Inflammatory Bowel Disease and Diet

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Hello Friends! I know I throw many acronyms around this blog all the time, but I want to be sure you understand today’s topic is primarily about inflammatory bowel disease (I.B.D.) and not my usual topic, irritable bowel syndrome (I.B.S.)! Although, IBS will be weaved throughout this post, I just wanted to be clear up front… so you are not confused.

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IBD vs. IBS

Inflammatory bowel disease (IBD) is a chronic immune disorder that presents with inflammation of the digestive tract; two forms include: ulcerative colitis and Crohn’s disease. Crohn’s can strike any part of the digestive tract while ulcerative colitis occurs only in the colon. IBD symptoms may include severe diarrhea (w/ blood and mucus), pain, fatigue and often weight loss.

The incidence of IBD is increasing globally and may in part be due to the spread of the Westernized diet, which is high in fat, protein and low in nutrient rich produce. Food emulsifiers such as polysorbate 80 and carboxymethylcellulose commonly added to food products have also been implicated in gut inflammation.

There is little research on diet and IBD. I find this very surprising and disappointing. Prescription medications have taken the center stage for IBD treatment and while they play a key role for many patients, I am hopeful that nutrition will become an equally important part of the treatment. Although there are limited studies looking at the role of diet in IBD… thankfully, this is changing.

Today, I will briefly discuss, the SCD or specific carbohydrate diet,  IBD-AID, and the low FODMAP diet. Another IBD nutritional therapy with good efficacy is using enteral feeding products (exclusive enteral nutrition is an extensively studied, well established, and valid approach to the remission of pediatric Crohn’s disease) but I will focus today’s discussion on these 3 other nutritional approaches.

SCD: The Specific Carbohydrate Diet is a diet that was developed by Dr. Sidney Haas and popularized by the book, Breaking the Vicious Cycle by biochemist, Elaine Gottschall.  The SCD is a dietary approach that eliminates complex carbohydrates under the premise that they are not easily digested, feed pathogenic gut microbes, which in turn, produce inflammatory metabolites that injure and inflame the intestinal wall. The guiding principle of the diet is that undigested carbohydrates will over feed harmful bacteria and are thus eliminated from the diet. The diet is used as a strategy to starve the microbes and reduce inflammation.  The SCD commonly uses almond flour in recipes instead of grains. Also, as honey does not contain any carbohydrates that require carbohydrate degrading intestinal digestive enzymes, it is the primary allowed sweetener. The SCD has phases: individuals start with phase 1 and move up as tolerated. The SCD diet is a highly restrictive diet. A small retrospective study by Suskind et al.  reviewed medical records of 10 children & adolescents with Crohn’s disease treated with the SCD for a period of 5–30 months. Symptom resolution occurred in all patients within 3 months post initiation of the SCD. Stool studies for calprotectin, a marker of intestinal inflammation, normalized on improved significantly as well. (1)

Resources for the SCD diet can be found on the following sites:

IBD-AID: Anti-Inflammatory Diet for IBD  {Please see the University of Massachusetts site for greater details here. }

The IBD-AID was derived from the Specific Carbohydrate Diet (SCD) but modified to include additional dietary components based on more recent novel gut microbiome research. Stool sample analysis has shown that IBD patients have alterations in their gut microbiome. Like the SCD,  IBD-AID has multiple phases too, depending on the stage of your disease. The first phase, for instance, includes only soft, well cooked foods without seeds and advances to a more liberal diet at phase IV.  There are 5 essential components included in the IBD-AID diet:

  1. Prebiotics:  inulin and beta-glucans: bananas, oats, leeks, onion, garlic, asparagus, artichokes, Jerusalem artichokes, spinach, oats, chia, and flax meal
  2. Probiotics: Yogurt, miso, kefir, sauerkraut, kimchi, and honey.  All of these must have live and active bacterial cultures.  
  3. Balanced nutrition
  4. Avoiding certain foods: The IBD-AID diet emphasizes avoidance of certain foods that may be disturbing the normal gut flora. Foods that contain lactose, wheat, refined sugar, trans fats, processed foods and corn are avoided in all phases of the diet.
  5. Texture: Depending on severity of GI symptoms, patients are encouraged to choose ground, blended or pureed foods. Pureeing foods may improve absorption and tolerance of nutrients in the foods. Intact fiber from seeds and stems may be restricted.

In a small retrospective case series, study participants following the IBD-AID had good success. All (100%) patients were able to discontinue at least one of their prior IBD medications, and all patients had symptom reduction including bowel frequency. (2)

Low FODMAP diet for overlapping IBS like symptoms in IBD.  I won’t review the low FODMAP diet in this post as you know there are many resources on my site about the low FODMAP diet! Here are some interesting research notes on the use of the low FODMAP diet in IBD:

IBS and IBD often co-exist.

Individuals who have with IBD often have an overlap of IBS symptoms.  Whether the IBS-like symptoms are due to subclinical relapsing IBD or more of an overlap of IBS, there is a cascade of IBS-like symptoms in a subset of IBD patients. One study revealed that about 39% of IBD patients experienced IBS. (3)  IBS-type symptoms were significantly more common in Crohn’s disease than in UC patients, and in those with active disease.  There have been a few studies showing symptom benefit of the low FODMAP diet in IBD patients. A small pilot study out of Monash University looking at the benefit of the low FODMAP diet in patients with IBD and IBS symptoms noted good compliance w/ the diet and improved symptom management. (4) Whether the low FODMAP diet modifies intestinal inflammation has yet to be proven, but University of Michigan researchers reported at Digestive Disease Week this year in one of their recent studies yet unpublished, that the low FODMAP diet reduced bacterial endotoxin (lipopolysaccharide or LPS) in a subset of patients with IBS-D (diarrhea predominant IBS).  LPS is associated with gut permeability and inflammation. Interesting science…stay tuned!

Caution! When NOT to use the full low FODMAP diet with IBD:

  • A strict low-FODMAP diet may not be appropriate choice for individuals w/ Crohn’s disease with strictures.
  • Strictures are narrowing of the lower small intestine which can lead to intestinal blockage. Strictures can make digestion of fiber difficult.
  • For those with IBD w/ strictures, a low-residue or low-fiber diet is important to prevent blockages. Because FODMAPs help maintain fluid in the bowel, they may actually help to keep food moving through a constricted bowel. FODMAPs w/ greater osmotic effects: lactose, polyols and excess fructose.

All three diets I briefly described today modify carbohydrates as one of their prime strategies to help decrease symptoms. Before you alter your diet, always check in with your health provider first! I do think there will be evidenced based diet therapies for IBD in the very near future. What we eat changes our gut microbiome and the gut microbiome is altered in IBD. Diet changes what microbes reside in our gut and what metabolites the microbes produce. Microbes ferment carbohydrates and produce short chain fatty acids. One of these SCFAs is butyrate, which is associated with colonic health. But perhaps there is too much fermentation occurring in IBD, resulting in too much acid in the intestine contributing to the inflammation? Perhaps microbes consume particular foods we can’t digest adequately and create inflammatory chemicals? Food is complicated and so is IBD. IBD is a complex disease with many underlying mechanisms contributing to its occurrence. Nutritional interventions can improve nutrient levels, pediatric growth, and bone health in individuals that suffer with IBD. My hope is that we find the least restrictive diet to allow for enjoyment of a variety of nourishing foods with the goal to reduce symptoms and inflammation in the gut. The answer is out there…and we will find it! Feel free to share your experiences with diet and IBD…we all learn from one another. 🙂

References:

  1. Suskind, D.L.; Wahbeh, G.; Gregory, N.; Vendettuoli, H.; Christie, D. Nutritional therapy in pediatric Crohn disease: The specific carbohydrate diet. J. Pediatr. Gastroenterol. Nutr. 2014, 58, 87–91
  2. Olenzki, BC, Siverstein TD, Persuitte GM, Ma Y, Baldwin KR, Cave D. An anti-inflammatory diet as treatment for inflammatory bowel disease: a case series report. Nutr J 2014;13-5.
  3. Halpin,SJ Ford, AC Am J Gastroenterol. 2012 Oct;107(10):1474-82.
  4.  Gearry, RB, Irving PM, Barrett JS, Nathan DM, Shepherd SJ, Gibson PR Reduction of dietary poorly abosrobed short chain carbohydrates (FODMAPs) improves abdominal symptoms in patients with inflammatory bowel disease-a pilot study. J Crohns Colitis. 2009 Feb;3(1):8-14.

20 replies on “Inflammatory Bowel Disease and Diet“

  • Glenna Wright

    A note of thanks about bringing 88 Acres into my life! I have ordered numerous times and enjoy the Chocolate and Sea Salt bars. They work very well with my low Fodmap diet. They have a new product, Seednola, but since it’s a mixture of all the bars I’m thinking it would not be best to try. Anyway, thanks again!

  • Beth Rosen, MS, RD, CDN

    As always, excellent information. I continue to learn from you. Thank you for sharing your knowledge. I hope to find a diet-related treatment for IBD as my husband was recently diagnosed with lymphocytic colitis, and I tried a few alterations with him (mostly lower fat since he had a cholecystectomy before his dx of IBD), but nothing seems to help more than the meds the MD prescribed. Looking forward to new research!

    • katescarlata

      I love the idea of fecal transplants for IBD and do feel that the gut microbiome is a big driver in IBD—but the research for fecal transplants in IBD has not been that impressive. I know there is more research being done–but preliminary studies–not great results.

  • Terry

    Thank you for this summary, there are so many special diets out there! I have Hashimotos and am sensitive to food maps so many of the auto immune diets look interesting but contain many high fodmap food like honey and cruciferous vegetables. I feel best following low fodmap lifestyle and lots of low fodmap vegetables and fruits.

  • Lisa

    Good information, but SCD as defined by Elaine Gottschall does not have 5 phases. There is an intro diet (which can be altered to allow for individual tolerance and availability of the suggested foods), and then a slow introduction of legal foods. There are some legal foods that she recommended avoiding for a period of time or until certain symptoms were no longer an issue. “Phases” have been suggested by various people promoting SCD, but they are not a necessary component of implementing the diet. Lots of people use SCD + low FODMAPS for Crohn’s especially when SIBO (or SBBO) exists.

  • Pingback: Nut & Seed Quinoa Salad with Cranberries - The well balanced FODMAPer—Kate Scarlata RDN

  • dkaj

    Kate, can you tell us why carboxymethylcellulose is inflammatory? Is it the cellulose that’s harsh on the GI tract, salts or another componenet of it? Also, is hydroxypropyl methycellulose (HPMC) safe for Gastritis and/or IBD. Reason why I ask is alot of capsules that meds come in on the market are made from HPMC. I know many of FM mom’s use capsule machines and fill their own probiotics with the powders to avoid all the inactive ingredients in many of the OTC probiotics, supps, and etc. TIA. as always.

    • katescarlata

      I am not sure fully, Deborah, animal studies shows carboxymethylcellulose (not cellulose) and polysorbate 80, commonly used emulsifiers changes the gut microbiome….in animal studies–changing the species in the gut and increasing pro-inflammatory potential by increasing LPS and flagellin. How this occurs–remains unknown at this time. Leading this research is Andrew Gewirz’s group out of Georgia State University in Atlanta.

  • Melanie Taylor

    Thank you for a great article, I was unaware of the SCD for Colitis. I have been diagnosed with both IBD (colitis) and IBS and am currently in the middle of an IBD flare. When i crossmatch the eating regime for IBS and ‘eating during a flare’ with IBD I am basically left eating white rice, eggs and bok choy. I was vegetarian but to add more to my diet I have started eating a bit of fish. I try to introduce foods but usually without success. My specialist has suggested I also include turmeric, probiotics and fish oil capsules which is refreshing to have a medic offering ‘alternative’ therapies, he also is not convinced yet as to the benefits of faecal transplants. I have just put a hold on Breaking the Viscious Cycle at my local library so hopefully this will enlighten me without causing more food choice confusion. I will continue to follow your articles with interest. Thank you

  • dkaj

    Thanks Kate for the followup on the HPMC. Looking back at your post, it looks like it’s the carboxy methylcellulose you were referencing. At this point, we will stay with the HPMC capsules and keep our fingers crossed this is not discovered down the road to be pro-inflammatory. Also, I will keep my eyes open for the polysorbate 80 which I have seen added to some of our local breads.

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