cooked	3/4 cup
Tofu	100g
Raw spinach	1 1/2 cups
Quinoa, cooked	1 cup
Rolled oats	60g
Peanut paste/ tahini	40g

What affects iron absorption?

Vitamin C (from fruit and vegetables) can help non-haem iron to be more efficiently absorbed. Some foods and drinks such as caffeinated beverages (tea, coffee, cola, energy drinks), wine and dairy products can reduce the efficiency of absorbing non-haem iron.

Dietary tips for increasing iron absorption

• Add fruit or fruit juice to a breakfast-style meal (rich in vitamin C)
• Add dark green leafy veggies to your meals or smoothies
• Avoid large amounts of dairy at main meals (e.g. glasses/mugs of milk)
• Have coffee / tea / wine between meals rather than with meals

Vitamin B12

Vitamin B12 naturally occurs in animal-based foods. Vitamin B12-rich foods include those with haem-iron (red meat, chicken, seafood, eggs) as well as milk and dairy products. Vitamin B12 does not naturally occur in plant-based foods except yeast-extracts (brewers yeast, vegemite). For this reason, people who do not eat animal products are likely to require an oral B12 supplement.

If you have inflammation or have had surgery to remove the last part of the small bowel (terminal ileum) where vitamin B12 is absorbed may require regular vitamin B12 intramuscular injections. Your doctor can advise on this and monitor your vitamin B12 levels.

Tips to include more iron and B12-rich foods

Breakfast	Lunch	Dinner	Snacks
1. Add nuts and berries to breakfast cereals 2. Include a glass of juice or fortified soy milk 3. Use toast toppers like nut butters, eggs, spinach, tinned fish 4. Scrambled eggs/tofu or omelette with veggies 5. Breakfast cereals with added iron e.g. WeetbixTM 6. Overnight oats/quinoa with yoghurt and berries 7. Grilled halloumi with hummus and flatbread 8. Congee with chicken, egg and onion 9. Labneh, za’atar, olives, flatbread, tomato/capsicum 10. Egg paratha with tomato chutney or raita 11. Chana dal or moong dal with roti and fruit	1. Add lean roasted meats, chicken, eggs, sardines, or falafel to sandwiches or wraps 2. Add lentils, beans and legumes to soups or salad 3. Add meats, beans, fish, eggs to hot meals 4. Top toast with sardines, anchovies, mackerel 5. Add quinoa to salads 6. Mujaddara (lentils + rice + caramelised onions) + boiled egg 7. Akara (blackeyed pea fritters) 8. Include a piece of fruit after lunch	1. Add lentils, chickpeas, split peas, kidney beans to curries, casseroles, dhal, salads, soups 2. Add nuts (if tolerated), tofu, meats, eggs to stir frys 3. Add nuts and seeds to salads 4. Add kofta, shawarma, chicken, falafel to flat breads and salads 5. Add beef, goat, lamb to injera or lentil stews 6. Palak paneer (spinach + Indian cheese) with brown rice 7. Egg fried rice with bok choy and tofu	1. Hommus with crackers or veggie sticks or pita 2. Roast edamame/chickpeas 3. Handful of dried fruits, nuts, seeds 4. Mini meatballs 5. Boiled eggs 6. Mini quiche/frittata 7. Roasted chickpeas 8. Yoghurt 9. Lassi with mango 10. Smoked mussels on toast 11. Baked samosa 12. Tuna & avocado sushi roll 13. Nut butter or vegemiteTM/ marmiteTM on toast 14. Quesadillas with black beans 15. Fortified milks e.g. SustagenTM, MiloTM, Up&GoTM

An IBD dietitian can make personalised dietary recommendations if certain iron and B12–rich foods are not well tolerated.