Ulcerative Colitis Diet: Managing Symptoms and Promoting Gut Health

Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) characterized by inflammation and ulcers in the lining of the colon and rectum. Since ulcerative colitis (UC), a condition that causes inflammation in the colon and rectum, is never medically cured, certain lifestyle behaviors can help you manage symptoms and better cope with your condition. While there is no medical gold standard for treating UC, diet plays a crucial role in managing symptoms, reducing inflammation, and promoting gut health. Thoughtful, well-planned diet and nutrition can make all the difference in reducing symptoms and improving your overall well-being.

Understanding Ulcerative Colitis

Ulcerative colitis (UC) belongs to the group of inflammatory bowel diseases (IBD). UC is a chronic inflammatory process of the colonic mucosa with alternating periods of exacerbation and remission. 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. 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. Due to the specificity of UC, besides pharmacological and surgical treatment, introduction of appropriate dietary and nutritional habits is an extremely important element of the therapy, which, however, is still underestimated and often omitted in medical practice. Despite the lack of specific dietary advice in IBD, even more than 70% of sufferers note that inadequate nutrition significantly affects the course of the disease and increases the frequency and severity of symptoms. Consequently, 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.

General Dietary Recommendations for Ulcerative Colitis

While there isn't a one-size-fits-all approach to UC-friendly foods, certain dietary strategies can help reduce inflammation, promote healing, and improve overall well-being. There is no single diet that works best for managing UC. In fact, no studies have shown that any specific diet improves symptoms or that any specific foods cause UC flare-ups. It’s usually a process of elimination. However, finding your trigger foods and those that make you feel good can help you better manage your condition.

Here are some general guidelines:

• Eat a well-balanced, healthy diet: You should eat a well-balanced, healthy diet rich in fresh fruits and vegetables, such as a Mediterranean style diet. The key is to find what works for you.
• Personalize your nutrition plan: The foods you should and shouldn’t eat are entirely unique to your UC symptoms and lifestyle. Nutrition, no matter which stage of UC you find yourself in today, should always be personalized.
• Identify trigger foods: Keeping a food diary can help you detect patterns. For example, you may notice that every time you eat a spicy food such as pasta with marinara sauce, you feel lousy later on. That’s a strong clue that spicy foods are a trigger for you, so you may want to avoid them. Maintaining a food diary takes a bit of time and patience, but it will help you track your condition and fine-tune your diet plan.
• Consult a professional: Having a nutritionist design a specialized diet plan for you may be helpful. If you need help managing what foods to eat with colitis, a Registered Dietitian Nutritionist can create a personalized nutrition plan tailored to your needs.
• Consider a 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.
• Adjust your diet during a flare: Your diet may look different during a UC flare. A flare may be the time to pull a GI gentle diet from your UC toolkit.

Best Foods to Eat During an Ulcerative Colitis Flare-Up

When experiencing a UC active disease flare-up, you may have been told to stick to low-fiber, easy-to-digest foods, but you actually need the anti-inflammatory benefits from fruits, vegetables, and whole grains. However, you may need to alter the particle size of these foods, opting for smoothies, soups, stews, nut butters, and fork-tender vegetables that are soft against the roof of your mouth. This allows for more digestive comfort during a time of ulceration while still getting your body the nutrition that it needs.

Read also: The Mediterranean Diet Guide

Some of the top food choices include:

• Grain-bowl bases: Carbohydrates may feel easy on the digestive tract. You can top with a protein-rich complete protein. Some examples include:
  • oats
  • millet
  • buckwheat
  • teff
  • cornflour
  • arrowroot
  • rice
  • Orzo
  • Farro
  • couscous
  • semolina or durum pasta
• Broth-based stews and soups: Hydrating and soothing, especially during flare-ups.
• Smoothies: Blending fruits and vegetables makes them easier to digest.

Another important goal while experiencing active disease flares is to continue nourishing your body. You may experience a decrease in appetite due to the inflammatory process. However, inflammation requires healing, which requires more, not less, nutrition.

Best Foods for Ulcerative Colitis Remission

When you're not amid a flare-up, you can slowly add more textures from fiber for a diverse, varied diet that is rich in omega-3 fatty acid from fish. Some options to consider include:

• Lean proteins: Chicken, turkey, fish, tofu, and edamame provide essential nutrients without irritating your colon. Complete proteins, when paired with carbs play an important role in muscle health. Poor muscle health is a risk factor for IBD active disease flare-ups, so these are important nutritional components to include in your diet!
• Plenty of fruit and vegetables: If you’re no longer bleeding, slowly experiment with increasing the textures in your diet to include seeds and skins of fruit. Remission is the time to play with texture (unless contraindicated by another medical condition or directed by your physician). Including the texture of different fibers in the diet can help aid in digestion.
• Fermented foods: Yogurt with live cultures, kefir, and sauerkraut can help improve gut flora, promoting overall digestive health.
• Fats: Avocado and olive-oil especially offer anti-inflammatory properties and fats to nourish your body.

Foods to Avoid with Ulcerative Colitis

While many foods can help manage colitis, some can worsen symptoms and possibly increase risk for shorter time spent in remission. Remember that nutrition needs to be personalized to each individual, but in general is best to avoid:

• Soft cheeses and cow’s milk: Dairy as a whole category is quite broad, and although there’s no increased risk of IBD flare-ups, many people as they age may experience lactose-intolerance, which can lead to bloating and discomfort. This may be an especially sensitive experience immediately after a flare-up or surgery.
• High-fat foods: Saturated fatty acids and those high in myristic acid, like palm and coconut oil, and high-fat dairy, are associated with an increase in disease flares.
• Spicy foods: The capsaicin in spicy foods may lead to more bowel movements and possibly more disease flares. When possible if culturally preferential, use herbs in lieu of spices that create heat.
• Alcohol: Alcohol be irritating to your digestive system, and alcohol is carcinogenic, or cancer-causing. It’s best to avoid in a flare with active disease to help your intestines heal.
• Caffeine: Coffee can be anti-inflammatory and liver-protective, but it is a stimulant laxative, so you may have increased bathroom frequency. In a flare, proceed with caution.

The Mediterranean Diet and Ulcerative Colitis

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. 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.

Read also: Managing UC in Children with Diet

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.

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.

Read also: The Mediterranean Diet

Other Dietary Considerations

• Exclusive Enteral Nutrition (EEN): 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.
• Partial Enteral Nutrition (PEN): 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.
• Specific Carbohydrate Diet (SCD): The Specific Carbohydrate Diet (SCD) is a restrictive diet that eliminates grains, most dairy, and certain sweeteners. While some patients find it helpful, it is important to consult with a healthcare professional before starting this diet to ensure adequate nutrition.
• Gluten-Free Diet: A gluten-free diet may help improve your symptoms. In a 2014 study, just over 65% of participants who ate a gluten-free diet experienced an improvement in IBD symptoms.

Lifestyle Habits for Managing Ulcerative Colitis

Following some good eating habits can help you manage ulcerative colitis, including:

• Think small. You may find that you do better with smaller meals throughout the day instead of three big ones.
• Snack wisely. When you make your diet plan, think about foods that you can carry with you for healthy snacks.
• Start slowly. If you have been avoiding fruit and vegetables, but you’re ready to increase your intake, add them to your diet in small amounts at a time to prevent your symptoms from flaring.
• Stay hydrated. Drink plenty of water throughout the day, especially if you’re experiencing UC symptoms and going to the bathroom often, which can leave you dehydrated.
• Plan ahead. If you’re dining out, check the restaurant’s menu online ahead of time so you can determine if it includes foods you can tolerate. When invited to a dinner party and you’re concerned that the meal may not agree with you, let the host know in advance that you plan to bring your own food.
• Manage stress: Focus on activities you like, such as biking, walking, yoga and swimming.
• Get enough sleep: A recent study in Japan found that participants who consistently got poor sleep had more UC flares, while quality sleep reduced the number of flares.

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.

How Do I Know if My Diet is Helping My Colitis?

With UC, it can take time to see the effects of dietary changes, but here are some signs that your food choices are supporting your healing process:

• Fewer flare-ups: You may notice fewer and less severe flare-ups over time.
• Stable blood work: As part of your disease monitoring strategy, your micronutrients need to be monitored, and you can work with a dietitian to ensure this is part of your care that is being addressed regularly. Less commonly-identified deficiencies may be indicative of dietary adjustments that are working.
• Increased energy: Nourishing yourself regularly will support more restful sleep and energy levels can also improve.
• Improved digestion: Reduced bloating, bathroom urgency,, and stomach discomfort can be signs of improved digestion
• Improved quality of life: Able to eat out with your friends? Feeling confident when it comes to ordering off of a menu? Do you know how to pivot IF a flare-up resurfaces to nourish your body through it? Are you able to participate rather than isolate when it comes to food-centric celebrations in your life?

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