The Ultimate Guide to How the Mediterranean Diet Can Transform Ulcerative Colitis Management

Ulcerative colitis (UC) is a type of inflammatory bowel disease (IBD) characterized by chronic inflammation and ulcers in the innermost lining of the colon and rectum. Managing UC often involves a combination of medication and lifestyle adjustments, with diet playing a crucial role. An anti-inflammatory diet, such as the Mediterranean diet, may help lower inflammation associated with ulcerative colitis (UC). While there isn’t a one-size-fits-all diet for UC, as it affects each person differently, several studies have demonstrated the benefits of lowering the intake of ultra-processed foods, added sugar, refined grains, and saturated fats for managing inflammation associated with conditions such as UC.

Understanding Ulcerative Colitis and the Role of Diet

UC is characterized by periods of active disease and remission. In the active phase, patients experience symptoms including bloody diarrhea with rectal urgency and tenesmus. The disease courses and therapies affect the health-related quality of life in UC patients, and the disease activity is the most significant factor. Therefore, the primary goals of treatments in these patients are to induce and maintain longstanding clinical and endoscopic remission, reduce the incidence of complications, and improve quality of life.

Dietary patterns are important in managing ulcerative colitis (UC), given their influence on gut microbiome-host symbiosis and inflammation. Inflammatory bowel diseases (IBD) are chronic, progressive and relapsing inflammatory disorders of unknown etiology that may cause disability over time. Data from epidemiologic studies indicate that diet may play a role in the risk of developing and the course of IBD. The number of patients with inflammatory bowel diseases (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is rising globally. Many medications may modulate the course of the disease; however, looking for non-pharmacological therapy for IBD seems to be a worth emphasizing element in improving patients' quality of life (QoL). One of these factors is diet. The study showed that the Western diet disturb gut microbiota and contains pro-inflammatory potential food. Food antigens are thought to cause an immune system response leading to the development of intestinal inflammation; however, we do not know a specific pathogenic antigens, which are responsible for that.

The Mediterranean Diet: An Overview

The Mediterranean diet (MD) is one of the most researched and promising nutritional strategies for people with inflammatory bowel disease (IBD). Ancel Benjamin Keys introduced the term “Mediterranean diet” (MD) for the first time in the 1960s. His milestone study showed that the populations living along the Mediterranean Basin had a lower mortality rate and incidence of cardiovascular disease and cancer than other populations. MD thus define eating habits characterized by high consumption of cereals, vegetables, fruit, olive oil, and small portions of dairy products, pastry, sugar and meat products at the same time. Additionally, the intake of fish and wine is moderate. The pyramid of the Mediterranean diet was presented in 2011 by Mediterranean Diet Foundation.

In general, the Mediterranean diet includes the following characteristics:

Being rich in plant foods (olives, fruits, vegetables, legumes, seeds, cereals)
High to moderate intakes of fish and seafood
Moderate consumption of eggs, poultry, and dairy products (cheese and yogurt)
Low consumption of red meat
Moderate consumption of alcohol (mainly red wine with meals)
Olive oil serving as the primary source of fat

The Mediterranean Diet (MED) emphasizes vegetables, fruits, olive oil, and wholesome fats, and has been shown to improve IBD symptoms and offer broad health benefits. 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).

Benefits of the Mediterranean Diet for Ulcerative Colitis

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. The benefits of MED also extend to pediatric patients. In a prospective, randomized study of 100 patients (aged 12-18) with mild to moderate disease, half were given MED for 12 weeks. After this dietary change, the MED group "showed a significant decrease in both clinical scores (PCDAI and PUCAI) and most inflammatory markers (CRP, calprotectin, TNF-α, IL17., IL 12 and IL13) compared to patients in their normal group". 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.

Reducing Inflammation

One of the protective effects of the Mediterranean diet is the fatty acid profile (35% total fat; high in monounsaturated fatty acids and low in polyunsaturated fatty acids). A Mediterranean diet is also rich in fruits and vegetables, and this may be helpful for UC prevention. The diet may also be beneficial for children with the disease. One study found that the Mediterranean diet reduced inflammatory markers and disease symptoms in 100 children and adolescents with IBD.

Some diseases may be related to chronic inflammation and gut microbiota imbalance. According to meta-analysis, MD may reduce inflammation and positively affects gut microbiota . Additionally, systematic review reported that adherence of MD reduce biomarkers of inflammation and oxidative stress. Koloverou et al. also reported that MD decreased systematic inflammation and increased total antioxidant capacity. Higher MD score was associated with decreased inflammatory markers-lower NF-κB; additionally, the adiponectin level was higher.

Modulating the Gut Microbiome

Research suggests that anti-inflammatory diets, such as the Mediterranean diet, may be therapeutic for IBDs such as ulcerative colitis because of their ability to lower inflammation and modulate the gut microbiome. This is important because people with IBD have an imbalance in the types of bacteria in their gut compared with those without IBD. This imbalance, called dysbiosis, is linked to inflammation in the digestive tract. MD affects gut microbiota, enriching beneficial bacteria, which support gut barrier function and reduce inflammation. MD stimulates Bifidobacteria, Lactobacilli, Eubacteria, Bacteroides, and Prevotella. Among healthy adults, subjects with high MD adherence presented lower Escherichia coli counts and higher bifidobacteria/E. coli ratio. The data suggest, MD affect gut microbiota positively, decreasing risk of IBD.

Read also: Delicious Mediterranean Recipes

Clinical Evidence

The MED has been shown to significantly reduce symptoms in patients with either Crohn’s disease or ulcerative colitis . A significantly larger portion of patients with either CD or UC following the MED experienced lower CRP and fecal calprotectin levels (<250 ug/g) as well as significantly improved quality of life scores. An important finding from the DINE CD trial was that patients with CD on either the SCD or MED had significant improvements in patient reported outcomes, including fatigue. Following pouch surgery for UC, patients with higher adherence to the MED were associated with decreased fecal calprotectin levels.

Key Components of the Mediterranean Diet and Their Role in UC Management

Olive Oil

Olive oil, the Mediterranean diet’s main source of fat, may be a major driver of the diet’s beneficial effects. Olive oil is a rich source of monounsaturated fats and antioxidants, both of which have anti-inflammatory effects on the body. One study of 40 people with UC found that consuming extra virgin olive oil improved UC symptoms. In particular, olive oil reduced inflammatory markers and significantly reduced:

Bloating
Constipation
Fecal urgency
Incomplete defecation

Fruits and Vegetables

Aim for two to four servings per day of fruits like applesauce, bananas, melon, avocados, grapes, peaches, oranges, strawberries, and tomatoes. You can also choose pureed fruit or blended smoothies. 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. Applesauce, bananas, melon, squash, potatoes, and spinach are all fantastic fiber options for people with ulcerative colitis, says Miranda Deal, RDN, a registered dietitian with the University of Michigan Health-West in Wyoming, Michigan. Research has found that UC patients who regularly consume fruits and vegetables have a lower prevalence of active disease than those who do not.

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. Oats and buckwheat are both whole grains that may be tolerated better by UC patients in a flare up. For bread, I usually recommend a sourdough since it is not too fiber heavy while also having a low glycemic index. Whole grains like quinoa, brown rice, and barley are more nutritious options than refined grains, and registered dietitians recommend them to people whose UC is in remission. This is because the refining process strips away many of the grains’ natural vitamins and nutrient content. Whole grains also have a low glycemic index, so they won’t raise blood sugar levels as quickly as refined grains. But whole grains can be difficult for some people with UC to digest during or right after a flare. For these individuals, Gardinier says refined grains like white rice or non-grain carbohydrates such as sweet potatoes or regular potatoes are better choices at these times.

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.

Seafood, Poultry, and Eggs

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, including chicken, chicken eggs, duck eggs, or quail eggs, can be enjoyed two or three times per week. Healthy, lean proteins, including chicken, fish, eggs, legumes, nuts, soy, and tofu provide energy and nutritional support whether you have UC or not. But these foods can have additional benefits if you're living with IBD. Protein is essential for inflammatory bowel disease as the amino acids from this macronutrient can help repair damaged tissue and alleviate inflammation.

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.

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.

Foods to Limit or Avoid

Certain foods may trigger or worsen UC symptoms. Here’s a list of foods you may want to limit or avoid.

Foods High in Insoluble Fiber

Sometimes known as “roughage,” insoluble fiber does not dissolve in water and therefore can be difficult to digest. This can worsen UC symptoms like bloating, gas, abdominal pain, and diarrhea. Examples of foods high in insoluble fiber include nuts, popcorn, raw carrots, raw cauliflower or broccoli, and fruits or vegetables with thick skin, Deal says. But removing the skin and cooking produce should make fruits and vegetables gentler on the digestive tract.

Red and Processed Meats

Processed meats like salami, ham, sausage, hot dogs, bacon, and lunch meat are proinflammatory to the colon because of the high sulfur content and heme iron, says Gardinier. Processed meat is also linked with colon cancer, which people who have UC are already at high risk for.

Spicy Foods

When your UC symptoms are flaring, it may be best to avoid spicy foods. These don’t necessarily cause damage to the lining of the colon but when the colon is already irritated, it’s like adding salt or acid to a scratch on your skin - it hurts.

Foods High in Simple Sugars

Candy, cakes, cookies, soda, and juices can irritate the gut and exacerbate UC symptoms, Dr. Chiplunker says. If these are not fully digested and absorbed by the bowel or your intake simply overwhelms your normal absorption system, these unabsorbed sugars act like a laxative. Most of these foods are also ultra-processed.

High Lactose Foods

Some people with IBD are lactose intolerant, meaning their body does not properly digest lactose, the sugar found in dairy products like cow’s milk, cheese, and ice cream. Others may have issues digesting these foods during a UC flare.

Practical Tips for Implementing the Mediterranean Diet for UC

Start Slowly: When beginning to follow a Mediterranean diet, focus on eating plant-based foods to increase your fiber intake.
Cook at Home: Cooking at home is one of the first steps you can take toward healthy eating.
Choose Foods You Tolerate: Look for foods you know you enjoy and tolerate well. For most, reserving foods like fresh fruit, raw vegetables, beans, and whole grains for periods of remission may be best.
Modify Textures: For some foods, you may need to change the texture to make them easier to digest. For example, consider eating peanut butter instead of whole peanuts or having hummus instead of whole chickpeas.
Consider Fiber Intake: Some evidence suggests this can be solved by increasing the consumption of anti-inflammatory foods that are higher in soluble fiber and lower in insoluble fiber.
Be Mindful of Additives: Certain additives, such as carrageenan, may also exacerbate UC. One study found that a carrageenan-free diet reduced relapse in people with UC.

Sample Mediterranean Diet Recipes

Here is a selection of recipes to help you get started with a Mediterranean diet.

Breakfast Recipes

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

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

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 Recipes

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

Identical to Mediterranean and DASH diets, 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. Previous studies showed the promising effect of these components on inflammatory factors. Moreover, consuming these foods together in a diet can have additive and synergistic effects.

Association Between MIND Diet Score and Disease Severity

A 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. 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 study indicated that the patients in the higher tertile of the MIND diet score had 61% lower odds of having severe UC than those in the first tertile. Previously, in a cohort study, higher adherence to the MIND diet was associated with a lower risk of IBD. However, no significant association was observed between MIND diet adherence and other gastrointestinal disease such as IBS.

MIND Diet Components and Their Benefits

Berries are most commonly rich in phenolic compounds and antioxidants. In addition to berries, whole grains are composed of bran and germ, which have unique health-promoting bioactive components such as phenolic acids and flavonoids. Green leafy vegetables also are good sources of phytochemicals such as carotenoids, and lutein. Previous studies indicated that polyphenols apply anti-inflammatory and antioxidant effects through the modulation of cellular signaling pathways and transcription factors important in IBD progression. Moreover, dietary polyphenols decrease intestinal inflammation by modifying gut microbiota composition and regulating macrophage activation.

Other Dietary Considerations

Specific Carbohydrate Diet (SCD)

Another anti-inflammatory diet often used for UC is the specific carbohydrate diet (SCD), a restrictive diet that eliminates grains, legumes, and processed foods and focuses on providing nutrients from whole, unprocessed foods (select vegetables, fruits, meats, and dairy products). The SCD is based on the idea that certain complex carbohydrates, such as those found in grains and legumes, can contribute to inflammation and digestive problems in people with IBD.

Fermented Foods

Fermented foods, such as yogurt or kefir, are also helpful for people with UC. According to research from 2022, this is because many people with UC have a depletion of certain bacteria found in fermented dairy products known as Fusicatenibacter saccharivorans, which help support microbiome diversity in your gut.

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