IBD: Crohn's Disease

Diet & Lifestyle Changes for Inflammatory Bowel Disease (IBD)

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Date Written: 09-2020

*This information is intended for educational purposes and is not intended to replace recommendations that have been provided by your Physician and Health Care Team.

Healthy eating objectives for IBD include managing symptoms, ensuring and optimizing adequate intake, promoting healing, reducing complications and meeting other relevant personal needs.

There is no miracle cure for Crohn’s and ulcerative colitis, through a special diet, food combinations, or exclusions of select foods or nutrients. Individuals with IBD, including Crohn’s disease and ulcerative colitis may feel well, or ill during a flare-up, leading to variations in appetite and nutritional intake depending on the state of their IBD.

During a flare-up and even when feeling well, it is important to be well-nourished to support healing, build strength, reduce inflammation and optimize nutritional intake. If you feel ill during a flare-up, making effective changes to diet may potentially help you to manage symptoms.

You may find some improvements or worsening in your symptoms based on certain foods. Keep a diary, it is worth tracking food intake to try and determine possible symptom triggers. However, it is important to assess whether other factors like stress, hormones, level of sleep and physical activity contribute to worsening of symptoms rather than merely foods as the cause.

Take the time to track your symptoms in the CDHF app that can help you and your doctor see patterns in your activities and identify specific triggers for your symptoms.

Canada’s Food Guide is a tool that can be used to guide your meal and snack choices. Consuming a variety of vegetables and fruits, whole grains, lean meat and protein choices provides a range of vitamins and minerals that you need daily.

Aim to fill half the plate with a variety of vegetables and fruit, fill one-quarter of the plate with healthy whole grains like bread, unsweetened cereals, pasta, rice and quinoa. Fill the remaining quarter of the plate with protein, including lean meat, poultry, fish, eggs, soy, dairy and non-dairy fortified milk, yogurt and cheese.

If your appetite is low, consume small frequent meals and snacks to consume adequate intake and prevent malnutrition.

Consume adequate amounts of fluid intake to move wastes through your system and prevent dehydration.

Flare-up Suggestions

  • Follow the advice of your Physician and Health care team during a flare-up.
  • Aim to consume a healthy diet.
  • Restrict only the foods that make you feel worse.
  • Do not try to limit intake to “rest your intestines”, as starvation provides an added stress to the body.

If your diet intake is inadequate due to poor appetite, reduced intake, or malabsorption and difficulty meeting nutritional needs, discuss strategies with your Physician and Registered Dietitian. Consuming small frequent meals and snacks, high-calorie foods, or supplements like Ensure or Boost may be beneficial.

Fibre

Daily fibre intake and goals should be discussed with your Physician, especially for those with Crohn’s disease with strictures and at risk of a bowel obstruction. 

Dietitian’s of Canada PEN Inflammatory Bowel Disease Practice Guidance Toolkit, 2020, does not recommend a high fibre nor a low fibre diet to help manage Crohn’s disease, either active or in remission, so it is best to maintain normal fibre intake.

Health Canada recommends Canadian women consume 25 grams of fibre/day and men consume 38 grams of fibre/day, though most Canadians are consuming about half that requirement.

Some people find fibre to improve their symptoms of constipation, yet others find fibre tends to irritate their symptoms during a flare. If you have concerns or questions about your fibre intake, consult your Physician or Registered Dietitian.

Protein

During a flare-up, protein needs are higher. Increase protein intake at meals, and with snacks, including meat, fish, poultry, soy and soy products like tofu, dairy and fortified non-dairy milk, yogurt and cheese, plain nuts and seeds and nut and seed butters.

Typical portion servings are about the size of a regular deck of playing cards, 2 tablespoons of nut butter, ¼ cup of plain nuts or 2 eggs.

Fats

Adults should consume 2-3 tablespoons of healthy fats in cooking and in foods throughout the day. Unsaturated fats like olive oil, avocado oil, omega-3 found in fatty fish like salmon, sardines, trout as well as plain nuts are all healthy choices.

Vitamin and Minerals

Some common nutrients of concern for adults with IBD, and select food sources containing the nutrients:

  • Iron: red meat, fish, dark leafy vegetables, iron-fortified cereals
  • Calcium: dairy products, almond and nut beverages, dark green vegetables, fortified soy
  • Folic acid: fortified pasta, flour and noodles and dark green vegetables
  • Niacin: meat, poultry, whole grains, enriched grains, milk
  • Selenium: eggs, fish, poultry, pasta, nuts
  • Zinc: shellfish, nuts, eggs, dairy products, poultry
  • Vitamin B12: beef, fish, eggs, shellfish
  • Vitamin C: strawberries, lemons, lime, orange, red pepper, mango
  • Vitamin D: milk, fortified soy beverages and milk alternatives, salmon, fatty fish, margarine
  • Vitamin K: leafy greens, asparagus, soybeans, broccoli

Source: Dietitians of Canada. 2019. PEN. Inflammatory Bowel Disease in Adults.

Certain medications (methotrexate and sulphasalazine) can increase the need for folic acid supplements.

Some individuals have increased nutrients needs, including calcium, iron, and vitamin D. Discuss your specific needs, including potential benefits of vitamin supplements with your Physician or Registered Dietitian. Regular screening for iron deficiency anemia may be advised.

Dealing with Flare-up Symptoms

Diarrhea

  • Rehydrate with plenty of fluids to replace losses. Consume 2 – 2.5 litres of fluid/day, including water, broth, sports beverages, diluted juices and weak tea.
  • Avoid sugary sweet drinks, alcohol and caffeine-containing beverages like coffee, tea, colas, and chocolate beverages. 
  • Limit or avoid foods high in fat, high in fibre foods, and those containing lots of sugar.
  • Your Physician may recommend rehydration solutions.

Gas and distension

  • Limit foods that typically cause gas, avoid fried and spicy foods, beer and carbonated beverages, beans, peas, lentils, broccoli, cabbage, cauliflower, mushrooms, onions and whole-grain products.
  • To limit gulping down extra air, avoid using a straw to drink liquids, talking while eating and chewing gum.
  • Chew your food well.

You could temporarily remove one food from your diet at a time to see if your gas symptoms improve.

If you find some dairy products cause gas and bloating, it could be due to lactose. Some people, particularly during a flare-up, may become intolerant to lactose, the sugar in dairy products. A lactose-free diet may help to alleviate symptoms. Look for lactose on food labels and buy lactose-free dairy products. The lactose intolerance may be temporary. Some of the symptoms of lactose-intolerance are like a flare-up, so before altering your diet, discuss your symptoms with your Physician.

Do you need to avoid any food groups, gluten or lactose?

Unless you have symptoms to specific foods, do not remove them from your diet. Everyone is different, and what causes issues for one person may not have the same reaction for others. If you remove foods from the diet, make sure to check your tolerance to these foods from time to time, as symptoms can vary over time. Also, restricting foods can lead to extensive lists of foods excluded from the diet, which can increase the risk of nutrient deficiencies.

Low FODMAP diet

If a low FODMAP diet is advised by your Physician, consult with a Registered Dietitian who has expertise with the diet. This diet is meant to only be temporary for just a few weeks, then foods are added back into the diet systematically to expand nutritional intake. Following the low FODMAP diet for longer than a few weeks can have negative effects on the body. The FODMAPs are food for the microbes that reside in your intestine and provide health benefits. Staying on this diet can have negative effects on your microbiome (microbes). The low FODMAP diet may be effective in helping you, and your Registered Dietitian determine what foods potentially trigger your symptoms.

Mediterranean Diet

The Mediterranean diet is rich in plenty of vegetables and fruit, cereal, nuts, legumes, fish, olive oil, and low in saturated fat, meat and sweets. A 2020 study of patients with Crohn’s disease and ulcerative colitis on the Mediterranean diet for 6 months found a significant reduction in malnutrition parameters, body mass index, clinical disease activity, reduced inflammation, improved gut microbiota balance, and improved quality of life. The researchers reported that the Mediterranean diet is effective for IBD patients as part of a multidimensional approach.

Paleolithic Diet

No clinical trials have been reported on this diet with IBD patients.

Tempted to trial an exclusion diet?

Eliminating various foods and nutrients from the diet should be done in consultation with your Physician and Registered Dietitian. Removing foods from your diet can increase the risk of malnutrition, weight loss and nutrient deficiencies.

Probiotic supplements

Probiotics have received increasing attention from patients and researchers. Probiotics are defined by WHO as “live microorganisms that, when administered in adequate amounts, confer a health benefit on the host”. However, the data are limited with respect to their efficacy for Crohn’s disease. The Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn’s Disease notes that individual probiotics may prove useful, and further study is warranted.

World Gastroenterology Organisation Global Guidelines, 2017 provided the following recommendations for probiotics, which included specific probiotic strains and dosages.

Pouchitis

“There is good evidence for the use of certain probiotics in preventing an initial attack of pouchitis, and in preventing further relapse of pouchitis after the induction of remission with antibiotics. Probiotics can be recommended to patients with pouchitis of mild activity, or as maintenance therapy for those in remission”.

Ulcerative colitis

“Certain probiotics are safe and as effective as conventional therapy in achieving higher response and remission rates in mild to moderately active ulcerative colitis in both adult and pediatric populations”.

Crohn’s disease

“Studies of probiotics in Crohn’s disease have indicated that there is no evidence to suggest that probiotics are beneficial for the maintenance of remission of Crohn’s disease”.

Specific probiotic recommendations for IBD-C and IBD-UC are available in the Clinical Guide to Probiotics Available in Canada, 2020.

Prebiotics

A prebiotic is defined as “a substrate that is selectively utilized by host microorganisms conferring a health benefit”. Prebiotics are frequently thought of as fibre, though not all fibres are prebiotic. Commonly known prebiotics are resistant starch, inulin, galactooligosaccharides (GOS), fructooligosaccharides (FOS), mannooligosaccharides (MOS) and xylooligosaccharides (XOS).

Small-scale prebiotic studies have been conducted, though further larger-scale trials are currently being planned.

Dietitians of Canada PEN Inflammatory Bowel Disease Practice Guidance Toolkit, 2020 recommends additional prebiotic and probiotic research with studies with larger numbers of participants targeting specific disease states (active, in remission and with IBS-like symptoms.

Additional Resources

Dietitians of Canada.

Provincial Call Centres with access to speak to a Registered Dietitian free of charge:

  • B.C. (8-1-1)                                                                        
    • Alberta (811)
    • Manitoba (1-877-830-2892) or (204-788-8248)              
    • Saskatchewan (1-833-966-5541) M-R, 10 – 4 pm CST
    • Ontario (Telehealth Ontario) (1-866-797-0000)
    • Newfoundland and Labrador (8-1-1)

Canada’s Food Guide

       Includes tips, recipes, meal and snack suggestions for healthy eating

Nutrition information, recipes, menus

Healthy Recipes


Information written by Sandra Saville, RD

Diet & Lifestyle Changes for Inflammatory Bowel Disease (IBD)

Date Written: 09-2020

*This information is intended for educational purposes and is not intended to replace recommendations that have been provided by your Physician and Health Care Team.

Healthy eating objectives for IBD include managing symptoms, ensuring and optimizing adequate intake, promoting healing, reducing complications and meeting other relevant personal needs.

There is no miracle cure for Crohn’s and ulcerative colitis, through a special diet, food combinations, or exclusions of select foods or nutrients. Individuals with IBD, including Crohn’s disease and ulcerative colitis may feel well, or ill during a flare-up, leading to variations in appetite and nutritional intake depending on the state of their IBD.

During a flare-up and even when feeling well, it is important to be well-nourished to support healing, build strength, reduce inflammation and optimize nutritional intake. If you feel ill during a flare-up, making effective changes to diet may potentially help you to manage symptoms.

You may find some improvements or worsening in your symptoms based on certain foods. Keep a diary, it is worth tracking food intake to try and determine possible symptom triggers. However, it is important to assess whether other factors like stress, hormones, level of sleep and physical activity contribute to worsening of symptoms rather than merely foods as the cause.

Take the time to track your symptoms in the CDHF app that can help you and your doctor see patterns in your activities and identify specific triggers for your symptoms.

Canada’s Food Guide is a tool that can be used to guide your meal and snack choices. Consuming a variety of vegetables and fruits, whole grains, lean meat and protein choices provides a range of vitamins and minerals that you need daily.

Aim to fill half the plate with a variety of vegetables and fruit, fill one-quarter of the plate with healthy whole grains like bread, unsweetened cereals, pasta, rice and quinoa. Fill the remaining quarter of the plate with protein, including lean meat, poultry, fish, eggs, soy, dairy and non-dairy fortified milk, yogurt and cheese.

If your appetite is low, consume small frequent meals and snacks to consume adequate intake and prevent malnutrition.

Consume adequate amounts of fluid intake to move wastes through your system and prevent dehydration.

Flare-up Suggestions

  • Follow the advice of your Physician and Health care team during a flare-up.
  • Aim to consume a healthy diet.
  • Restrict only the foods that make you feel worse.
  • Do not try to limit intake to “rest your intestines”, as starvation provides an added stress to the body.

If your diet intake is inadequate due to poor appetite, reduced intake, or malabsorption and difficulty meeting nutritional needs, discuss strategies with your Physician and Registered Dietitian. Consuming small frequent meals and snacks, high-calorie foods, or supplements like Ensure or Boost may be beneficial.

Fibre

Daily fibre intake and goals should be discussed with your Physician, especially for those with Crohn’s disease with strictures and at risk of a bowel obstruction. 

Dietitian’s of Canada PEN Inflammatory Bowel Disease Practice Guidance Toolkit, 2020, does not recommend a high fibre nor a low fibre diet to help manage Crohn’s disease, either active or in remission, so it is best to maintain normal fibre intake.

Health Canada recommends Canadian women consume 25 grams of fibre/day and men consume 38 grams of fibre/day, though most Canadians are consuming about half that requirement.

Some people find fibre to improve their symptoms of constipation, yet others find fibre tends to irritate their symptoms during a flare. If you have concerns or questions about your fibre intake, consult your Physician or Registered Dietitian.

Protein

During a flare-up, protein needs are higher. Increase protein intake at meals, and with snacks, including meat, fish, poultry, soy and soy products like tofu, dairy and fortified non-dairy milk, yogurt and cheese, plain nuts and seeds and nut and seed butters.

Typical portion servings are about the size of a regular deck of playing cards, 2 tablespoons of nut butter, ¼ cup of plain nuts or 2 eggs.

Fats

Adults should consume 2-3 tablespoons of healthy fats in cooking and in foods throughout the day. Unsaturated fats like olive oil, avocado oil, omega-3 found in fatty fish like salmon, sardines, trout as well as plain nuts are all healthy choices.

Vitamin and Minerals

Some common nutrients of concern for adults with IBD, and select food sources containing the nutrients:

  • Iron: red meat, fish, dark leafy vegetables, iron-fortified cereals
  • Calcium: dairy products, almond and nut beverages, dark green vegetables, fortified soy
  • Folic acid: fortified pasta, flour and noodles and dark green vegetables
  • Niacin: meat, poultry, whole grains, enriched grains, milk
  • Selenium: eggs, fish, poultry, pasta, nuts
  • Zinc: shellfish, nuts, eggs, dairy products, poultry
  • Vitamin B12: beef, fish, eggs, shellfish
  • Vitamin C: strawberries, lemons, lime, orange, red pepper, mango
  • Vitamin D: milk, fortified soy beverages and milk alternatives, salmon, fatty fish, margarine
  • Vitamin K: leafy greens, asparagus, soybeans, broccoli

Source: Dietitians of Canada. 2019. PEN. Inflammatory Bowel Disease in Adults.

Certain medications (methotrexate and sulphasalazine) can increase the need for folic acid supplements.

Some individuals have increased nutrients needs, including calcium, iron, and vitamin D. Discuss your specific needs, including potential benefits of vitamin supplements with your Physician or Registered Dietitian. Regular screening for iron deficiency anemia may be advised.

Dealing with Flare-up Symptoms

Diarrhea

  • Rehydrate with plenty of fluids to replace losses. Consume 2 – 2.5 litres of fluid/day, including water, broth, sports beverages, diluted juices and weak tea.
  • Avoid sugary sweet drinks, alcohol and caffeine-containing beverages like coffee, tea, colas, and chocolate beverages. 
  • Limit or avoid foods high in fat, high in fibre foods, and those containing lots of sugar.
  • Your Physician may recommend rehydration solutions.

Gas and distension

  • Limit foods that typically cause gas, avoid fried and spicy foods, beer and carbonated beverages, beans, peas, lentils, broccoli, cabbage, cauliflower, mushrooms, onions and whole-grain products.
  • To limit gulping down extra air, avoid using a straw to drink liquids, talking while eating and chewing gum.
  • Chew your food well.

You could temporarily remove one food from your diet at a time to see if your gas symptoms improve.

If you find some dairy products cause gas and bloating, it could be due to lactose. Some people, particularly during a flare-up, may become intolerant to lactose, the sugar in dairy products. A lactose-free diet may help to alleviate symptoms. Look for lactose on food labels and buy lactose-free dairy products. The lactose intolerance may be temporary. Some of the symptoms of lactose-intolerance are like a flare-up, so before altering your diet, discuss your symptoms with your Physician.

Do you need to avoid any food groups, gluten or lactose?

Unless you have symptoms to specific foods, do not remove them from your diet. Everyone is different, and what causes issues for one person may not have the same reaction for others. If you remove foods from the diet, make sure to check your tolerance to these foods from time to time, as symptoms can vary over time. Also, restricting foods can lead to extensive lists of foods excluded from the diet, which can increase the risk of nutrient deficiencies.

Low FODMAP diet

If a low FODMAP diet is advised by your Physician, consult with a Registered Dietitian who has expertise with the diet. This diet is meant to only be temporary for just a few weeks, then foods are added back into the diet systematically to expand nutritional intake. Following the low FODMAP diet for longer than a few weeks can have negative effects on the body. The FODMAPs are food for the microbes that reside in your intestine and provide health benefits. Staying on this diet can have negative effects on your microbiome (microbes). The low FODMAP diet may be effective in helping you, and your Registered Dietitian determine what foods potentially trigger your symptoms.

Mediterranean Diet

The Mediterranean diet is rich in plenty of vegetables and fruit, cereal, nuts, legumes, fish, olive oil, and low in saturated fat, meat and sweets. A 2020 study of patients with Crohn’s disease and ulcerative colitis on the Mediterranean diet for 6 months found a significant reduction in malnutrition parameters, body mass index, clinical disease activity, reduced inflammation, improved gut microbiota balance, and improved quality of life. The researchers reported that the Mediterranean diet is effective for IBD patients as part of a multidimensional approach.

Paleolithic Diet

No clinical trials have been reported on this diet with IBD patients.

Tempted to trial an exclusion diet?

Eliminating various foods and nutrients from the diet should be done in consultation with your Physician and Registered Dietitian. Removing foods from your diet can increase the risk of malnutrition, weight loss and nutrient deficiencies.

Probiotic supplements

Probiotics have received increasing attention from patients and researchers. Probiotics are defined by WHO as “live microorganisms that, when administered in adequate amounts, confer a health benefit on the host”. However, the data are limited with respect to their efficacy for Crohn’s disease. The Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn’s Disease notes that individual probiotics may prove useful, and further study is warranted.

World Gastroenterology Organisation Global Guidelines, 2017 provided the following recommendations for probiotics, which included specific probiotic strains and dosages.

Pouchitis

“There is good evidence for the use of certain probiotics in preventing an initial attack of pouchitis, and in preventing further relapse of pouchitis after the induction of remission with antibiotics. Probiotics can be recommended to patients with pouchitis of mild activity, or as maintenance therapy for those in remission”.

Ulcerative colitis

“Certain probiotics are safe and as effective as conventional therapy in achieving higher response and remission rates in mild to moderately active ulcerative colitis in both adult and pediatric populations”.

Crohn’s disease

“Studies of probiotics in Crohn’s disease have indicated that there is no evidence to suggest that probiotics are beneficial for the maintenance of remission of Crohn’s disease”.

Specific probiotic recommendations for IBD-C and IBD-UC are available in the Clinical Guide to Probiotics Available in Canada, 2020.

Prebiotics

A prebiotic is defined as “a substrate that is selectively utilized by host microorganisms conferring a health benefit”. Prebiotics are frequently thought of as fibre, though not all fibres are prebiotic. Commonly known prebiotics are resistant starch, inulin, galactooligosaccharides (GOS), fructooligosaccharides (FOS), mannooligosaccharides (MOS) and xylooligosaccharides (XOS).

Small-scale prebiotic studies have been conducted, though further larger-scale trials are currently being planned.

Dietitians of Canada PEN Inflammatory Bowel Disease Practice Guidance Toolkit, 2020 recommends additional prebiotic and probiotic research with studies with larger numbers of participants targeting specific disease states (active, in remission and with IBS-like symptoms.

Additional Resources

Dietitians of Canada.

Provincial Call Centres with access to speak to a Registered Dietitian free of charge:

  • B.C. (8-1-1)                                                                        
    • Alberta (811)
    • Manitoba (1-877-830-2892) or (204-788-8248)              
    • Saskatchewan (1-833-966-5541) M-R, 10 – 4 pm CST
    • Ontario (Telehealth Ontario) (1-866-797-0000)
    • Newfoundland and Labrador (8-1-1)

Canada’s Food Guide

       Includes tips, recipes, meal and snack suggestions for healthy eating

Nutrition information, recipes, menus

Healthy Recipes


Information written by Sandra Saville, RD