Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) characterized by inflammation and sores in the inner lining of the colon. Managing UC often involves a combination of medication and lifestyle adjustments, including dietary changes. While there's no one-size-fits-all diet for UC, a vegetarian diet, particularly a whole food plant-based diet (WFPBD), has shown promise in managing symptoms and supporting remission. This article explores the role of a vegetarian diet in managing ulcerative colitis, drawing on research and expert recommendations.
Understanding Ulcerative Colitis
Ulcerative colitis is influenced by a combination of genetic, environmental, and immunological factors. Certain medications and dietary choices are known to increase disease risk and trigger flares. For example, an observational study of over 67,000 middle-aged French women found that frequent consumption of meat and fish was significantly associated with a higher risk of developing IBD.
The Role of Diet in Managing UC
Diet plays a significant role in managing UC. Diet and lifestyle factors are heavily implicated in the pathogenesis of the disease, with diets high in meat and ultra-processed foods and low in fiber-rich plant foods thought to be central to the disease process. While no elimination diet has been proven to cure ulcerative colitis, certain dietary changes can help manage symptoms and potentially shorten flares.
General Dietary Recommendations
- Keep a food and symptom journal: During flares, track your food intake and symptoms to identify bothersome foods.
- Limit fiber during flares: Ask your doctor whether to limit fiber until symptoms pass. Eating a maximum of 10 grams of fiber per day may reduce irritation and lower the risk of intestinal blockage.
- Fruits and vegetables: High fruit and vegetable intake appears to protect against ulcerative colitis. A diet that is rich in fruits and vegetables provides fiber and antioxidants, which are linked to lower disease risk.
- Dairy: This one is controversial as long-term IBD sufferers tend to have an increased need for calcium.
Vegetarian Diets and UC: A Promising Approach
A whole food plant-based diet (WFPBD) is an attractive option given its emphasis on foods that promote gut health and reduce inflammation and the avoidance of foods that are associated with dysbiosis and inflammation. A whole food, plant-based diet successfully led to remission for ulcerative colitis in three individuals in a new case series published in the American Journal of Lifestyle Medicine. Two people eliminated their need for medication, and the third reduced the dose. Returning to a meat-based diet resulted in a recurrence of symptoms.
Case Studies: WFPBD and UC
Three case histories presented, with more than 2 years of follow-up, highlight the potential role of a WFPBD in the treatment approach for people with UC. All three of our patients had failed to respond adequately to first-line treatment, namely, mesalazine.
Read also: Is a Vegetarian Elimination Diet Right for You?
- Case 1: A 35-year-old female presented with UC symptoms, including bloody stools and constipation. After experiencing worsening symptoms with mesalazine, she adopted a WFPBD. Initially, she experienced bloating and constipation, which were managed by limiting FODMAPs and gradually increasing fiber intake. Her symptoms improved, and she achieved resolution. A relapse occurred when she reintroduced animal foods, but remission was regained upon returning to the WFPBD.
- Case 2: A 35-year-old male with UC symptoms, including bloody stools and diarrhea, commenced a WFPB diet under dietetic supervision. He lost some weight (3kg), which the patient did not want, so higher calorie plant meals were recommended, including avocado, banana and peanut butter smoothies and increased portions of quinoa, seeds, pulses and sweet potato. A repeat colonoscopy in November 2021 was normal, and his clinical team advised him to stop mesalazine.
- Case 3: A 41-year-old male with recurrent UC relapses adopted a WFPBD. Within a few weeks, he reported improvement in symptoms, a reduction in mesalazine dose from 6 times per day to 4 and no further need for enemas. His repeat colonoscopy in April 2021 showed complete remission for the first time in 3 years. On review in February 2022, the patient reported a relapse of symptoms with blood diarrhoea and a rise in calprotectin levels to 345 ug/g. He reported going through a stressful life event related to his family situation, and he had also reintroduced meat into his diet.
These cases suggest that a WFPBD can be a viable treatment approach for UC, even in individuals who have not responded well to conventional treatments.
Key Principles of a WFPBD for UC
- Focus on whole, unprocessed plant foods: Emphasize fruits, vegetables, legumes, whole grains, nuts, and seeds.
- Limit or avoid animal products: Minimize or eliminate meat, poultry, fish, dairy, and eggs.
- Avoid processed foods: Steer clear of refined sugars, processed grains, and foods with artificial additives.
- Personalized approach: Work with a dietitian to tailor the diet to your specific needs and tolerances.
Specific Vegetarian Diets for UC
Several specific vegetarian diets have been explored for their potential benefits in managing UC.
Semi-Vegetarian Diet
The semi-vegetarian diet has not been studied in ulcerative colitis patients. There have been no studies on the diet to date. The use of plant-based diets in IBD has been pioneered by Japanese researchers who have used this in clinical practice for over 15 years, with remarkable results. Their plant-based diet is a semi-vegetarian diet that includes yoghurt and allows for fish once a week to make it more acceptable to patients. Their plant-based diet scoring system considers eight foods to be preventive factors for IBD (vegetables, fruits, pulses, potatoes, rice, miso soup, green tea, and plain yoghurt) and eight foods to be harmful (meat, minced or processed meat, cheese/butter/margarine, sweets, soft drinks, alcohol, bread and fish). They have achieved very good results and durable remissions in both UC and Crohn’s disease and have also demonstrated higher remission rates in combination with biological therapies.
IBD-AID and Specific Carbohydrate Diet (SCD)
The IBD-AID limits complex carbohydrates and eliminates refined sugar and lactose. The IBD-AID includes prebiotic and probiotic foods and a specific ratio of healthy fats. Small studies have shown the IBD-AID (and SCD mentioned above) to improve IBD symptoms.
Low FODMAP Diet
It’s believed the disease doesn’t cause FODMAP sensitivity but that there is an overlap between the two conditions. It’s important to note that the low FODMAP diet should not be followed long-term. Patients with pain, gas or bloating during remission may wish to work with a dietitian to identify any FODMAP sensitivities.
Read also: Healthy Vegetarian Eating
Important Considerations
- Fiber Intake: While high fruit and vegetable intake is generally protective against UC, it's essential to manage fiber intake, especially during flares. High vegetable intake was linked to lower risk in a review of 19 studies that included 1340 ulcerative colitis patients.
- Omega-3 Fatty Acids: Some of the richest dietary sources of omega-3 fats come from fish. It’s not yet known if plant sources of omega-3 fatty acids increase risk. Non-meat sources include flax and chia seeds, walnuts, omega-3 enriched eggs, and leafy greens.
- Probiotics: Certain probiotics are helpful in bringing about and maintaining remission. Also promising is the probiotic blend VSL#3. Probiotics are safe for most people but can be very expensive.
- Supplements: Many supplements claim to bring about or maintain remission.
- Food Additives: Patients are asked to avoid the following food additives and emulsifiers; carboxymethylcellulose, polysorbate 80 (P80), propylene glycol alginate, carrageenans, gums, (Arabic, Guar, xanthan), maltodextrin, glycerol monolaurate, locust bean gum, magnesium stearate, titanium dioxide, artificial colouring, hydrogenated oil (in supplements).
Vegetables to Include and Avoid
While every gut is different, many people with UC find that they can tolerate a wide range of vegetables when their symptoms are in remission (or they haven’t recently had GI surgery).
Vegetables Recommended During Remission:
- Shredded carrots
- Butternut squash
- Acorn squash
- Zucchini
- Summer squash
- Potatoes
- Sweet potatoes
- Green beans
- Asparagus tips
These vegetables are often high in soluble fiber, which pulls water into the GI tract to turn the fiber into a thick, gel-like substance during digestion and is gentle on the gut.
Vegetables to Consume During a Flare-Up:
- cooked or steamed until they’re soft
- canned
- peeled
- made into vegetable stock, juice, or soup
Cooked vegetables you may be able to eat during a UC flare-up include:
- carrots
- potatoes
- squash
- green beans
- parsnips
- rutabaga
- eggplant
- zucchini
- pumpkin
It’s important to avoid eating the skins of vegetables because they’re typically high in insoluble fiber.
Vegetables to Avoid During a Flare-Up:
Certain types of vegetables, such as cruciferous vegetables and those with seeds, contain insoluble fiber and have tough stalks. These may irritate your GI tract and trigger UC symptoms such as gas, bloating, and abdominal pain. Vegetables to avoid may include:
Read also: Is a Chicken-Inclusive Vegetarian Diet Right for You?
- broccoli
- Brussels sprouts
- cauliflower
- peas
- corn
- beans and lentils
- cabbage
- leafy green
- raw onions and garlic
- peppers
Sample Vegetarian Menu Ideas for UC
Living with UC doesn’t mean you have to eat bland food. Here are a few menu ideas with vegetables for people in remission.
Breakfasts
- scrambled eggs with avocado, spinach, and low fat cheddar cheese
- honey-sweetened butternut squash and muffins
- goat cheese, zucchini, and dill frittata
- smoothie with spinach, cucumber, and mint
Lunches
- shepherd’s pie with sweet potato topping
- butternut squash bisque
- carrot soup
- oat risotto with peas and pecorino cheese
- smoothie with coconut milk, coconut yogurt, bananas, pineapple, and spinach
- canned tuna mixed with mayonnaise and diced peppers on cucumber slices
Dinners
- bell peppers stuffed with diced onions, chickpeas, ground turkey, steel cut oats, feta, and sun-dried tomatoes
- foil-baked tilapia (or other white fish) with chopped zucchini, cherry tomatoes, red bell pepper, and lemon
- zucchini lasagna
- spinach-butternut squash pizza
- rice noodles with tofu, carrots, green beans, bell pepper, and baby corn in peanut-soy sauce
- root vegetable mash with turnips, carrots, parsnips, and sweet potatoes
Snacks
- spinach-artichoke yogurt dip
- mushrooms stuffed with chopped spinach and farmer’s cheese
- carrot, beet, and celery root chips
- lactose-free yogurt topped with banana slices and nut butter
- toasted gluten-free bread topped with cottage cheese, squeezed lemon, and sliced cucumbers
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