Unlock the Power of the Mediterranean Diet to Manage Ulcerative Colitis Effectively!

Ulcerative colitis (UC) is a type of inflammatory bowel disease (IBD) characterized by inflammation in the colon and rectum. Dietary patterns play a significant role in managing UC, influencing the gut microbiome, host symbiosis, and inflammation. While various specialized diets may be helpful for some IBD patients, no one plan has been proven to prevent or control IBD with the exception of enteral nutrition, which is delivered in a nutrient-rich formula. The best diet is one that meets your individual nutritional needs and helps you manage your IBD symptoms.

Understanding Inflammatory Bowel Disease (IBD)

IBD, including Crohn's disease (CD) and ulcerative colitis (UC), are chronic disorders that can lead to disability. The number of individuals with IBD is increasing globally, with 6.6 million cases reported in 2017, a rise from 3.7 million in 1990. North America has the highest age-standardized prevalence rate of IBD, while the Caribbean has the lowest.

In UC, inflammation occurs in the mucosa and submucosa of the rectum and colon, extending proximally and continuously. The goals of current treatment options (antibiotics, steroids, immunosuppressive drugs, biological therapies, small molecules) are to induce symptomatic remission, maintain steroid-free remission, enhance the QoL, prevent/treat complications of the disease avoiding short and long-term toxicity of therapy. Therapy should modify the course of the disease and prevent the disabling condition and irreversible tissue damage. Furthermore, therapy should be tailored according to patients' risk of developing disabling disease

The Role of Diet in Managing IBD

Diet can be helpful in managing IBD during flares and periods of remission. Your healthcare team, including a registered dietitian specializing in IBD, may recommend a particular diet based on your symptoms.

Specialized IBD diets are often debated in the medical community because they don’t work in every case and can be restrictive, which may lead to weight loss or malnutrition. Long term, most of these approaches involve reintroduction of foods that are rich in vitamins, minerals, and other nutrients. It is important to keep in mind that these diets may require changes based on the individual patient and nutrition-related factors.

Overview of Different Diets for IBD

Several dietary approaches have been studied for their potential benefits in managing IBD. It's crucial to consult with a healthcare professional or registered dietitian before starting any new diet. Here's an overview of some of the commonly discussed diets:

Anti-inflammatory Diet (IBD-AID):
- Developed to restore balance between helpful and harmful gut bacteria, addressing the imbalance often seen in IBD patients.
- Incorporates features of the Specific Carbohydrate Diet (SCD) by avoiding certain carbohydrates and adding more prebiotic and probiotic foods to improve the gut microbiome.
- Designed to be implemented in phases, progressing the texture of food.
Autoimmune Protocol Diet (AIP):
- Focuses on staged elimination of grains, legumes, nightshade vegetables (tomatoes, eggplants, potatoes, peppers), sugar (refined sugars), dairy, eggs, nuts, seeds, and processed foods.
- Emphasizes nutrient-dense foods, lean protein, fruits, and vegetables, adjusted as needed.
- Aims to reduce dietary factors contributing to dysbiosis, inflammation, and food intolerance.
- Emphasizes improving other lifestyle factors, including sleep, stress, physical activity, and social connection.
Crohn’s Disease Exclusion Diet (CDED):
- A whole foods diet designed to limit or exclude foods that may negatively affect the gut microbiome, inflammation, and the intestine’s ability to absorb nutrients or other functions.
- Excludes wheat, dairy, animal fat, additives, processed foods, and red meat.
- Includes readily available foods such as fruits, vegetables, rice, potatoes, lean meats, and eggs.
- Often combined with partial enteral nutrition (PEN) to meet energy needs and provide extra protein, calcium, and vitamin D. The diet is set in three phases designed to gradually reintroduce diversified foods, provides progressively greater flexibility and improved quality of life. In phase 1, PEN comprises 50% of your calories during the first 6 weeks, decreasing to 25% of your calories over the following 6 weeks.
CD-TREAT Diet:
- An anti-inflammatory, whole foods-based diet designed to recreate the effects of exclusive enteral nutrition (EEN) by using whole foods (foods that are not prescribed formulas).
- Involves eliminating certain complex carbohydrates (gluten, lactose, alcohol) while increasing specific fruits, vegetables, and proteins.
Exclusive Enteral Nutrition (EEN):
- Involves receiving all calories through a special nutrition formula, eliminating regular food intake.
- Liquids contain all the proteins, carbohydrates, fats, minerals, and vitamins necessary to sustain you.
- Proven to induce remission in children with Crohn’s disease and may improve response rates for IBD patients already on biologic therapy.
- May improve surgical outcomes for patients with IBD when used in the perioperative setting.
Low FODMAP Diet:
- Originally developed for people with irritable bowel syndrome (IBS) to reduce symptoms, but has also been shown to reduce symptoms in people with IBD who have overlapping IBS.
- Involves cutting back on a group of fibers and sugars that can be poorly absorbed by the GI tract, including foods containing fructose, lactose, sugar polyols (sorbitol and mannitol), fructans, and galacto-oligosaccharides.
- Meant only for short-term use and may be recommended to help reduce IBD symptoms, but research hasn’t yet shown it to reduce IBD inflammation.
Mediterranean Diet (MED):
- Emphasizes vegetables, fruits, olive oil, and wholesome fats.
Specific Carbohydrate Diet (SCD):
- Limits or totally excludes grains, fiber, and certain sugars, with the idea that undigested starch products may trigger changes in intestinal bacterial growth and inflammation.
- Eliminates all refined and processed foods (e.g. processed meats, artificial sweeteners), along with soy, lactose, sucrose, and grains.
- Certain vegetables are also taken out of the diet, including potatoes, okra, and corn.
- Can cause deficiencies in B vitamins, calcium, vitamin D, and vitamin E, and may lead to weight loss, so close monitoring is necessary.
Semi-Vegetarian Diet:
- Includes eggs, yogurt, fruit, vegetables, legumes, brown rice, miso, and pickled vegetables, along with limited animal proteins (fish once a week and meat just once every two weeks).
Ulcerative Colitis Exclusion Diet (UCED):
- Limits animal fats and sulfated amino acids, and has been suggested to improve symptoms in patients with mild-to-moderate UC.

The Mediterranean Diet: A Promising Approach for IBD

The Mediterranean Diet (MED) is characterized by a high intake of vegetables (2 servings per meal) and fruits (1-2 servings per meal), extra virgin olive oil (3 tablespoons per day), breads and cereals (1-2 servings per day), legumes (2 or more servings per week), seafood (more than 2 servings per week), eggs (2-4 servings per week), poultry (2 servings per week), limited dairy (1-2 servings per day), low intake of red meat (less than two servings per week), and limited sweets (less than two servings per week).

The Mediterranean diet is one of the most researched and promising nutritional strategies for people with IBD. Following the Mediterranean diet includes eating more plant-based foods like fruits, vegetables, nuts, beans, and whole grains - along with a moderate intake of seafood, poultry, and eggs while limiting red meat.

Potential Benefits of the Mediterranean Diet in IBD

In addition to improving symptoms in IBD, data support its health benefits in other disease states such as cardiovascular disease, cancer, and diabetes, with much of its benefit attributed to reductions in inflammation from higher consumption of vegetables, fruits, nuts, and healthful fats from avocados, fish, and olive oil. The Mediterranean diet may further serve as a preventive strategy against colon cancer and later-onset of Crohn's Disease.

Reduced Inflammation: The Mediterranean diet's emphasis on anti-inflammatory foods like olive oil, fruits, vegetables, and nuts may help to reduce intestinal inflammation.
Improved Gut Microbiome: Its focus on plant-based foods can favorably affect the microbiome.
Symptom Reduction: The MED has been shown to significantly reduce symptoms in patients with either Crohn’s disease or ulcerative colitis.

Implementing the Mediterranean Diet for UC

Following the MED can be a challenge for some patients with IBD, especially if they have been following a low-fiber diet or they have strictures present. Some recommendations include to juice or puree fruits and well-cooked vegetables when beginning the diet. As symptoms improve or inflammation goes down, patients can start incorporating whole fruits and vegetables. Cereals in the diet refer to ancient grains (farro, wild rice, spelt, etc.). Rice is a good carbohydrate choice for this diet. Nuts and seeds for the MED can be consumed cooked and pureed (peanut butter and hummus), or even as homemade almond milk.

Read also: Delicious Mediterranean Recipes

Andrea Hardy, registered dietitian nutritionist and founder of Ignite Nutrition, told MyCrohnsAndColitisTeam that she often recommends the Mediterranean diet to her clients. In a separate interview with MyCrohnsAndColitisTeam, gastroenterologist Dr. Uma Mahadevan, co-director of the UCSF Colitis and Crohn’s Disease Center, also recommended the Mediterranean diet.

When beginning to follow a Mediterranean diet, Hardy said it’s important to focus on eating plant-based foods to increase your fiber intake. Dr. Mahadevan recommended starting at home. She said cooking at home is one of the first steps you can take toward healthy eating.

Shopping List for the Mediterranean Diet

The following list includes daily serving recommendations for a wide variety of foods on the Mediterranean diet. The Mediterranean diet is mostly plant-based, but seafood is recommended about twice a week.

You don’t need to buy every item on this list to follow the diet. In fact, many people with IBD may have trouble with the high-fiber foods that are typically recommended on the Mediterranean diet. For most, reserving foods like fresh fruit, raw vegetables, beans, and whole grains for periods of remission may be best. Just look for foods you know you enjoy and tolerate well.

Fruits: Aim for two to four servings per day of fruits like avocados, apples, grapes, peaches, oranges, strawberries, and tomatoes. You can also choose pureed fruit or blended smoothies.
Vegetables: For optimal nutrition and fiber intake, eat four to six servings per day of vegetables in a variety of colors. However, you should avoid veggies that upset your digestive system. You can peel and cook your favorite vegetables to help your body tolerate them better.
Whole Grains and Lentils: Make sure to eat two to four servings per day of whole-grain foods such as oats, quinoa, or whole-grain bread if you tolerate them well. People with IBD may do better with easier-to-digest tofu and lentils versus beans.
Healthy Fats: Have four to six servings per day of healthy plant-based fats, like those found in olive oil or almonds, pistachios, and walnuts. Olive oil is the cooking oil of choice for the Mediterranean diet. Grinding nuts and seeds helps with digestion.
Dairy Products: Incorporate one to two servings of dairy products each day. Consider cheeses (brie, feta, Parmesan, ricotta), Greek yogurt, and milk. Nut milk and soy milk are plant-based alternatives.
Seafood: Seafood can be healthy in moderation. Aim for two or three servings per week. Try clams, crab, eel, lobster, mussels, octopus, oysters, salmon, sardines, sea bass, shrimp, squid, tilapia, tuna, or yellowtail.
Poultry and Eggs: Poultry and eggs, including chicken, chicken eggs, duck eggs, or quail eggs, can be enjoyed two or three times per week.
Herbs and Spices: Liven up your dishes with basil, bay leaves, cumin, garlic, mint, oregano, parsley, rosemary, sage, tarragon, or thyme, which can be used fresh or dried to enhance flavor.

Easy Mediterranean Diet Recipes

Here is a selection of recipes to help you get started with a Mediterranean diet. Try them out and share your results on MyCrohnsAndColitisTeam.

Breakfast Recipes: Breakfasts on the Mediterranean diet often center around whole grains or eggs. Fresh fruit in a rainbow of colors adds sweetness to your morning.
- Baked Spinach and Eggs - Only four ingredients
- Banana Berry Pancakes - Made with whole-wheat flour for extra fiber intake
- Egg and Brown Rice Breakfast Bowl - Great for leftover brown rice (or any other grains)
- EVOO (Extra Virgin Olive Oil) Oatmeal With Berries - Sweet and savory
- Muffin Pan Frittatas - Freezes easily for breakfast all week long
- Smoothie Bowl - A creative use for whatever fruits are in your fridge
Lunch Recipes: Of course, you’d expect to eat fresh salads and hearty soups on the Mediterranean diet, but what about pizza and tacos? This versatile food plan lends itself to a variety of meals.
- Avocado, Arugula, Tomato, and Walnut Toast - Chock-full of healthy fats
- Chickpea and Quinoa Salad With Tahini Dressing - A simple plan for whatever vegetables are in your fridge
- Greek Lentil Soup - Filled with lentils, a vegetarian protein that is easy to digest
- Mediterranean Pita Pizza - A fun recipe to make with your family
- South American Vegetable and Rice Soup - A quick, hearty meal
Snack Recipes: Following healthy diet guidelines doesn’t mean going hungry. Sweet and savory snacks can be easily assembled or baked ahead of time.
- Almond Cookies With Tahini and Honey - The Mediterranean diet version of peanut butter cookies
- Anything-Goes Energy Balls - Sweet, salty, and simple to make ahead and freeze
- Avocado Hummus - For guacamole enthusiasts
- Black Bean Brownies With Walnuts - A dense, grain-free brownie that will inspire kids to eat their beans
- EVOO Cake - Uses extra virgin olive oil instead of butter for a lighter, healthier dessert
Dinner: Healthy dinners on the Mediterranean diet include lots of fresh vegetables and whole grains. Dairy products, seafood, and poultry are not the focus of these meals, but they can add flavor and a healthy source of protein. Experiment with new dishes and ingredients to find your favorites.
- Asparagus and Ginger Fried Rice - Made with brown rice
- Brazil Nut Pesto With Pasta - Works with any nuts in your pantry
- Chickpea Sweet Potato Shawarma Salad - A fresh summer salad with a tangy lemon-yogurt dressing
- Cod and Corn Chowder - A quick, 20-minute meal to get your weekly intake of seafood
- Mediterranean Lentil-Stuffed Peppers - Packed with protein and two servings of vegetables
- Summer Green Pea Salad - A delicious, healthy side dish for any meal

MIND Diet and Ulcerative Colitis

Considering the importance of induction and maintenance of remission in patients with ulcerative colitis (UC), different studies investigated the association between adherence to healthy dietary patterns and disease severity. This cross-sectional study investigated the association between Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet score and disease severity in patients with UC. In this study, 158 patients with UC were included. Disease severity was determined by a gastroenterologist using the Mayo score. We assess the dietary intake over the past year by a 168-item food frequency questionnaire. The MIND diet score was calculated based on the Morris et al. method. The logistic regression was used to analyze the association between disease severity and MIND diet score tertiles, adjusted for demographic, disease-related, and nutritional covariates. The mean age of participants was 42.52 ± 12.61 years old. There were no significant differences in demographic characteristics of patients across different tertiles of the MIND diet score except for prednisolone use, and following a special diet (p < 0.05). The patients in the higher tertiles of the MIND diet score consumed significantly more green leafy vegetables (P < 0.001), other vegetables (P < 0.001), berries (P = 0.02), nuts (P = 0.02), and olive oils (P = 0.0), but consumed less fast fries’ foods (P = 0.03) than those in the lower tertiles. The results of adjusted regression showed that compared with the patients in the first tertile of the MIND diet score, the patients in the third tertile had significantly lower odds of disease severity (OR: 0.39, 95% CI: 0.16, 0.97). High adherence to the MIND diet score was significantly associated with lower odds of severe UC.

The MIND diet highlights the consumption of natural plant-based foods and limits the intake of animal and high saturated fat foods. This pattern is unique in recommending the consumption of berries and green leafy vegetables. These food items are good sources of different phenolic compounds, fibers, and antioxidant vitamins and minerals.

Important Considerations

Individual Tolerance: Not all foods in the Mediterranean diet are well-tolerated by everyone with IBD. It's essential to identify and avoid foods that trigger symptoms.
Fiber Intake: While fiber is generally beneficial, some individuals with IBD may need to moderate their fiber intake, especially during flares.
Professional Guidance: Work with a healthcare professional or registered dietitian to create a personalized dietary plan that meets your specific needs and helps manage your UC symptoms.
The importance of induction and maintenance of remission: In patients with ulcerative colitis (UC), different studies investigated the association between adherence to healthy dietary patterns and disease severity.

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