Inflammatory bowel disease (IBD) is becoming increasingly prevalent, impacting up to 1.6 million Americans. The majority of diagnoses occur before the age of 35. IBD encompasses chronic conditions, primarily Crohn's disease (CD) and ulcerative colitis (UC), characterized by inflammation in the digestive tract. While there's no definitive cure for ulcerative colitis (UC), dietary modifications play a crucial role in managing symptoms, minimizing inflammation, and fostering overall gut health. Since certain foods can trigger flare-ups or exacerbate existing symptoms, it is crucial for patients with IBD to be mindful of their dietary choices.
Understanding Ulcerative Colitis
Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) characterized by chronic inflammation and ulcers in the colon and rectum lining. UC is an incurable, diffuse, and chronic inflammatory process of the colonic mucosa with alternating periods of exacerbation and remission. Symptoms of UC can vary in severity and presentation from individual to individual. Common symptoms include:
- Diarrhea
- Abdominal pain and cramping
- Rectal pain and bleeding
- Fatigue
- Urgent bowel movements
UC has been recognized as a global disease because the incidence is steadily increasing worldwide, with the highest reported in Northern Europe, Canada, and Australia. UC is most commonly diagnosed between the ages of 30 and 40. The exact etiology of UC is not known. The most common presenting symptoms of UC are bloody stools. Associated symptoms may also include urgency to defecate, abundant rectal mucus excretion, increased frequency of bowel movements, nocturnal bowel movements, abdominal discomfort (pain, cramping), urinary incontinence, fatigue, fever, dehydration, and malnutrition. Tenderness, soreness, and abdominal bloating may be noted on palpation, as well as blood on rectal examination. The number of stools passed, as well as the presence of other symptoms can vary. Symptoms may reflect the severity of intestinal mucosal inflammation and the extent of changes. In addition, the results of the tests performed may show signs of anemia. Axial or peripheral arthropathy, scleritis, and erythema nodosum appear to be the most common extraintestinal manifestations. Moreover, primary sclerosing cholangitis (PSC) is a rare but poor prognostic complication of UC. According to the current state of knowledge, there is no gold standard for the diagnosis of UC. The current marker used to rule out or confirm IBD is fecal calprotectin levels. Low levels of this indicator indicate a less than 1% probability of developing IBD. The form of treatment for UC is tailored to the severity, distribution, and type of disease, including its course, patient’s response to prior medications and side effects, relapse rate, and extraintestinal symptoms. The age of the patient at diagnosis and the duration of the disease are also significant variables. The main goal of treatment is to obtain clinical remission confirmed by endoscopic examination, without the need to start treatment with steroids. The treatment of choice in most cases is mesalazine, to which aminosalicylate enema is added in some patients. In the absence of response, systemic corticosteroids are included in the therapy, which are also recommended for patients with severe UC flare-ups. Biologic or immunosuppressive drugs present an alternative treatment option for patients with UC when previous pharmaceuticals have not worked.
The Role of Diet in Managing UC
While diet doesn't cause UC, it significantly influences the course of the disease. Inadequate nutrition can affect the course of the disease and increases the frequency and severity of symptoms. Patients with UC intensively seek nutritional guidance to help improve their quality of life and contribute to symptom relief. Unfortunately, studies to date do not provide a solid basis for creating strong evidence-based dietary recommendations. Patients’ curiosity about diet and lack of precise recommendations compel them to seek information from the Internet and other non-medical sources. Certain food components can greatly influence the course of UC, inducing changes in the composition and function of the gut microbiome. This activity may be an important part of therapy for people with IBD.
Dietary strategies aim to:
Read also: The Mediterranean Diet Guide
- Reduce inflammation
- Promote healing
- Support medications
- Improve overall well-being
It's important to recognize that there is no one-size-fits-all diet for UC. Individual responses to foods vary, and dietary needs may change during flare-ups and remission periods.
Dietary Approaches for Ulcerative Colitis
Several dietary approaches may benefit individuals with UC.
Mediterranean Diet
One of the safer dietary models, additionally recommended by ESPEN (European Society for Clinical Nutrition and Metabolism) as an optional method for UC patients, is the Mediterranean Diet. The Mediterranean diet has shown the most promising results in the treatment of patients with UC due to its high content of biologically active foods. This diet based on a high intake of vegetables and fruits as well as legumes and whole grains, which are rich in antioxidants and dietary fiber as well as nuts, fish, and olive oil abundant in monounsaturated and polyunsaturated fatty acids. The Mediterranean diet also includes moderate amounts of dairy, especially fermented dairy products (such as yogurt, kefir, cheese) and eggs. In exchange for red meat, whose consumption should be reduced, this diet endorses the consumption of its leaner counterparts, such as turkey, chicken, and rabbit. Each dish is further enriched with herbs and spices (including parsley, thyme, oregano, basil, cumin, cinnamon, turmeric), whose antioxidant effects have been confirmed scientifically.
Diet is extremely important for every human being, especially those dealing with IBD, as it is, among other things, one of the primary factors regulating the gut microbiota. The modern Western diet, which is high in saturated fats and simple sugars and low in dietary fiber, may lead to a disparity in the composition of the gut microbiota. Dysbiosis can cause many health disorders because the microorganisms found in the gut play an important role in the functioning of the body’s immune system. Thus, the development of unfavorable microorganisms, which may be stimulated by an inadequate diet, results in the impairment of immune system function and thus may lead to increased production of inflammatory factors, which in turn stimulates the development of intestinal inflammation (leading to an increase in serum C-reactive protein and fecal calprotectin levels). These disorders can be modified by incorporating dietary changes. Adherence to the Mediterranean diet, as shown by studies, improves the ratio between pathogenic microorganisms such as Firmicutes and Eschericha coli, and beneficial bacteria including Bifidobacterium and Bacteroides fragilis. It is worth noting that an increase in intestinal colonization by unfavorable microorganisms, such as those of the genera Fusobacterium, Peptostreptococcus, Bacteroides vulgatus, and Bacteroides thetaiotaomicron, and a decrease in probiotic bacteria, such as Lachnospiraceae, Bifidobacterium animalis, and Streptococcus thermophilus, may promote inflammation, DNA damage, and cancer cell proliferation, which contribute to the development of colorectal cancer. Due to the beneficial effects of the products consumed in the Mediterranean diet on the composition of the gut microbiota, this nutritional plan may be a helpful component of therapeutic management in patients with UC. Studies show that the use of the Mediterranean diet in UC patients after reconstructive proctocolectomy with ileo-rectal anastomosis with a created intestinal reservoir and in children with IBD, respectively, has a positive effect on fecal calprotectin levels. A recent prospective interventional study published in 2021 evaluated how a 6-month Mediterranean diet applied in patients with IBD affects their nutritional status, quality of life, disease activity, and steatohepatitis, which often accompanies IBD. The study included 142 adults with IBD (including 84 with UC). At the beginning of the study, the participants were given a dietary consultation, during which they received advice on how to change their current eating habits in order to eat according to the Mediterranean diet model. Researchers have noticed that the diet in patients with UC has many beneficial effects. There were significant improvements in quality of life and indicators of malnutrition in the participants. The number of patients with active inflammation decreased after 6 months on the diet from 24% to 7%, the number of patients with high C-reactive protein levels was reduced from 50% to 37.5%, and the number of patients with fecal calprotectin levels greater than 250 mg/kg was reduced from 44% to 28%. In addition, it was noted that patients had improved anthropometric indices correlating with steatohepatitis and metabolic syndrome.
According to the Mediterranean diet scheme, the main foods included in the diet should be vegetables, followed by fruits. These products are a crucial source of vitamins and minerals. Of the vegetables, patients with UC should mainly choose those that are not rich in water-insoluble dietary fiber, including beets, potatoes, carrots, and zucchini, which can be eaten cooked and, if well tolerated, raw. However, others rich in dietary fiber of the water-insoluble fraction, such as brassica vegetables, broccoli, and peppers, should be boiled and pureed or blended. The same should be done when incorporating fruits into the menu. Initially, those not rich in water-insoluble fiber fractions, such as bananas or apples, are recommended. If raw fruits, low in dietary fiber of the water-insoluble fraction, are well tolerated by the patient (no gastrointestinal symptoms) it is possible to introduce the consumption of other seasonal fruits. However, they should be incorporated carefully and gradually depending on the individual tolerance of UC patients. A very good alternative, especially in the period of disease exacerbation, is the consumption of freshly squeezed vegetable or fruit juices, which contain all valuable nutrients contained in the product (vitamins, minerals), but lack dietary fiber insoluble in water.
Read also: Managing UC in Children with Diet
Legumes are a very good source of plant protein with high biological value and complex carbohydrates, while being low in fat. These products, when properly composed with cereal products to complement the amino acid composition of legume seed proteins, can be an alternative choice to high meat consumption, especially red meat. However, it is recommended to consume them peeled or after squeezing them through a sieve, preceded by long cooking. It is also very important to take into account other technological and thermal procedures in the preparation of dishes based on legumes, which may deprive them of fiber of the water-insoluble fraction while retaining the water-soluble fraction, causing a reduction in the content of antinutrients and thus improving their nutritional value and digestibility. A review by Satya et al. noted that sprouting is one of the best legume seed treatments to induce the previously mentioned changes. Comparable effects were noted for thermal treatments, which include treatments such as plain or pressure cooking and microwave preparation. The review also evaluated the benefits of prior soaking of legumes and concluded that soaking the seeds in water or 0.1% citric acid solution for 9 h is appropriate for the best preservation of vitamins and other nutrients. Among the legumes that patients with UC should especially pay attention to are peas and red lentils, which have the best digestibility. Lentils are rich in complex carbohydrates, including mainly starch, and are characterized among other legume seeds by the highest protein, high iron, zinc, and calcium content, while having the lowest fat content. Additionally, very important is the low content of anti-nutritional substances (e.g., protease inhibitors) in this type of legume seed. Due to its soft seed coating, it requires less cooking time than other legumes. Therefore, it seems reasonable to recommend that patients with UC eat legumes, especially red lentils. However, their inclusion in the menu should take into account the period of exacerbation of the disease, symptoms, and individual tolerance. Particular attention should be paid to adequate prior technological and thermal treatment, as well as the amount of food consumed. It is best to start with smaller portions.
Dietary fiber is an important component of the diet, but an important issue is which fraction of fiber is present in the product (water-soluble or water-insoluble fraction) because, depending on the type, it can adversely affect the intestinal mucosa and is therefore not always recommended for patients with UC. All elements of dietary fiber of the water-soluble fraction, including inulin, pectin, gums, and beta-glucans, do not irritate the colonic mucosa, while stimulating the growth of microorganisms producing butyric acid and propionic acid in the lumen of the large intestine. These substances show protective activity against the intestinal mucosa, and butyric acid additionally inhibits the synthesis of pro-inflammatory factors. A study conducted by Desai et al. in mouse models demonstrated the significant effect of dietary fiber on the occurrence and treatment of intestinal pathology.
This diet emphasizes:
- Vegetables
- Fruits
- Legumes
- Whole grains
- Nuts
- Fish
- Olive oil
UC Exclusion Diet (UCED)
Patients with UC may benefit from the UC Exclusion Diet (UCED); however, it is a new nutritional plan that requires further research.
Low-FODMAP Diet
If you have inflammatory bowel disease and also irritable bowel syndrome (IBS), a low-FODMAP diet may be helpful. FODMAP stands for the short-chain carbohydrates known as fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. Some people who eat high-FODMAP foods have an increased risk of problems like diarrhea, bloating, abdominal pain, and flatulence. A low-FODMAP diet can help reduce abdominal pain, bloating, and diarrhea and improve stool consistency in people with IBS who also have well-controlled IBD.
Read also: The Mediterranean Diet
Exclusive Enteral Nutrition (EEN)
Exclusive enteral nutrition (EEN) is a primary treatment for mild to moderate active CD, involving a liquid nutritional formula for 6 to 8 weeks to help achieve remission. This diet, tailored to the patient, can be consumed orally or through a feeding tube and is suitable for all ages. It has the highest success rates in children, with remission achieved in 60% to 80% of cases. This diet not only alleviates side effects but may also help heal the stomach lining. EEN is available in polymeric (e.g., Modulen, Nestle) or elemental (e.g., Elemental O28, Nutricia) formulations, differing in protein source. While EEN is recommended for CD, its implementation can be challenging.
Crohn’s Disease Exclusion Diet (CDED)
CDED can benefit patients of all ages, but consultation with a health care professional is advised to determine the most suitable approach. The goal is to limit triggers and emphasize whole, unprocessed foods.
Partial Enteral Nutrition (PEN)
Partial enteral nutrition (PEN) serves as an intermediate option between EEN and CDED for managing disease flare-ups. Unlike EEN, PEN combines regular food with formula while still limiting foods high in fiber, fats, sugars, or additives that can irritate an inflamed gut. PEN for UC involves a dietary plan where part of the patient’s daily caloric intake comes from a liquid nutritional formula, with the remainder from regular food. This approach offers flexibility while ensuring essential nutrients to manage inflammation.
Foods to Include in Your UC Diet
While individual tolerances vary, some foods are generally well-tolerated and may even help manage UC symptoms:
- Lean Proteins: Chicken, turkey, fish, tofu, and eggs provide essential nutrients without causing excessive irritation.
- Omega-3 Fatty Acids: Fatty fish like salmon have anti-inflammatory effects.
- Probiotic-Rich Foods: Yogurt with live cultures, kefir, and sauerkraut can help improve gut flora, promoting overall digestive health.
- Soluble Fiber: Foods like oats, buckwheat, bananas, avocado, and peeled apples can help with symptoms in active flares with UC.
- Non-Cruciferous Vegetables: Potatoes, sweet potatoes, cucumbers, and carrots are generally well-tolerated.
- Low-Fiber Fruits: Bananas, honeydew melon, cooked or peeled fruits, avocado, and mango are good options.
Foods to Avoid or Limit
Certain foods can trigger flare-ups and worsen UC symptoms. Common culprits include:
- Insoluble Fiber: Raw cruciferous vegetables and the skins and peels of fruits can be irritating, especially during flare-ups.
- High-Fat Foods: Saturated fatty acids and high-fat dairy products may increase the risk of disease flares.
- Spicy Foods: Capsaicin in spicy foods may lead to more bowel movements and possible disease flares.
- Alcohol: Alcohol can be irritating to the digestive system.
- Caffeine: Coffee can be a stimulant laxative, increasing bathroom frequency.
- Dairy Products: Some people with UC are lactose intolerant and may experience bloating, gas, or diarrhea after consuming dairy.
- High-Sugar Foods: Sugary foods and drinks, such as cookies and soda pop.
- Red Meat and Processed Meats: Some meats, including red meat and processed meats.
- Nuts and Seeds: Steer clear of nuts, seeds, corn and popcorn.
Dietary Strategies for Managing UC
- Keep a Food Diary: Track what you eat and when symptoms occur to identify potential triggers.
- Introduce New Foods Slowly: Avoid exacerbating symptoms by gradually introducing new foods.
- Eat Small Meals: Eating five or six small meals a day may be better tolerated than three large meals.
- Stay Hydrated: Drink plenty of liquids every day, especially water, electrolyte-rich drinks, bone broth, and herbal teas.
- Manage Stress: Stress can worsen UC symptoms and trigger flare-ups. Focus on stress-reducing activities like biking, walking, yoga, and swimming.
- Adjust Your Diet During a Flare: The "GI gentle diet" focuses on soft-textured foods and moderate fiber.
- Personalize Your Nutrition Plan: The foods you should and shouldn’t eat are entirely unique to your UC symptoms and lifestyle.
The Gut-Brain Connection
The brain and digestive system are closely linked, and stress management techniques can positively impact UC symptoms. Lowering stress levels can send calmer vibes to your gut, alleviating symptoms like cramping.
The Importance of Sleep
Quality sleep is crucial for managing UC. A recent study found that participants who consistently got poor sleep had more UC flares, while quality sleep reduced the number of flares.
Exercise and UC
Light to moderate exercise works wonders for UC. Regular physical activity can help reduce stress, improve mood, and promote overall well-being.
Supplements for Ulcerative Colitis
Ideally, you should try to get all of the vitamins, minerals, and other nutrients your body needs from eating a balanced diet. But sometimes, dealing with flares means you may have to avoid certain nutritious foods. In that case, your doctor may suggest that you take dietary supplements to help provide the nutrients you’re missing. Some common supplements that doctors recommend for UC patients include:
- Calcium
- Folic acid
- Iron
- Vitamin B12
- Vitamin D
- Vitamins A, E, and K
- Zinc
When you buy a dietary supplement, be sure to read the label and find out if the product is made with any ingredients that could cause a flare-up, such as lactose or sugar alcohols.
Working with a Registered Dietitian
Consulting a registered dietitian specializing in gastrointestinal disorders is highly recommended. They can help you:
- Identify your unique food triggers
- Tailor your diet during flare-ups
- Develop a personalized nutrition plan
- Ensure you meet your nutritional needs
Monitoring Your Progress
Pay attention to how your body responds to different foods and dietary changes. Signs that your diet is helping your colitis include:
- Fewer flare-ups
- Stable blood work
- Increased energy
- Improved digestion
- Improved quality of life
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