What is the ideal diet for a person with an ileostomy?

Ideal Diet for a Person with an Ileostomy

For standard ileostomy patients, consume a diet high in complex carbohydrates (starches like pasta, rice, white bread, mashed potatoes), normal in fat, low in fiber, with liberal salt intake (0.5-1 teaspoon extra daily), and restrict hypotonic fluids (water, tea, coffee) to less than 500-1000 mL daily while replacing remaining fluid needs with oral glucose-saline rehydration solutions. 1, 2, 3, 4

Fluid Management: The Most Critical Component

Fluid restriction and replacement is the cornerstone of ileostomy management. The most common mistake is allowing patients to drink large volumes of plain water, which paradoxically worsens dehydration and increases output. 2, 4

• Restrict hypotonic fluids (water, tea, coffee, alcohol) to less than 500-1000 mL daily 1, 2, 4
• Replace all remaining fluid requirements with oral glucose-saline rehydration solutions containing at least 90 mmol/L sodium 2, 4
• The modified WHO cholera solution (St. Mark's solution) is recommended: 60 mmol sodium chloride (3.5g), 30 mmol sodium bicarbonate (2.5g), 110 mmol glucose (20g) in 1 liter water 1, 4
• Target urine volume of at least 800 mL daily with urinary sodium >20 mmol/L to confirm adequate hydration 2, 4
• Avoid hypertonic drinks (fruit juices, colas) as these also increase output 1

Macronutrient Composition

Carbohydrates: High Complex Carbohydrates

• Emphasize complex carbohydrates (polysaccharides/starches) rather than simple sugars 1
• Recommended foods: pasta, rice, white bread, mashed potatoes, bananas 2, 3
• This approach increases energy absorption and reduces risk of D-lactic acidosis 1
• Avoid high monosaccharide diets which can cause D-lactic acidosis 1

Fat: Normal Intake (Not Restricted)

• Maintain normal fat intake (20-30% of total energy) with long-chain triglycerides 1
• While theoretically a low-fat diet might be ideal, it is impractical—fat provides twice the energy of carbohydrates and makes food palatable 1
• Medium-chain triglycerides offer marginal benefit but require attention to essential fatty acid deficiency 1
• If fat is restricted, consider topical sunflower oil application to prevent essential fatty acid deficiency 1

Fiber: Low Fiber

• Follow a low-fiber diet to reduce loose stools, flatulence, and blockage risk 1, 3, 5, 6
• Avoid nuts, wholemeal products, fruit and vegetable skins, sweetcorn, celery 1, 3
• Do not add soluble fiber (pectin) as it does not enhance absorption 1

Sodium and Electrolyte Management

• Add 0.5-1 teaspoon extra salt daily to meals to prevent sodium depletion 2, 3, 4
• Maintain diet osmolality close to 300 mOsm/kg with oral sodium intake around 90 mmol/L 1
• Correct sodium and water depletion FIRST before addressing other electrolytes 2, 4
• Hypokalemia typically resolves once sodium balance is corrected; potassium supplements are rarely needed 2, 4

Foods That Thicken Output

These foods help manage stoma output and should be incorporated regularly:

• Marshmallows, bananas, pasta, rice, white bread, mashed potatoes, jelly 2, 3
• These are particularly useful for high-output situations (>1.5 L/day) 3

Meal Pattern and Energy Intake

• Consume small, frequent, nutrient-dense meals/snacks rather than large meals 2, 3
• Increase total energy intake above normal requirements as 50% or more may be malabsorbed 1
• Consider oral nutritional supplements or nocturnal enteral feeding if weight loss occurs 1

Foods to Approach Cautiously

• Lactose: Only exclude if documented clinical intolerance (clear association with increased output) 1
• Oxalate-rich foods: Limit beetroot, chocolate, most nuts, parsley, rhubarb, spinach, tea to reduce kidney stone risk 1
• Most patients can eat normally after an initial adaptation period; systematic food exclusion is unnecessary unless proven problematic 6, 7

Monitoring Requirements

• Monitor body weight regularly 4
• Check urinary sodium concentration (target >20 mmol/L) 1, 2, 4
• Assess for vitamin B12 deficiency (especially if terminal ileum resected) 1, 3
• Monitor for deficiencies in selenium, zinc, vitamins A, D, E, K 1

Pharmacologic Adjuncts to Diet

• Loperamide 2-8 mg taken 30 minutes before meals reduces output by 20-30% 2, 3, 4
• For persistent high output, add proton pump inhibitors or H2 antagonists to reduce output by 1-2 L/day 2, 4

Critical Pitfalls to Avoid

• Never allow unrestricted plain water intake—this is the most common error and worsens dehydration 2, 4
• Do not supplement potassium before correcting sodium and water balance—it is ineffective 2, 4
• Avoid high-fiber "healthy" diets—fiber increases output and complications 2
• Do not use hyperosmolar elemental diets—they exacerbate high output 1