Special diets for IBD
IBD symptoms can usually be managed with medications and simple dietary changes to control symptoms.
Everyone is different, and there is no particular diet that helps everyone with IBD.
For some, a flare-up can be so severe that no food or drink seems to be tolerated. Under these circumstances, your doctor may recommend a special diet to replace your normal diet for between 2–4 weeks, until symptoms resolve.
Liquid diets: nutritionally complete, liquid medical foods provide all the nutrients needed to speed recovery.
Standard liquid feeds are milk-based and lactose free. They are available on prescription to supplement your diet or to replace all food when symptoms are severe.
Elemental feeds are nutritional liquids containing purified forms of protein, carbohydrates and fats absorbed without further digestion, which is of benefit if you have had previous small bowel surgery. Flavouring is often needed to disguise their chemical taste. Elemental feeds induce and maintain remission in Crohn’s disease, although recent research has shown similar benefits with both types of liquid diets.
The benefits provided by liquid diets may be due to:
- Bowel rest from dietary fibres and other substances in food
- Reduced ‘antigenic load’ from intestinal contents, helping reduce inflammation
- An optimal supply of beneficial amino acids, the ‘building blocks’ of protein
- Vitamins and minerals in a more easily assimilated form
- Modified intestinal bacteria profile, having a beneficial effect on faecal pH
- Reduced intestinal ‘leakiness’, improving its function
- Liquid diets can also be used alongside an exclusion diet to manage IBD.
Food intolerances/exclusion diets
Food intolerance: although what you eat is not the cause of your IBD, keeping a food and symptom diary allows you to identify potential dietary triggers that worsen symptoms.
Carry a small notebook to record everything you eat and drink, while at the same time, keeping a note of your symptoms and their severity. Most people find it easy to score symptoms on a numerical scale, where a low number is a symptom of minor concern and a higher number is a severe reaction.
You need to bear in mind that it may take a few hours from eating the trigger foods for the symptoms you experience to develop. Stress and other factors (such as the menstrual cycle) can also influence symptom severity.
Once a food is identified as a potential ‘trigger’, it can be cut out of the diet whilst symptoms continue to be noted. If symptoms don’t improve within a week the excluded food is returned to the diet.
Once confirmed, food triggers should remain excluded for some time – usually a couple of months – before being re-introduced to ‘challenge’ the bowel again. This is very important, as you need to prove that a food is a dietary trigger by not only showing an improvement in symptoms once it is excluded but also a worsening of symptoms when it is returned to the diet. You should avoid unnecessary food exclusion otherwise your diet will become unnecessarily limited in both food choice and nutritional quality.
Exclusion diets may prove useful if a food and symptom diary fails to identify specific dietary triggers. Exclusion diets initially cut most foods from your diet and allow only foods thought to have little effect on the bowel. Once symptoms have settled after 2–3 weeks, foods are re-introduced in a regulated manner to try and identify triggers. Some foods need to be tested for longer, as the time taken for symptoms to develop may be slow. Although often successful at aiding remission this approach is often a measured one, requiring 2–3 months to complete. A dietician is essential to help you to plan a diet that excludes suspect foods, prevents nutritional deficiencies and provides enough calories to keep you at a healthy weight.
Exclusion diets can be combined with a background ‘liquid diet’ which continues as foods are introduced and is only stopped when a more complete diet is tolerated. This helps ensure a nutritionally adequate diet throughout the testing period.
A personal story – elemental diet
“I am now 43. I grew up healthily, with a robust stomach. It was quite a shock when at 18 I suddenly started to get unwell. I went to see my GP after about 4 months of having diarrhoea and stomach pain. I had blood tests and gave samples; however, the tests came back showing nothing was wrong.
By the age of 19 I’d also started passing blood and had pain in my chest, something like reflux. A year later I had also developed rashes all over the trunk of my body. None of the tablets I was given for these symptoms had any impact.
I then developed about 20 ulcers running between my cheek and my gums. During a dental check up, the dentist, a Professor at a London hospital, said he had a good idea what was wrong and referred me to specialists. I had Crohn’s disease in the colon, mouth and oesophagus. I was prescribed tablets (not steroids) several times a day for about 6 months. They made no difference except for making me feel incredibly bloated.
About this time my mum and step-dad read about Dr Hunter’s pioneering work at Addenbrooke’s Hospital, treating Crohn’s through diet. I asked my GP for a referral and in 1988 I moved to Addenbrooke’s, and was immediately put on an elemental/elimination diet [a liquid which provides nutrients in their simplest form including carbohydrates, fats, minerals, vitamins and amino acids].
But by then my Crohn’s disease had been pretty much untreated for 4–5 years; it had got very bad and I needed a resection to remove part of my colon surgically. I was in hospital for the summer of 1989 – it was one of my lowest points. However, once the resection had been done the elemental diet had the most incredible impact. It took a while to get it right – taking the elemental drink and re-introducing food to my diet – but changing what I ate, and knowing I had the backup of the elemental diet, was like being handed a winning lottery ticket. I felt that at last I had some control over this illness.
One of the hardest things with Crohn’s disease, which I’m not sure is the same with other illnesses, is the way that the disease changes and moves that makes you feel like you are chasing something you can never quite catch. I sometimes have this feeling that my body has suddenly decided that it doesn’t like a particular food, it has become intolerant, but I don’t know which food it is. So I go back on my elemental diet and start reintroducing food...and then I find that my body does not now like pineapple, and then equally something that I was intolerant to will suddenly become OK.
I’m quite often on my drink, I was during Fame Academy for instance. The people I work with will often ask if I’m having any food, and I’ll say, ‘No, I’m on my elemental drink’. They ask if I’m trying to lose weight, and I laugh and say ‘No’. Then a week later they’ll come up and ask ‘Are you still not eating?’ And again a month later they’ll say ‘Are you ever going to eat again?’ I’ll say ‘Yes, but for now this is what I’m on’.
I think some people feel uncomfortable. For example, when I go out for dinner, it’s a bit embarrassing when everyone else is eating and I’m not, but I’ve learned to live with that, and I tell them ‘Well I’m a really cheap date’.
I have a number of very bad strictures which sometimes cause a lot of pain. The biggest thing is dealing with pain, it means that something really bad is happening and I get scared and think ‘What is going on?’ I then get on to my elemental diet immediately – sometimes for up to 3 months where I don’t eat food or drink – that for me is like a fall back.
When I first got ill it was as if someone had dropped me in the middle of Piccadilly Circus and said find your way out. Having found my way out I now have the map. It’s not as if I never find myself in Piccadilly Circus, because I have been in hospital in agony since, but I do know that even when I’m in that place, I will get out of it; I will get through it because I have done it before. I’ve made that journey, and the end result is that you do deal with it.”
Research has shown that certain foods are more likely to cause problems than others, and this knowledge has been abbreviated into a diet called the LOFFLEX diet- the LOw Fat, Fibre Limited EXclusion diet. The LOFFLEX diet allows you to eat a wide variety of foods that rarely upset patients with Crohn’s disease. Once Crohn’s disease is in remission with a liquid diet, the LOFFLEX diet is followed for two weeks, before reintroducing foods in a planned manner. If symptoms return during the first two weeks on the LOFFLEX diet, an elimination diet may be necessary instead.
Specific Carbohydrate Diet (SCD)
The SCD allows only the simplest of dietary carbohydrates (fructose, glucose and maltose), whilst cutting out other sugars, and starchy foods. Its rationale is that IBD is more prevalent in urban diets high in dietary sugars, and a low sugar/carbohydrate diet will address this.
The SCD claims to work by ‘starving’ pathogenic (but unspecified) intestinal bacteria of fuel, reducing their number and improving symptoms. There are two main concerns with this diet:
- There is no association between sugar intake and IBD once the condition has developed.
- We now know that a healthy level of bowel bacteria is essential to maintain health; however, the SCD approach serves to reduce bacteria numbers.
This diet takes the opposite approach to current knowledge and recommendations. As with any change to your diet, it is important to discuss this with your HCP
The lack of properly conducted research into the clinical benefits of probiotics means that the evidence supporting their use is relatively weak and their benefits (if any) are not universally accepted.
Probiotic bacteria are an essential part of our bowel protection, and are important for health. These bowel bacteria might work in many different ways to maintain our bowel health; there are over 300 types of ‘friendly’ bacteria in our bowels, and it is thought that their ecosystem works in harmony with us.
Healthy levels of bacteria in the gut work to our benefit, as they:
- ‘Prime’ bowel immune cells for instant defence against bacteria that can cause illness (pathogenic bacteria)
- ‘Sense’ large surges in bacterial numbers and can modify them, keeping levels of bacteria in check
- Produce a mucus-type substance that lines bowel walls, improving absorption of beneficial minerals but acting as a sticky swamp to keep pathogenic bacteria at bay
- Make Vitamin K, biotin, and vitamin B12, to supplement dietary sources
IBD, together with antibiotic use, gastroenteritis and a poor diet, all serve to reduce background levels of healthy bacteria. We can, however, boost bacterial levels by eating foods rich in soluble fibre, while we can also replace those lost with probiotic foods and drinks containing bacteria from the Lactobacillus and Bifidobacteria families, or certain yeasts and bacilli.
If you have a healthy bowel, there’s no noticeable benefit in taking these supplements. However, if you suffer from wind or bloating, diarrhoea, or constipation, you may find these supplements help. However, despite extensive research, there’s no evidence that taking probiotics keeps your IBD in remission for longer. Probiotics do, however, help to reduce the risk of pouchitis in ulcerative colitis patients who have had small bowel pouch formation.
Probiotic-rich foods include:
- Fermented foods e.g. tempeh, quark, crème fraiche
- Pickled foods e.g. sauerkraut, kimchi
- Probiotic capsules of freeze-dried bacteria
Probiotic yoghurts (bioyoghurt) and drinks also contain probiotic bacteria; however, there is no evidence to suggest that the bacteria survive the stomach acids in transit.
The lack of properly conducted research into the clinical benefits of prebiotics means that the evidence supporting their use is relatively weak and their benefits (if any) are not universally accepted.
Prebiotic supplements are a food source for probiotic bacteria. You can buy prebiotics which may be useful if you can’t eat particular foods. However, bear in mind that your food intolerances may be related to the prebiotic content of foods, so taking a pure fibre supplement may recreate the same intestinal problems. If you suffer from strictures it is useful to exercise caution when considering using prebiotic supplements.
It is important to take a big enough dose of prebiotic at one go if you want to boost the balance of healthy bacteria in the bowel. A typical dose needs to be between 3-8g of prebiotic. Types of prebiotic fibre include: germinated barley foodstuff (GBF); inulin; fructo-oligosaccharide (FOS); galacto-oligosaccharides (GOS).
Commercial supplements are available which contain inulin, wheat dextrin, galacto-oligosaccharides, or psyllium seeds – also known as isphagula husk or Plantago ovata seeds. However, there is no evidence for a clinical benefit in patients with active disease.
High fibre foods are rich in insoluble fibre and provide ‘roughage’ that passes undigested along the bowel, providing ‘bulk’ to our stool, and so helping prevent constipation. When your IBD is active this source of fibre should be reduced in order to minimise pain.
Check food labels for fibre content. A high-fibre food is one that contains at least 6 g fibre per 100 g of food, or at least 6 g of fibre per serving.
The following foods are high in ‘roughage’ fibre:
- Wholemeal, granary and softgrain varieties of bread, wholemeal pitta
- Jacket potatoes, new potatoes in their skins and baked potato skins
- Wholegrain cereals e.g. wheat, rice, rye, oats
- Breakfast cereals, e.g. Weetabix, Branflakes, unsweetened muesli, Shreddies
- Wholemeal pasta and brown rice
- Wholemeal flour
- Beans, lentils and peas
- Fruit skins and pips, e.g. figs, dates, pears, dried fruits (raisins, prunes, apricots etc), tomatoes
- Vegetables – particularly if the skins are eaten; spinach, chard
- Nuts and seeds, and pastes and spreads made from these
If your Crohn’s disease has caused strictures (areas of the intestine that have narrowed) you may be recommended to exclude high roughage foods such as nuts, seeds and raw fruits and vegetables. Foods such as meat, fish and dairy products contain no dietary fibre. Fibre is only found in the cell walls of plants.