Nearly every patient with inflammatory bowel disease (IBD) has the same query—which has a not-so-simple answer.
“‘Doctor, what should I eat when living with IBD?’ is likely the most frequently asked question following diagnosis,” says Dr. Maitreyi Raman, an associate professor of medicine at the University of Calgary.
Raman, who’s a gastroenterologist, physician nutrition specialist, and researcher, has closely studied the topic and reviewed the available evidence for dietary patterns that may be of benefit (or not) to patients.
IBD includes Crohn’s disease, which can cause inflammation in any part of the digestive tract and commonly affects the small intestine; ulcerative colitis, limited to the large intestine, or colon, and rectum; and indeterminate colitis, which has features of both Crohn’s and colitis. IBD can cause diarrhea, cramping, pain in the abdomen, unintended weight loss, nausea, and fatigue.
Because chronic illness can cause major life disruption, many patients feel motivated to find relief.
“The role of diet as a risk factor and therapy for IBD has been of great interest to patients,” says Raman, who co-authored a review of diets for IBD published in Hepatology and Clinical Gastroenterology It will be March 2021. Those findings indicate that exclusive enteral nutrition is the most well-supported approach, but isn’t realistic for everyone. You may also find other plans useful, like the particular carbohydrate diet.
Unfortunately, there’s a relative dearth of research on the best diet for IBD. However, there is increasing evidence. Raman says that science has advanced over the last decade to better understand the microbiome of your gut, which is composed of trillions (helpful or harmful) of bacteria. IBD may be caused by an imbalanced gut microbiome. The diet is a key factor.
Raman says that recent high-quality, randomized controlled trials showed that diet changes can improve IBD symptoms and reduce gut inflammation. This has led to improved patient outcomes.
Before diving into options for what you might put on your plate and in your body if you have IBD, know that experts emphasize that dietary changes aren’t a wholesale substitute for medical treatment.
“Diet is one of many therapies,” says Dr. James Lewis, associate director of the Inflammatory Bowel Diseases Program at the University of Pennsylvania Perelman School of Medicine. “While a diet-based strategy may be preferred and practical for some patients, it may be much harder to implement for other patients.” Certain diets for IBD are quite restrictive, and any significant changes in eating patterns can be challenging to sustain. Still, many patients—especially those with mild to moderate disease—look to diet as one therapy option for IBD.
According to experts, patients should seek professional assistance in creating a personal eating plan. The University of Pittsburgh’s lead dietitian, Therezia Alchoufete stresses the importance of tailoring dietary options to each individual.
Your goals should not be limited to IBD, but for overall health. And make sure the focus is on what you can eat, not just what you’re eliminating. Alchoufete encourages patients to make thoughtful food choices while increasing variety and nutrition. “My goals for each patient would be to begin building this positive relationship with food—really understanding which foods can help them feel good.”
Exclusive enteral nutrition
The most widely studied and data-supported diet for IBD—and Crohn’s in particular—is an all-liquid, formula-based meal-replacement diet. It’s called exclusive enteral nutrition, and it’s typically prescribed and overseen by doctors. Most commonly recommended for children, this can be consumed by drinking a speciality formula prepared by a doctor, or administered via a feeding tube inserted through the patient’s nose and into the stomach.
There’s strong evidence to show it leads to reduced inflammation and improved healing, and it’s comparable to treatment with steroids in helping patients achieve remission from Crohn’s, which means the disease is no longer active. The treatment is also quick. The goal of short-term, exclusive enteral nutrition is to induce remission within six to twelve weeks.
However, it’s primarily been studied in children, not adults. And there’s an even more obvious con: it’s challenging to stick with the diet “from a quality-of-life standpoint, since it requires entirely eliminating normal food,” says Dr. Ashwin Ananthakrishnan, a gastroenterologist in the Digestive Healthcare Center at Massachusetts General Hospital.
CD-TREAT
Some attempts have been made to duplicate the success of exclusively enteral nutrition using solid food. One small, 2019 study has been published in Gastroenterology found consuming an individualized “ordinary food-based” diet with a similar composition to exclusive enteral nutrition, dubbed CD-TREAT, led to changes in the microbiome that mirrored those found with exclusive enteral nutrition. It was well-tolerated by both children and adults and resulted in a decrease in gut inflammation.
CD-TREAT can be prescribed by a physician or dietitian and is personalized to your needs. It excludes gluten, lactose and alcohol. All macronutrients are included (with higher protein, fat, and fewer carbohydrates) as well as a reduced amount of fiber. A person could eat rice cereal, nondairy full fat milk and grilled cheese with an apple as breakfast and dinner, while salmon is grilled with potatoes and cucumber for lunch.
Although more study is needed, the findings provide a framework for treating active Crohn’s without relying on a liquid diet.
Crohn’s disease exclusion diet
IBD diets that are successful avoid processed Western foods, which can be harmful to your gut. Research suggests the shift toward that way of eating bears much blame for increases in IBD rates—even in the East, like Japan, where the Western diet has been adopted as well.
To counter that, the Crohn’s disease exclusion diet seeks to cut out Western diet staples, such as processed meat, artificial sweeteners, and alcohol, which may affect gut health. Evidence from high-quality comparative trials demonstrates the diet’s effectiveness in relieving symptoms and reducing inflammation—and it could start to work within three to six weeks.
In 2019, a study was published. Gastroenterology demonstrated that for children with mild to moderate Crohn’s disease, the Crohn’s disease exclusion diet can induce and sustain remission. The Crohn’s disease exclusion diet was the next study to be published in November 2021. Lancet Gastroenterology & Hepatology found it was effective for inducing and maintaining remission in adults with mild to moderate Crohn’s.
But as its name indicates, the Crohn’s disease exclusion diet is highly restrictive. In the 2021 study examining the approach, participants were only allowed to have chicken breast, eggs, and partial enteral nutrition—or liquid formula for a portion of their calories—as sources of animal protein, and limited to certain fruits and vegetables, for the first six weeks. In the second phase, almost all fruits were allowed to be introduced over six weeks. However, beef and legumes were restricted and only one slice of whole grain bread was permitted daily.
Induction is the 12-week phase that’s most crucial for reaching remission. This is the third phase of six weeks, called the maintenance phase. It adds more food to the diet, making it more sustainably while still achieving results.
Even after these adjustments, it may prove difficult to stick to the diet for the long-term. This requires careful planning and home cooking. Dr. Henit Yanai is the head of IBD Center at Rabin Medical Center, Petah Tikva.
Specific carbohydrate diet
The specific carbohydrate diet, which is a grain-free elimination diet, is based on the idea that consuming certain complex carbs feeds unhealthy bacteria, causing an overgrowth of these “bad” bacteria in the small intestine. This could lead to inflammation.
Based on that concept, the diet avoids everything from table sugar to grains—including wheat and corn—starchy foods like potatoes, and other exclusions. The adherent can eat meats and fish without additives as well fresh and frozen veggies, but they cannot be canned. You can use honey to sweeten your food.
However, experts express concern about patients’ ability to sustain the diet and advise that the eating plan should be monitored by a dietitian.
Mediterranean diet
Some IBD sufferers are also advised to try the Mediterranean diet. It’s been well studied and is highly touted for its overall benefits, including for heart and brain health. Best of all, it’s an eating style recommended for nearly everyone and is easier to follow than more restrictive diets. If you follow this plan, you’ll load up on fruits and vegetables, whole grains, nuts, and lean protein such as fish.
Lewis conducted a head-to-head comparison between diets for IBD that featured the Mediterranean diet. It was referred to as the DINE CD trial. The journal published the study in May 2021. Gastroenterology,It was compared to the carbohydrate diet. More than 190 patients with mild to moderate Crohn’s were involved in the research.
Both diets helped patients to achieve symptomatic relief and improve their quality of living. Neither option had a significant impact on a biomarker used to measure inflammation, something the Crohn’s disease exclusion diet has been documented to help improve.
The Mediterranean diet allows for a wider variety of food and has been better researched than the carbohydrate-based approach.
Low-FODMAP diet
Patients whose Crohn’s disease is well controlled in regards to inflammation but who are still suffering from irritable bowel symptoms may benefit from the low-FODMAP diet. FODMAP stands for fermentable olive-, di–, monosaccharides (and -polyols). The diet was designed to help IBS sufferers. This diet restricts or avoids certain foods, such as wheat, dairy and some fruits, like apples and vegetables, like artichokes, asparagus, and others.
“If people have significant pain and bloating, and nothing else is working, then perhaps I might try the FODMAP elimination diet,” says Dr. Jean Fox, gastroenterologist at Mayo Clinic in Rochester, Minn. But generally she has patients follow the approach under the supervision of a dietitian, so they don’t continue the restrictive phase for more than six weeks.
The reintroduction phase is where foods are gradually reintroduced slowly over six to eight week to determine which ones might be trouble. After diagnosing the cause of symptoms, foods can either be eliminated or reduced. The downside, says Fox, is that patients who don’t see any symptom relief following this diet may be unnecessarily restricting a wide range of foods.
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