Diet for IBD

“Dining with Inflammatory Bowel Disease” is such a great article by Dr. Gu and Dr. Feagins. It’s a review covering research about the dietary causes and treatment of IBD. If you can, read the whole thing. It was limited access before, which motivated me to write up this summary, but now it’s open access.

In terms of what *may* trigger, or increase the likelihood of IBD:

IBD is increasing…and associated with a Western lifestyle. Many suspect diet is a main component of that.

General beliefs

  • Nearly half of people with IBD believe diet contributes to the development of the disease
  • 69% of people say they get little to no info from providers.
  • Info found on online is often restrictive, conflicting and of poor quality.

What diet components might contribute?

  • Meat—especially red meat, may be a component. When meat is digested and broken down in the gut, it releases hydrogen sulfide, which might be a part of the development of UC. There are several potential mechanisms, including that the gut mucosa may be more permeable to pathogens. While studies are mixed in their findings of the relationship between meat and IBD, there is generally a trend toward finding that relationship, and a prospective study showed that people with UC who had a higher red meat consumption had a greater risk of relapse.
  • Fat—a Western diet tends to have inflammatory fats. There’s been a lot of interest, and suggestion that omega 3 fats might be protective. One large study showed that women consuming healthier fats had lower risks of UC, particularly.
  • Emulsifiers—Much of the research is on animals, showing that these may cause bacterial changes through less diversity in the microbiome, a general increase in inflammation, less butyrate (a helpful short chain fatty acid) and may cause increased intestinal permeability and changes in the mucosa (!!!) Not good! Few studies have looked at humans, the little study that has been done suggests that carrageenan may cause problems for IBD patients.
    • These are nearly ubiquitous in anything found on a shelf in the grocery store in a package. This means things like carrageenan, polysorbate 80, carboxymethylcellulose and the range of gums found in so many foods on the shelves.
  • Microparticles: these are small particles of aluminum, titanium dioxide and silicon—more study is needed to see where these fit and what impact they may have.

Beneficial effects

Finally! Research is starting to support the protective effect of fiber. Most studies are suggestive of a protective effect, although not all are statistically significant. Fiber may help with mucosal function because it supports the production of short chain fatty acids.

Preventing relapse

One study reports that ~68% of people make diet changes to prevent relapse, with 66% giving up favorite foods. But what are they choosing? And does it help?

  • Spicy, dairy, fatty foods and fibrous foods and possibly alcohol were what patients ID’d as a problem, but studies haven’t backed it up.
  • There is brief, but important mention that many test positive for lactose malabsorption, but a smaller portion have symptoms, mainly diarrhea—43% with CD, and 32% with UC. That’s a lot, but it isn’t all patients, either.

The diets…oh, the diets.

Exclusive Enteral Nutrition (EEN)

This means only 100% liquid feeding, either orally or by tube feeding. This is generally done for pediatrics, and it is unknown why it works, but it does for Crohn’s. Polymeric is as helpful as elemental. Studies are good for children, as good as steroids are; this isn’t the case for adults. (Cheryl’s note—my understanding is that EEN is often used in Japan with good rate for success—and many adults are unwilling to do it. I can’t blame them!) EEN does not seem to help UC.

CD-TREAT/ CDED (Crohn’s Disease Exclusion Diet) are two diets that try to mix EEN and “whole foods” to increase tolerability for children. This is very promising. (Cheryl’s note—details of the CDED have not been fully released because studies are still ongoing. While some info is available, it isn’t enough to fully design a diet. It’s frustrating as a clinician. Stay tuned.)

SCD—Specific Carbohydrate Diet

The SCD removes many foods that are believed to be poorly absorbed. It removed all grains, and focuses on fruits, vegetables, proteins, nuts. Etc. While studies are still limited, there is indication of improvement, including reduction in medications, and results have been promising, especially in pediatric patients.

(Cheryl’s note: I wrote a review of the research on the SCD for RDs a few years back which is mostly up to date.)

There are ongoing studies, including the DINE SCD and PRODUCE study, which looks at comparing a strict SCD diet with a modified SCD. These will be great additions to our overall knowledge.

Low FODMAP

Low FODMAP is generally used for IBS. It restricts rapidly fermentable carbs, and if patients benefit, reintroduces them in a systemic way to identify culprit foods.

There have been only a few studies, but those found that people on a low FODMAP diet did see decreases in symptoms for people with IBD. Changes were in symptoms like pain, bloating, etc.—fecal calprotectin did not change.

  • Low FODMAP is not intended as a long-term diet—it is an elimination diet. Following the elimination long term might lead to nutrient deficiencies. Don’t do it!

Cheryl’s note: The article notes that low FODMAP is notoriously hard to follow. May I suggest that with the support of an experienced professional, it really should be quite manageable. 🙂 Monash University has a list of RDs around the world who are extensively trained. I do have some resources for low FODMAP here.

Semi-vegetarian diet

A small, prospective study found benefits in Japan. This has not been duplicated in other places by other researchers. However, studies of reducing meat in other circumstances have not yielded benefits. This may be about different diet practices or adherence.

Curcumin may be a helpful adjunctive therapy. There is some data for mild to moderate UC. There is also now data for patients with CD showing endoscopic improvements as well. (Chery’s note—exciting!)

Moral of the story—more data is needed. And give lots of love to providers who you see who know and care about diet and IBD, because they are awesome!

Many thanks to Phillip Gu, MD and Linda A Feagins, MD.

October G-Free Newsletter

Halloween toys as treats
Halloween toy treats

Halloween candy lists are out for 2019. As many of you know, sometimes candies that are normally GF are not gluten-free when they are in holiday shapes. But those of you who have been reading for a while know my feelings on Halloween candy—skip it, and go for toys! It’s more inclusive, and you’re less likely to eat the leftovers.

HuffPo has a GF bread roundup. Is your favorite there? Maybe your new favorite will be.

ghost-shaped meringues
Spooky Meringues

Looking for a fun recipe? Spooky meringues are a staple around here. Meringues are a regular here because they’re simple…. And I appreciate that they are gluten-free, dairy-free, soy-free, low FODMAP, gastroparesis friendly, GERD friendly…and delicious! The recipe is here for the bunnies, just draw a squiggle instead of a bunny. ?

Interesting research

Why get relatives screened for Celiac? Because they’re more likely to have it, even without symptoms. 44.4% had Celiac, 28% with no symptoms.

Isn’t this fascinating–> different probiotics may be able to suppress or even reverse food allergies. Granted, studies are currently only in mice, but it’s still a neat and encouraging concept.

Ah, the new cross-contamination study…I have so many thoughts. First, food anxiety is real. It’s a problem. I see it in clients, and I experience it, too. It’s no fun to get sick when eating out, or with friends. And study after study has shown that people with Celiac often have incomplete healing from intestinal damage. And then there’s a new study showing that it’s safe to be less concerned with casual contact and cross contamination at home. It’s a very small study, and that’s been a major concern. It addresses components (toasters, pasta water, etc.) when the real question is, what would the implication be for a real person over a typical day? The study contradicts all of the major Celiac orgs and what I’ve seen with clients over the years. I’m really curious to see if/when it’s repeated, and I have very mixed feelings. And, of course, if people are getting all the “allowed” contamination at home, what happens when they inevitably go out?

Bottom line:

  1. This is a very small study
  2. The test methods seem to be inadequate (my background isn’t in this arena)
  3. People with Celiac can only tolerate trace amounts of gluten. It’s often easier to control contamination at home than out.
  4. I absolutely agree with study authors in articles saying this study means that people should feel safe traveling without bringing their own pots and pans and utensils with them as they travel. I have rarely encountered clients who do that, and if this study provides peace of mind on that front, great.
  5. As summed up by Dr. Fasano from the Center for Celiac research: interesting, but it’s not enough to change any of the current guidelines at this point.

I look forward to more research on this as it comes out…and will keep you all posted.

And re: food fears, there’s a great post here from Kate Scarlata on food fears.

A new study on the AIP diet shows that it helps IBD (Crohn’s & UC). This is great news! The AIP is a very restrictive diet that removes grains, sugars, nuts, seeds, eggs, nightshade veggies, beans, and more. But…the rates of improvement were about the same as studies that were less restrictive, which is disappointing. It’s possible it helped people who had more severe damage. But the study doesn’t try to separate the effect of unlimited RD support, a health coach and a community focused on stress reduction better sleep, etc. and attributes all the positive changes in quality of life to diet change, which isn’t reasonable.

Cheryl Harris, MPH, RD is a Registered Dietitian Nutritionist and Certified Wellcoach in Fairfax, VA.  She helps people with a range of dietary issues, including Celiac Disease, digestive issues, food allergies, vegetarian and vegan diets, preventing diseases and “whole foods” eating. Let’s get you on your way to achieving your goals and feeling great!  Email or call 571-271-8742.