What to Eat Based on the IBD Clinical State? New AGA Clinical Practice Update

Diet is central in all stages of inflammatory bowel diseases (IBDs), from prevention to management. While one of the most frequent questions that patients with IBD ask after diagnosis is “What should I eat?” Navigating the optimal dietary approach for people living with IBD is fraught with controversies and uncertainties due to the complex interplay of clinical factors.

The American Gastroenterological Association (AGA) has recently launched a guideline that provides practical information and dietary guidance that will help gastroenterologists, nurses and registered dietitians improve quality of life and disease outcomes in patients with IBD.

First Line Dietary Advice for IBD

There is strong evidence that a Mediterranean diet rich in fresh fruits and vegetables, olive oil, pulses, whole grains and lean protein from fish and poultry and with reduced ultra-processed foods, sugar-sweetened beverages, salt and red meat is a healthy diet for people with IBD.

‍A diet low in red (e.g., beef, pork and lamb) and processed meat (e.g., hot dogs, bacon and lunch meats) may reduce the risk of flares in Ulcerative colitis (UC).

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Dietary Advice For Strictures

Patients with IBD have been traditionally told to avoid fiber-rich foods during a flare of illness and when there is a narrowing of the bowels because of poor tolerance.  However, current evidence supports modifying the texture of rich-fiber foods during a flare or in patients with symptomatic strictures instead of avoiding plant-based foods. 

Some dietary tips for strictures:  

• Chew food well and eat meals slowly

• Peel and cook fruits and vegetables (e.g., applesauce) instead of consuming them in raw form (e.g., apple with peel)

• A way to diversify fiber content in the diet is by using nut and seed butters as a snack, consuming fruits and vegetables in smoothies, adding vegetables to soups then blend and cooking vegetables until they are soft enough to be cut easily with a fork.

• Avoid tough meats, use a slow cooker to soften.

• Avoid unpeeled fruits, broccoli, lettuce, stringy foods and corn that can increase the risk of intestinal obstruction.

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Exclusive Enteral Nutrition (EEN) for Crohn’s Disease and Malnourished Patients Undergoing Surgery

EEN in the form of liquid formulas is an effective treatment for induction of remission in Crohn’s disease (CD) -with most studies completed in children- and as a steroid sparing tool in cases of steroid dependency. Emerging evidence shows liquid nutrition used as a strategy to replace food for the first two months of therapy will induce states of remission which are equivalent to corticosteroids.

‍EEN can also be used in patients with strictures and as an oral nutritional supplement to help improve nutrition, reduce surgical complications and induce remission in patients undergoing surgery. 

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Crohn’s Disease Exclusion Diet for the Treatment of Crohn’s Disease

For pediatric and adult patients with mild-to-moderate CD who are unable to follow an EEN regimen, the Crohn’s Disease Exclusion Diet (CDED) could serve as an alternative for inducing clinical, biochemical and endoscopic remission. This diet can be used as a combination of oral liquid formulas (by mouth or feeding tube) and specific whole foods with beneficial effects on the gut microbiome and intestinal barrier. 

This dietary approach includes three phases of six week duration and combines the anti-inflammatory properties of EEN with the tolerability of whole foods. Due to its complexity, it is best pursued under the supervision of an IBD-trained registered dietitian. Data on the efficacy of CDED in the treatment of UC is limited.

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Parenteral Nutrition when Adequate Nutrition Cannot Be Achieved through Oral or Enteral Nutrition

In patients with IBD who have intra-abdominal abscess (i.e., a pocket of pus caused by a bacterial infection) and are unable to follow oral or enteral nutrition due to intestinal failure, short-term parenteral nutrition may be used as a bridge to surgery and to improve surgical outcomes.

‍Feeding nutritional products to a patient with IBD intravenously is also indicated for:

• Patients who lack sufficient bowel function to maintain or restore nutrition status (e.g., patients with gastrointestinal fistula, prolonged delay in the return of normal bowel function or short bowel syndrome)

• Patients with a contraindication to enteral nutrition or who do not tolerate adequate enteral nutrition

• Patients with severe malnutrition

However, providing nutrients by vein is expensive and increases the risk of serious adverse events. To avoid complications, the new AGA guidelines state that parenteral nutrition should be transitioned to personalized hydration management and oral intake when possible.

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All Patients with IBD Should Undergo Malnutrition Identification and Treatment

While undernutrition is common in patients with IBD, particularly in patients with active CD and with multiple surgeries, overnutrition is becoming increasingly common as a result of the global obesity epidemic. Nutrient deficiencies in IBD are associated with anorexia, malabsorption, increased gastrointestinal losses and dietary restrictions. Thus, all patients should undergo malnutrition screening at diagnosis and routinely during IBD management.

‍Micronutrients that should be monitored in patients with IBD –during quiescent IBD because their serum levels can be affected by active inflammation– include:

• Vitamin D

• Folic acid, especially in patients on methotrexate and sulfasalazine

• Vitamin B12 in patients with extensive ileal resection or prior ileal surgery as this vitamin is only absorbed in the last part (ileum) of the small intestine

• Iron

• Zinc

• Copper 

Registered dietitians are the go-to healthcare professionals for optimizing nutrition in all patients with IBD, in particular in those cases where composition of the nutrition support may differ (e.g., patients on a restrictive diet or with obesity). 

Dietitians are not only for malnourished patients and it is important for individuals with IBD to work closely with them to effectively manage both the underlying disease and the potential complications related to malnutrition.

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Reference:

^{Hashash JG, Elkins J, Lewis JD, et al. (2024). AGA Clinical Practice Update on Diet and Nutritional Therapies in Patients With Inflammatory Bowel Disease: Expert Review. Gastroenterology. 2024; 166(3):521-532. doi: 10.1053/j.gastro.2023.11.303.}

‍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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Dr. Natasha Haskey is a clinical scientist and Registered Dietitian with over 20 years of practical experience in nutrition therapy for IBD.  

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