Graft versus Host Disease (GvHD) can present in many ways this information helps explain how to manage your diet.
Graft-versus-host disease (GvHD) can present in many ways. Its severity is graded using a1 to 4 scoring system.
GvHD of the gut scoring depends on the following:
- Volume and frequency of loose stools
- Pain
- Nausea and vomiting
The diet for GvHD has four phases and you may start the diet at different points depending on your symptoms. Your doctor, dietitian and nursing team will ensure you understand how best to deal with your condition.
Phase 1 (Stage IV – III GvHD)
During this phase you will be advised to rest your bowel and remain nil by mouth as food and fluid intake can increase the severity of your stool output and pain. You will need to be fed by an artificial route to rest your bowel. This is an intravenous (IV) preparation that provides you with the calories, protein and nutrients you need called Parenteral Nutrition (PN). The PN is given as an intravenous infusion into your blood stream through your line, and therefore avoids the gut.
This treatment is likely to continue even when you start to eat again as we need to ensure you continue to get the nutrients your body needs.
Phase 1 (Stage IV – III GvHD)
The second phase is the introduction of a clear liquid diet. If you are on PN, this will continue to meet your nutritional requirements. If PN has not been started then this may be considered depending on your stool output.
You can try the following:
- Water
- Diluted squash (¼ squash to ¾ water)
- Half strength apple juice (made from concentrate)
- Weak decaffeinated tea (no milk)
If this is tolerated then the team may discuss enteral feeding with you. This usually means receiving nutrition through a tube which is passed into your stomach (nasogastric tube).
Back to topPhase 3 (Stage II – I GvHD)
The third phase is the re-introduction of foods. After resting your bowel it is important to add foods in slowly.
Foods advised at this stage will be:
Low in fat: Fats are hard to digest and can increase diarrhoea.
Low in fibre: Certain fibres can increase diarrhoea, gas and pain.
Low in lactose: Dairy products contain a sugar called lactose that can be hard to digest. Dietary products that are lactose free can be used to avoid this. Soya milk, soya butter and soya yoghurt products can be useful.
Low acid and irritants: High acid and spicy foods can irritate the mouth, stomach and bowel.
It is very important to remember every person is different. Some people will progress slower than others. The decision to advance from one stage to the next is based on each patient’s symptoms. It is paramount that you listen to your own body; don’t force yourself to eat foods that cause discomfort or that you think you should be eating.
It may help to:
- Try small frequent meals
- Avoid eating foods that are too hot or too cold
- Add new foods slowly to your diet. This will ensure you are aware of what foods are irritants and which foods you can tolerate
- Keep a food and symptom diary (noting any pain, spasms or diarrhoea). Your nurse and/or family can help you with this.
Your dietitian may advise you to introduce only one food at a time. This is not a nutritionally complete diet and therefore you should continue PN and/or enteral feeds (via the gut) if appropriate, although these may be at a reduced volume.
Basic diet
Cereals
Rice Krispies, puffed rice
Starches
- Plain white rice – boiled
- Plain potato – boiled, mashed or baked (no skin)
- Plain rice cakes
Drinks
- Clear fluids
- Water
- Diluted squash (¼ squash to ¾ water)
- Half strength apple, pear or peach juice (made from concentrate)
- Weak decaffeinated tea
- Rice milk
- Soya milk
- Lactofree milk (if having more than ½ pint per day, use semi-skimmed variety instead of whole)
If tolerated then add the following
Protein source
- Lean chicken or turkey – breast meat only (no skin)
- Plain white fish – baked or poached (no breadcrumbs or batter)
Other starches
- Soft plain white bread
Vegetables
- Well cooked carrot or parsnip
Fruit
- Pears, peaches or apricots tinned in their own juice
Fats
- Small scraping of dairy free margarine
Miscellaneous
- Vegetable stock powder/cube (check lactose free)
- Sugar free jelly (not containing Sorbitol)
- Ice pops
Phase 4 (Stage I GvHD)
As your gut improves you will be advised to try a greater variety of foods. As this increases, your PN/enteral feed will be stopped. Your dietitian or doctor may recommend starting oral nutritional supplements depending on your intake.
You will be advised to continue with a low lactose, low fat, low fibre, low acid diet but more foods may be permitted.
Food Groups
Drinks
Try
- Water, Diluted squash, Half strength apple, pear, peach or cranberry juice, Weak decaffeinated tea or coffee
- Rice milk, Soya milk, Lactofree milk (if having more than ½ pint per day, use semi-skimmed variety instead of whole)
Avoid
- Carbonated drinks (pop), Orange, grapefruit, pineapple or tomato juice, V-8 juices
- Cow’s milk – whole, semi-skimmed, skimmed or powdered, Coffee creamers
Bread, Cereals, Pasta
Try
- Rice Krispies, Cornflakes, puffed rice, Cheerios, Frosties,
- Plain boiled white rice,Plain dried pasta – boiled, Plain rice cakes
- Baked, boiled or mashed potato (a small amount of dairy free margarine can be used in mashing)
- Plain white bread, plain bagel, plain pitta bread
Avoid
- Weetabix, Branflakes, Shredded Wheat, Chocolate coated cereals
- Macaroni Cheese, Tinned pasta in sauce, Fresh pasta
- Chips, crisps, roast potato, instant mashed potato
- Wholemeal, granary or multigrain breads, milk loaf, glazed loaf
Meat, Poultry, Fish and Eggs
Try
- Chicken or turkey breast (no skin)
- Lean and tender lamb, beef, pork
- Lean ham
- Lean vacuum packed sliced meat
- Plain white baked, poached white fish
- Tuna canned in water/brine
- Eggs – well cooked (boiled, poached)
Avoid
- Breadcrumbs or batter
- Fried meat, bacon, sausage, hot dogs, corned beef
- Oily fish – salmon, mackerel, trout, sardines, Batter or breadcrumbs, Fried fish, Tuna canned in oil, Fried egg/omelette
Fruits
Try
- Tinned peaches, pears, apricots, Banana, Stewed apple, Peeled mango, peaches, melon, nectarine
Avoid
- Citrus fruits – oranges, grapefruit, Prunes, plums, dried fruit, pineapple, rhubarb, tomato, grapes
Vegetables
Try
- Cooked carrot, parsnip, mushrooms, asparagus tips, sweet potato
- Baked, boiled or mashed potato (a small amount of dairy free margarine can be used in mashing)
Avoid
- All other vegetables, pulses, beans, lentils
- Chips, crisps, roast potato, instant mashed potato’s
Dairy Products
Try
- Milk substitutes – rice milk, soya milk, Lactofree milk (if having more than ½ pint per day, use semi-skimmed variety instead of whole)
- Soya yoghurt, Soya ice cream
- Small portion soya cheese
Avoid
- All types of cow’s milk – fresh, powdered, skimmed, semi-skimmed evaporated, condensed, Goat’s milk, sheep’s milk, Coffee creamers, Cream – all types
- Dairy desserts, mousses, yoghurt, fromage frais, crème fraîche, ice cream
- Cheese – cheese spread, cheese strings, cottage cheese, cream cheese.
(note – cheddar, edam, feta and mozzarella all have a lower lactose content). They are still high in fat therefore it is advised to have small portions only
Fats and Oils
Try
- Small portions dairy free margarine, Small amount vegetable oil
Avoid
- Butter, margarine, All other fats and oils
Miscellaneous
Try
- Boiled sweets, jelly type sweets
- Jelly type jams, honey
- Clear broth, consommé
- Salt and pepper in cooking
- Sugar
- Plain low fat crisps – maximum of 1 small packet
Avoid
- Chocolate, toffees, fudge, biscuits
- Jam with seeds
- All other soups – creamed, vegetable, tomato
- Herbs and spices
- Sorbitol and products containing Sorbitol
- All other crisps and snacks
- Vinegar, salad dressings, tomato ketchup
Drinks
Try
- Water, diluted squash
- ½ strength apple, cranberry, pear juice
- Weak coffee, tea
Avoid
- Orange, pineapple, grape, tomato juice
- All other fruit juices
- Carbonated drinks (pop)
Final Phase
At this stage your gut will be almost back to normal so you may find you can tolerate more fat and fibre foods in your diet. The enzyme in the gut which breaks down lactose (a milk sugar) is one of the last things to improve therefore it is advised that you continue a low lactose diet for longer and re-introduce these foods last.
Lactose Free Diet
Lactose is the sugar found in milk, which can be hard to digest during gut illness. It is usually a temporary problem but can take a while to return to normal tolerance once the gut is healed. Therefore at regular intervals re-introduce some lactose foods to check your tolerance level. If you tolerate it then you can gradually return to a normal balanced diet slowly increasing the amounts of these foods.
If symptoms persist then you may be advised to exclude all lactose from the diet. This would include all milk, milk products and manufactured foods containing milk need to be avoided.
Back to topIf any of the following names appear in the list of ingredients, please avoid the product as it contains milk or milk products:
Milk and Milk products
- Cow’s milk, goat’s milk, sheep’s milk, Cheese, cream, butter, margarine
- Ice cream, yoghurt, fromage frais,crème fraîche.
- Chocolate.
Milk Derivatives
- Skimmed milk powder, milk solids, milk protein, non-fat milk solids, separate milk solids.
- Whey, hydrolysed whey protein, margarine or shortening containing whey, whey syrup sweetener.
- Casein, hydrolysed casein, sodium caseinate, calcium caseinate, hydrolysed caseinate.
- Lactose.
- Buttermilk, butterfat, butter oil, animal fat (may be butter) ghee, artificial cream.
- Cheese powder.
Lactose as a filler may be used in
- Flavourings
- Table-top or tablet artificial sweeteners.
Food Groups
Milk and Dairy Foods
Try
- Milk substitute (as advised
- by dietitian)
- Soya milk
- Rice milk
- Lactofree milk
- Soya yoghurt
- Soya cheese
- Soya ice cream
- Soya drinks
- Soya desserts
Avoid
- All types of cow’s milk – fresh, powdered, skimmed, semiskimmed evaporated, condensed
- Goat’s milk, sheep’s milk
- Coffee creamers and coffee whiteners
- Cream – all types
- Ready made custard
- Lactolite
- Dairy desserts, mousses, yoghurt, fromage frais, crème fraîche, ice cream
- Cheese – all types including hard cheese, cheese spread, cheese strings, cottage cheese, cream cheese
Fats and Oils
Try
- Milk free margarine e.g. Tomor, Pure, soya margarine, vegetable oils, lard, dripping, suet
Avoid
- Butter, margarine, low fat spreads, Ghee
Flours, Pasta & Rice
Try
- All flours – wheat, oat, rice, semolina, corn, sago, rye, barley, maize, tapioca, potato, arrowroot and buckwheat.
- Any dried pasta e.g. macaroni, spaghetti, dried noodles.
- Plain dried rice, Plain rice cakes.
Avoid
- Macaroni cheese, tinned pasta in sauce (check ingredients), Fresh pasta.
- Flavoured rice cakes, Rice pudding.
Breakfast Cereals
Try
- Rice Krispies, Cornflakes, Weetabix, Shreddies, Shredded Wheat, Frosties, Cheerios, Original Ready Brek.
Avoid
- Chocolate flavoured breakfast cereals, Special K, Weetos, Any other cereal unless known to be lactose free.
Bread
Try
- Wholemeal, granary, multigrain and white bread – known to be lactose free.
Avoid
- Milk roll, malted bread, crumpets, croissants, bagels, Danish loaf, Bread sticks, garlic bread, naan bread, chapattis made with fat, Brioche, muffins, scones Pizza bases.
Eggs
Try
- All types – well cooked without milk.
Avoid
- Scrambled egg or omelette made with milk.
Meat and Fish
Try
- Fresh meat, chicken, turkey
- Ham and bacon – check ingredients as lactose may be used as a flavour enhancer
- Processed meat only if known to be lactose free
- Fresh or frozen plain fish
- Tinned fish in water or brine (check ingredients if canned in a sauce)
Avoid
- Any processed meat – check the label
- Vacuum packed sliced meat – check the label.
- Sausages, burgers, pies.
- Meat with batter or breadcrumbs.
- Fish with breadcrumbs or batter.
- Fishfingers, fishcakes – check ingredients.
Vegetables
Try
- Potatoes – boiled, chipped, baked, roast or mashed with milk substitute or milk free margarine.
- Vegetables -all fresh, frozen, tinned and dried.
- Lentils and pulses – dried and tinned e.g. red kidney beans, chick peas.
- Baked beans in tomato sauce – check label.
Avoid
- Mashed potato with ordinary milk or margarine, Potato waffles/shapes, Potato croquettes, Instant potato, Potato salad.
- Vegetables in batter or breadcrumbs.
- Vegetables tinned in sauce unless known to be lactose free, Coleslaw
- Baked beans in tomato sauce unless known to be lactose free.
Fruits
Try
- Fruit – all fresh, frozen and tinned.
Avoid
- Fruit pie fillings, Yoghurt or chocolate covered fruit
Drinks
Try
- Soya milk, soya milk drinks.
Avoid
- Cocoa, drinking chocolate powders – unless known to be lactose free.
Soups, Sauces and Miscellaneous
Try
- Soups made with lactose free ingredients.
- Salt, pepper, herbs, spices, vinegar, mustard (remember whilst immuno-suppressed to only add pepper, herbs and spices during cooking).
- Marmite, Bovril, Oxo.
- Tomato ketchup.
- Essences, colouring, baking powder, sodium bicarbonate, gelatine, marzipan.
- Sugar, honey, treacle, jam, marmalade, syrup.
Avoid
- Tinned or powdered soups – unless known to be lactose free.
- Mayonnaise, salad cream, sauce mixes, sweet pickles – unless known to be lactose free.
- Sauces made from milk or containing lactose as a filler.
- Lemon curd, peanut butter, chocolate spread.
If you are experiencing any problems with this diet, please contact the dietitian: