The Search for a Dietary Culprit in IBD

Uniformly, patients diagnosed with inflammatory bowel disease (IBD), both ulcerative colitis and Crohn disease, are interested in whether there is a dietary culprit which triggered their IBD and what modifications in their diet can help improve their IBD.  A really good summary of what we know has been published (Inflamm Bowel Dis 2014; 20: 732-41).

A summary of the key points:

Traditional dietary recommendations:  These diets may help decrease symptoms but are not thought to improve disease control.

  • Low-residue: <10-15 g/d of fiver. Potential deficiencies: folate, vitamin A, vitamin C, and potassium.  Overall, this diet is poorly studied.  “One small randomized controlled trial showed that low-residue diet made no difference in symptoms, need for hospitalization, need for surgery…when compared with an unrestricted diet.”
  • Lactose-free: potential deficiencies: calcium, vitamin D

Carbohydrate-restrictive:  Potential deficiencies with all carbohydrate restriction: folate, thiamine, vitamin B6

  • Specific carbodydrate diet: allows only monosaccharides.  Restricts complex sugars, starches, grains and legumes.  This diet was popularized by Elaine Gottschall in 1994 (Breaking the Vicious Cycle) but was developed by Dr. Sidney Haas in 1924.  The premise of SCD is that “complex carbohydrates and legumes are poorly absorbed in gastrointestinal disease…they promote bacterial overgrowth and fermentation.  By-products from bacterial dysbiossis are postulated to contribute to gut inflammation.”  Nevertheless, it “has been poorly studied.”
  • Low FODMAPs (see numerous previous posts).  “A small restrospective study…showed that the low FODMAPs diet resulted in improvement in functional symptoms present in patients with IBD who were in remission.”  This diet is difficult for long-term adherence.
  • Gluten-free: not truly a carbohydrate-restrictive diet, but breads/cereals contain large amounts of carbs. “No evidence that a gluten-free diet has any effect on disease activity in IBD.”

Fat-modified diets

  • Fat-restrictive diets: “On a cellular level, multiple animal studies have shown that prolonged feeding of a high-fat diet seems to promote colitis/ileitis and to perturb barrier function…shifts in microbiome composition…Despite some biologic plausibility, there is a paucity of data evaluating efficacy of fat-restrictive diet for IBD management.”
  • Vegetarian/semi-vegetarian: Potential deficiencies: iron, vitamin B12 (vegans), calcium, vitamin D, ω-3 fatty acids.   A small study of 22 patients with Crohn’s disease who adhered to a semi-vegetarian diet, had lower rate of relapse.  “There does not seem to be sufficient evidence at this time to recommend eliminating meat to patients with IBD as a means to control their disease.”
  • Modified ratio of ω-3/ω-6 polyunsaturated fat: “The efficacy of dietary interventions with ω-3 PUFA has been disappointing..recently, 2 large multicenter clinical trials demonstrated that ω-3 PUFA (fish oil) at a dose of 4 g/day was not significantly better than placebo at maintaining remission in CD.”

Restriction of Multiple food groups

  • Paleolithic: based on the “premise that human genetics have scarcely changed over the past 3000 years, and thus modern humans are genetically adapted to the diet of their Paleolithic ancestors (i.e. Stone Age)…daily calories should come from plant sources (50-65%) and from animal sources (35-45%) with fish preferred over meat.  Most of the restricted foods are carbohydrates..refined salt, and refined oils as well as any “processed foods.”  However, there are “no data that this diet has any effect in IBD.”  Previous reports of improvement in IBD are mainly testimonials (anecdotal evidence).
  • Exclusive enteral nutrition (EEN)/Elemental/Semielemental: In pediatric CD, “EEN has been shown to be as effective as corticosteroids in inducing remission (70-90%)..EEN does not seem to be effective in UC.”  High rate of relapse when diet is stopped.  Formula type does not seem to be very important.

Take-home message: “Clinical trials in all dietary strategies (with possible exception of EEN in pediatric patients) are lacking and further study is needed.” “From the current evidence available, a low FODMAPS or gluten-free diet may be the most helpful in controlling diarrheal and bloating symptoms…However, …symptom improvement does not equate to remission or objective evidence of disease regression.”

Related Blog Posts:

ImproveCareNow has published information on IBD and Nutrition as well.  Here’s an excerpt from their Circle eNewsletter:(initially published April 2013, Stacie Townsend, MS, RD, LDN, CSP)

Diet is an important part of your IBD treatment plan and should be used in conjunction with medications. Proper nutrition plays a critical role in managing IBD. Eating healthfully and in appropriate amounts will improve IBD symptoms, contribute to age-appropriate growth, and decrease risk of anemia, poor bone density, and vitamin/mineral deficiencies. It can also increase effectiveness of IBD medications.

No one diet has been proven to prevent IBD or to prevent flare ups, although several diet books and plans have claimed to “cure IBD”. Unfortunately, there is little scientific evidence to prove that these diet plans, such as the Specific Carbohydrate Diet (still being studied) and the Guts and Glory Program, are effective, and most of these plans avoid entire food groups, which can then lead to vitamin and mineral deficiencies and poor weight gain.

Nutritionists frequently get asked what foods are safe for people with IBD, and creating a diet plan for you is often trial and error… The best diet plan is one that includes all food groups (proteins, grains, fruits, vegetables, dairy, and oils) and in appropriate portions for your age, weight, and physical activity level… If gas, bloating, and diarrhea are among your symptoms, lactose free dairy products may be better tolerated.

So what IS the most appropriate diet for IBD? The United States Department of Agriculture’s food guidance system, MyPlate, is the appropriate diet plan for you… and the SuperTracker within the MyPlate website can help you track what you eat each day, and how your diet measures up to the recommended diet plan for you.

General nutrition guidelines for individuals with IBD include:

  • choose foods from all food groups
  • limit fried/fatty foods, caffeine and spicy foods, especially if these foods worsen symptoms of IBD
  • drink fluids at each meal to maintain hydration
  • consume a multivitamin daily to aid nutrient absorption
  • consume small frequent meals (eat every 2-3 hours while awake) if volume of foods at a meal is an issue

…If you want additional help with your diet, make an appointment to see our nutritionist.

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.