Food the Main Course: Practice Update on Dietary Options for IBD and Overlapping Conditions

In August 2024, Nutritional Therapy for IBD attended virtually Food the Main Course to Digestive Health. Discover emerging research on diet and nutritional therapies' role in managing IBD and overlapping gastrointestinal conditions.

Nutrition advice for IBS and overlapping conditions

One in every three patients with IBD in remission struggles with IBS-like symptoms, including mild abdominal pain, bloating, and a change in bowel habits. Common underlying factors for these symptoms include the pathologic contraction of the diaphragm and relaxation of the abdominal wall, mast cell activation syndrome, congenital sucrase-isomaltase deficiency, and gynecologic conditions (endometriosis and polycystic ovary syndrome).

When the brain mistakenly signals the abdominal wall to relax rather than contract and the diaphragm to rise rather than descend after eating, abdominal distension occurs—not due to excess intestinal gas, but as a primary cause of distension often accompanying bloating. Other common causes include diet, constipation, small intestinal bacterial overgrowth, and abnormal bowel sensitivity.^1,2 

There is no one-size-fits-all solution, and bloating should be approached by cause. Emily Haller, MS, RDN, from Trinity Health Ann Arbor, delved into practical tips to improve bloating, including:^3,4,5

• Treating constipation as first-line treatment (involving biofeedback therapy when a pelvic floor disorder is identified)
• The low FODMAP diet
• Diaphragmatic breathing
• Pooping from a semi-squat position
• Engaging in moderate-intensity aerobic exercise
• Limiting or avoiding triggers as needed (high sodium meals, FODMAPs, gluten, carbonated drinks, and alcohol)

Shanti Eswaran, MD, from the University of Michigan, updated non-pharmacologic treatments for IBS that target the main bothersome symptom for the patient while also acting on the causes:

• Peppermint oil for abdominal pain (typical dose 180-225 mg of enteric-coated peppermint oil capsules, 1-3 capsules per day)⁶‍
• Glutamine for restoring intestinal permeability and improving severity of symptoms in post-infectious IBS with diarrhea (5 g/three times a day)⁷ and improving the efficacy of a low FODMAP diet (15 g/day)⁸‍
• ‍Iberogast® (STW5 - a mixture of 9 plant extracts) for improving colonic gas tolerance (20 drops/three times a day)⁹ 
• ‍Soluble and poorly fermented fiber (Psyllium) for improving global IBS symptoms in IBS with constipation or diarrhea (1 rounded teaspoon (6g) once a day to three times a day; start low and go slow)¹⁰‍
• ‍Kiwifruit and prunes also provide symptom relief of chronic constipation (2 green kiwifruits or 12 prunes per day provide 6 grams of fiber helpful for symptom relief)¹¹ 

At the microscopic level, a patient's gut with IBS often looks different from a healthy gut. Prashant Singh, PhD, from the University of Michigan, presented data showing mast cells are activated in mucosal biopsies of patients with IBS and, together with gut dysbiosis, may activate neurons leading to abdominal pain. Diet (certain foods like milk, wheat, and wine, but also certain odors), temperature change, and stress can activate mast cells. Singh also introduced drugs that block the action of histamine after it’s released by mast cells and drugs that stop mast cells from releasing inflammatory chemicals as novel treatment options to manage chronic abdominal pain in IBS.^12-15 

While originally sucrase-isomaltase deficiency was a congenital pediatric disease, it is estimated that acquired disease (e.g., secondary to mucosal injury) affects up to 10% of children and adults with chronic diarrhea, abdominal pain, and bloating. Some tips suggested by Kate Scarlata, MPH, RDN, GI expert dietitian who writes “For A Digestive Peace of Mind” blog, and Daksesh Patel, DO, from Illinois Gastroenterology Group, to detect whether a patient has this condition include symptom exacerbation with sugar or starch intake, no response to traditional IBS therapy, such as the low FODMAP diet, long-standing digestive symptoms since childhood, and previous history of trying a specific carbohydrate diet or keto diet to manage symptoms. 

From the lab to the kitchen: nutrition tips for implementing gastrointestinal specialty diets

Patsy Catsos, MS, RDN, LDN, a registered dietitian in private practice, acknowledged that 68% of patients with digestive issues report spending more on groceries since they started a special diet, while 62.5% can afford to follow the special diet their healthcare provider prescribed. Healthcare providers should be sensitive to the potential of food insecurity of patients and provide budget-informed care, discuss necessary dietary advice (e.g., celiac disease) versus it that is negotiable (e.g., reducing FODMAP intake), offer creative strategies to redirect resources from eating out and less nutrient-dense foods to more suitable foods, and build shopping and cooking skills. 

Scarlata highlighted food is complicated, and in a particular food, multiple triggers within different food groups might overlap to worsen a patient's gastrointestinal symptoms (for example, fructans rather than gluten are the primary culprits of gastrointestinal symptoms in most patients)¹⁶. Some patients with IBS symptoms show decreased diamino oxidase levels in blood, suggesting a histamine intolerance.¹⁷ To complicate things further, gut microbiota-produced histamine induces abdominal pain, leading to the accumulation and activation of mast cells in the colon.¹⁸

While there are no randomized clinical trials of a low histamine diet in IBS, emerging data suggests the low FODMAP diet can help minimize mast cell activation and colonic barrier dysfunction in patients with IBS with diarrhea. If the patient does not want or cannot follow the traditional 3-phase low FODMAP diet, a low FODMAP diet with a simple restriction phase that only eliminates fructans and galactooligosaccharides is feasible and is similarly effective to a traditional low FODMAP diet in improving abdominal symptoms in patients with IBD with diarrhea. Further research should explore the role of reducing dietary histamine in patients with overlapping conditions that may increase gut inflammation or reduce surface area that may impact DAO production (e.g., SIBO, IBD).

Regarding dietetic management of sucrase-isomaltase deficiency, digestive symptoms will relate to the amount of sugar and starch in the diet, and the goal is to follow the more liberal diet as possible while maintaining symptom control. Enzyme replacement therapy (sacrosidase) allows no need to restrict dietary sucrose. Reducing starch-rich foods (potatoes, rice, bread, pasta, and ingredients such as dextrins, maltodextrins, and glucose polymers) is not needed unless symptoms persist after instituting a sucrose-free diet.¹⁹

Nutrition tips for improving starch tolerance with the guidance of a dietitian include chewing foods slowly to maximize salivary amylase exposure and eating starches with greater fiber content (e.g., oats) to prolong exposure to amylase throughout the digestive tract. The patient also needs to recognize sucrose and starch in food labels. While the amount of starch is not listed on the label, it can be calculated by subtracting the amount of fiber and sugar from the total carbohydrates. Potential nutrients of concern in sucrase-isomaltase deficiency that should be monitored include fiber, potassium, calcium, magnesium, and folate.^20-22

Nutritional tips to enhance recovery in IBD-related surgeries

Up to 30-80% of patients with Crohn’s disease and 10-30% of patients with ulcerative colitis will need IBD-related surgery, which puts them at a high nutritional risk. Nutrition assessment should start before surgery due to its well-documented role in reducing the length of stay, readmission risk, hypoglycemia, postoperative complications, rates of infection, and muscle loss. 

If a patient meets the criteria for malnutrition, personalized dietary advice is preferred over the elimination of foods before surgery. Stacey Collins, MA, RDN/LD, a registered IBD dietitian, focused on pearls on the dietary management of patients with IBD before and after IBD surgeries.

Restoring and preserving nutrition status before surgery includes:^23-26

1. Correct deficiencies and undernutrition

The critical nutrients to cover are protein, omega-3 fatty acids, fiber, iron, vitamins B9 and B12, calcium, vitamin D, potassium, magnesium, and zinc. Some medications may require close monitoring of particular micronutrients (e.g., folic acid in patients on methotrexate or sulfasalazine). Oral nutrition supplements may be needed for people who may not meet more than 50% of their energy for more than a week. 

As re-feeding syndrome often occurs, a registered dietitian is critical to ensuring that formulas meet calorie goals gradually. 

2. Avoid pre-operative fasting

Patients can consume solid foods for up to 6 hours before surgery and 50 g of carbohydrates for up to 2 hours before surgery. Solid foods and carbohydrates before surgery are safe and may reduce the number of patients with IBD undergoing surgery who stay in the hospital for more than four days.

3. Reduce fasting time

Continuing food and beverage intake up to 4 hours before surgery is safe.

After surgery, the medical team will determine if it is safe to start eating 4 hours post-surgery. Setting patient expectations early and reminding them will likely improve health outcomes. Specific dietetic advice is needed regarding dehydration and bowel obstruction so patients can learn to identify and anticipate issues while scar tissue is healing:^27-30

• IBD-related surgeries such as J-pouch surgery can increase the risk of dehydration. Instead of encouraging the patient to “stay hydrated” or “drink more fluids”, it is worth giving specific fluid goals and helping the patient choose the right type of fluid and dose based on ostomy type.‍
• As patients heal, their diet can expand but build gradually. There is no evidence supporting the use of a low-fiber diet to prevent bowel obstruction in people with IBD. Instead of saying “avoid fiber”, it is paramount to guide the patient in adapting the fiber texture of their diet (peeled/fork-tender/small particle size).

Learn more about FOOD: The Main Course

Further reading:

Conditions overlapping with IBS:

1. Damianos JA, Tomar SK, Azpiroz F, et al. Abdominophrenic dyssynergia: a narrative review. Am J Gastroenterol. 2023; 118(1):41-45. doi: 10.14309/ajg.0000000000002044. 
2. Lacy BE, Cangemi D, Vazquez-Roque M. Management of chronic abdominal distension and bloating. Clin Gastroenterol Hepatol. 2021; 19(2):219-231.e1. doi: 10.1016/j.cgh.2020.03.056.  
3. Dean G, Chey SW, Singh P, et al. A diet low in fermentable oligo-, di-, monosaccharides and polyols improves abdominal and overall symptoms in persons with all subtypes of IBS. Neurogastroenterol Motil. 2024; 36(8):e14845. doi: 10.1111/nmo.14845.
4. Peng AW, Juraschek SP, Appel LJ, et al. Effects of the DASH diet and sodium intake on bloating: results from the DASH-sodium trial. Am J Gastroenterol. 2019; 114(7):1109-1115. doi: 10.14309/ajg.0000000000000283.
5. Bianco A, Russo F, Franco I, et al. Enhanced physical capacity and gastrointestinal symptom improvement in Southern Italian IBS patients following three months of moderate aerobic exercise. J Clin Med. 2023; 12(21):6786. doi: 10.3390/jcm12216786.
6. Ingrosso MR, Ianiro G, Nee J, et al. Systematic review and meta-analysis: efficacy of peppermint oil in irritable bowel syndrome. Aliment Pharmacol Ther. 2022; 56(6):932-941. doi: 10.1111/apt.17179.
7. Zhou QQ, Verne ML, Fields JZ, et al. Randomised placebo-controlled trial of dietary glutamine supplements for postinfectious irritable bowel syndrome. Gut. 2019; 68(6):996-1002. doi: 10.1136/gutjnl-2017-315136. 
8. Rastgoo S, Ebrahimi-Daryani N, Agah S, et al. Glutamine supplementation enhances the effects of a low FODMAP diet in irritable bowel syndrome management. Front Nutr. 2021; 8:746703. doi: 10.3389/fnut.2021.746703.
9. Aguilar A, Benslaiman B, Serra J. Effect of Iberogast (STW5) on tolerance to colonic gas in patients with irritable bowel syndrome: A randomized, double-blind, placebo control clinical trial. Neurogastroenterol Motil. 2024; 36(10):e14765. doi: 10.1111/nmo.14765.
10. Moayyedi P, Quigley EMM, Lacy BE, et al. The effect of fiber supplementation on irritable bowel syndrome: a systematic review and meta-analysis. Am J Gastroenterol. 2014; 109(9):1367-1374. doi: 10.1038/ajg.2014.195.
11. Chey SW, Chey WD, Jackson K, et al. Exploratory comparative effectiveness trial of green kiwifruit, psyllium, or prunes in US patients with chronic constipation. Am J Gastroenterol. 2021; 116(6):1304-1312. doi: 10.14309/ajg.0000000000001149.
12. Akin C. Mast cell activation syndromes. J Allergy Clin Immunol. 2017; 140(2):349-355. doi: 10.1016/j.jaci.2017.06.007.
13. Lobo B, Ramos L, Martínez C, et al. Downregulation of mucosal mast cell activation and immune response in diarrhoea-irritable bowel syndrome by oral disodium cromoglycate: A pilot study. United European Gastroenterol J. 2017; 5(6):887-897. doi: 10.1177/2050640617691690.
14. Ferjan I, Lipnik-Stangelj M. Chronic pain treatment: the influence of tricyclic antidepressants on serotonin release and uptake in mast cells. Mediators Inflamm. 2013; 340473. doi: 10.1155/2013/340473. 
15. Decraecker L, De Looze D, Hirsch DP, et al. Treatment of non-constipated irritable bowel syndrome with the histamine 1 receptor antagonist ebastine: a randomised, double-blind, placebo-controlled trial. Gut. 2024; 73(3):459-469. doi: 10.1136/gutjnl-2023-331634.
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    From the lab to the kitchen: nutrition tips for implementing gastrointestinal specialty diets:
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16. Ford AC, Staudacher HM, Talley NJ. Postprandial symptoms in disorders of gut-brain interaction and their potential as a treatment target. Gut. 2024; 73(7):1199-1211. doi: 10.1136/gutjnl-2023-331833.
17. Schnedl WJ, Lackner S, Enko D, et al. Evaluation of symptoms and symptoms combinations in histamine intolerance. Intest Res. 2019; 17(3):427-433. doi: 10.5217/ir.2018.00152.
18. De Palma G, Shimbori C, Reed DE, et al. Histamine production by the gut microbiota induces induces visceral hyperalgesia through histamine 4 receptor signaling in mice. Sci Transl Med. 2022; 14(655):eabj.1895. doi: 10.1126/scitranslmed.abj1895.
19. Haller E, Scarlata K. Diet interventions for irritable bowel syndrome: separating the wheat from the chafe. Gastroenterol Clin North Am. 2021; 50(3):565-579. doi: 10.1016/j.gtc.2021.03.005.
20. Chey WD, Cash B, Lembo A, et al. Congenital sucrase-isomaltase deficiency: what, when, and how? Gastroenterol & Hepatol. 2020; 16(10 Suppl 5):3-11.
21. Sucraid® (sacrosidase) [prescribing information]. QoL Medical, LLC; Vero Beach, FL; 2023.
22. Boney A, Elser HE, Silver HJ. Relationships among dietary intakes and persistent gastrointestinal symptoms in patients receiving enzyme treatment for genetic sucrase-isomaltase deficiency. J Acad Nutr Diet. 2018; 118(3):440-447. doi: 10.1016/j.jand.2017.11.005.
    
    The registered dietitian role in IBD-related surgeries:
    
    
23. Jabłońska B, Mrowiec S. Nutritional status and its detection in patients with inflammatory bowel disease. Nutrients. 2023; 15(8):1991. doi: 10.3390/nu15081991.
24. Lynch KT, Hassinger TE. Preoperative identification and management of anemia in the colorectal surgery patient. Clin Colon Rectal Surg. 2023; 36(3):161-166. doi: 10.1055/s-0043-1760868.
25. Gold SL, Manning L, Kohler D, et al. Micronutrients and their role in inflammatory bowel disease: function, assessment, supplementation, and impact on clinical outcomes including muscle health. Inflamm Bowel Dis. 2023; 29(3):487-501. doi: 10.1093/ibd/izac223.
26. Malnutrition is endemic to IBD, but can be managed. Gastroenterology & Endoscopy News. August 21, 2024. Available: https://www.gastroendonews.com/Inflammatory-Bowel-Disease/Article/08-24/malnutrition-IBD-inflammatory-bowel-disease/74559‍
27. Hasil L, Fenton TR, Ljungqvist O, et al. From clinical guidelines to practice: The nutrition elements for enhancing recovery after colorectal surgery. Nutr Clin Pract. 2022;37(2):300-315. doi:10.1002/ncp.10751. 
28. Whelan K, Murrells T, Morgan M, et al. Food-related quality of life is impaired in inflammatory bowel disease and associated with reduced intake of key nutrients. Am J Clin Nutr. 2021; 113(4):832-844. doi: 10.1093/ajcn/nqaa395. 
29. Haskey N, Gibson DL. An examination of diet for the maintenance of remission in inflammatory bowel disease. Nutrients. 2017; 9(3):259. doi: 10.3390/nu9030259.
30. Wischmeyer PE, Carli F, Evans DC, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway. Anesth Analg. 2008; 126(6):1883-1895. doi: 10.1213/ANE.0000000000002743

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Dr. Andreu Prados is a science and medical writer specializing in making reliable evidence of non-prescription therapeutics for gastrointestinal conditions understandable, engaging and ready for use for healthcare professionals and patients.
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Amanda Lynett, MS, RDN is the lead outpatient GI dietitian at Michigan Medicine with the Department of Gastroenterology and Hepatology and co-director for the annual GI nutrition training program called FOOD: The Main Course to Digestive Health.

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‍‍‍Dr William D. Chey is the H. Marvin Pollard Professor of Gastroenterology at the University of Michigan where he holds a joint appointment as Professor of Nutrition Sciences. His research interests focus on the diagnosis and treatment of disorders of gut-brain interaction and H. pylori infection.‍^{‍‍‍‍‍}

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