Review Article

Evidence-Based Dietary Advice for Patients With Inflammatory Bowel Disease

E. Richman; J. M. Rhodes

Disclosures

Aliment Pharmacol Ther. 2013;38(10):1156-1171. 

In This Article

Dietary Guidance

Taking into account the evidence presented above, noting the caution necessary in extrapolating from epidemiological correlations and laboratory studies, we would suggest that the following represents reasonable dietary advice for patients with IBD:

Dietary Guidance for Patients With CD.

(i) In about two-thirds of patients, remission of CD may be achieved, usually over about 3 weeks, by stopping all normal food and taking a formula-defined liquid diet ('enteral nutrition'), with appropriate flavouring, as the sole feed. This is of course fairly tedious and will usually only be the first choice treatment for a minority of adults, but may more commonly be first choice treatment for children and adolescents.

(ii) Unfortunately, about 50% of patients treated by enteral nutrition relapse within 6 months of return to a normal diet.

(iii) The mechanisms by which enteral nutrition benefits CD are unclear and no specific food exclusion or inclusion has yet been proven definitively to benefit patients

(iv) The following advice is therefore based on a combination of evidence from interventional studies together with more indirect (and therefore probably less reliable) evidence based on statistical associations between risk of CD and diets in individuals and across countries.

This evidence suggests that it may be reasonable to have a diet that –

Is low in animal fat – guidelines suggest that a low-fat intake is approximately 30% of energy requirements, which equates to 90 g fat for someone who has an intake of 2500 kcal/day.

Avoids foods that are high in insoluble fibre – stringy or fibrous vegetables such as green beans, corn on the cob (whole maize), tomato skins, orange pith, potato skins and wheat bran.

Avoids processed fatty foods – often high in fat and usually contain emulsifiers – these are detergents that alter the behaviour of the intestinal lining – exposure to dish-washing detergents should also be minimised by careful rinsing.

Includes supplementary vitamin D – up to 1200 IU/day.

Dairy products if tolerated can be consumed to help ensure adequate calcium intakes.

Dietary Guidance for Patients With UC.

(i) Short-term use of total bowel rest with intravenous feeding has proved ineffective in active UC and therefore, the general conclusion has been that diet has little role in causation of UC.

(ii) There is, however, evidence from several studies that risk for UC, and risk of relapse in patients who have UC, is increased in those with a high intake of red meat or margarine.

(iii) One small study showed that about one in five patients benefited from exclusion of milk and cheese. This study has yet to be repeated and strict avoidance of dairy products is not justified.

(iv) Lactose intolerance has probably been overemphasised as a clinical problem. Half the world's population does not retain the intestinal enzyme (lactase) necessary for lactose absorption into adult life, and a double-blind controlled trial failed to show correlation of symptoms with ingestion of 240 mL of lactose-containing milk in people with proven lactase deficiency.

This evidence suggests that it may be reasonable to have a diet that –

Is low in meat – particularly red meat and processed meats, e.g. restricting their intake to no more than once per week

Avoids margarine. There is weak evidence that olive oil might be protective.

Strict avoidance of dairy products and/or lactose is not justified on the basis of current evidence.

Conclusions. There are some clear signals that diet is relevant to IBD pathogenesis, yet frustratingly little good evidence from interventional studies. Published guidance provided by professional bodies varies considerably between different sources and is often based on consensus of opinion rather than evidence.[96] The guidance provided here attempts to give advice that is supported by the best available evidence and not inappropriately restrictive. We have compared this with other guidance provided by 'best hit' internet sites in supplementary Tables 1 and 2 . There is a clear need for greater priority to be given to the conduct of high-quality interventional studies of dietary manipulation in IBD so that we can obtain a much clearer understanding of the associations between diet and IBD.

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