Inflammatory bowel diseases (IBD) is a generic name for a group of chronic, recurring, immune-based disorders of the gastrointestinal tract.  Or, in more simple terms, these gut-based diseases are lifelong conditions that have periods of ‘active’ and ‘inactive’ disease and the immune system plays a central role.  During ‘active’ phases of the disease people experience increased symptoms including pain, changes in bowel habits and, may potentially, have an increase risk of weight loss.  

IBD affects the gastrointestinal (GI) tract, which is a long continuous tube starting at the mouth and ending at the anus and is often referred to as ‘the gut’. The GI tract or gut is made up of different sections and certain sections, for example the small intestine and the colon, are more commonly affected by IBD.  The GI tract plays an important role in the digestion and breakdown of food as well as other important functions.  Because IBD affects the GI tract, nutrition can play a key role in the management of the conditions but nutrition can also be affected by the diseases.  A healthy, balanced diet is important, but more on this later.  

Types of IBD

There are two main types of IBD: 

1. Crohn’s disease is characterized by patchy inflammation which can occur anywhere along the GI tract.  The most common site for Crohn’s disease is the small intestine followed by the colon.  The main symptoms associated with Crohn’s disease, particularly during an ‘active’ episode include pain?, diarrhoea?, weight loss which can potentially increase the risk of malnutrition in some patients.  ?
2. Ulcerative colitis is the second type of IBD and, in contrast to Crohn’s disease, it only affects one part of the GI tract, the colon, which is commonly known as the large intestine.  A common symptom of ulcerative colitis is bloody diarrhoea but other symptoms can occur.  

The number of people diagnosed with IBD throughout the world is increasing.  A recent scientific study from scientists in China, Canada and the UK looked at the prevalence of IBD (how common it is) and they found that there are a growing number of people being diagnosed with IBD but it varies depending on geography and, interestingly, how developed the country is.  IBD was previously more common in Europe and North America but the study reported that people in newly industrialised countries such as Africa, Asia, and South America are increasingly being diagnosed with IBD.  There is little data available on how common IBD is in Ireland but it is estimated that there are approximately over 40,000 people with a diagnosis of IBD in Ireland ¹.

Despite much research in the area, the simple answer is we do not fully understand what causes IBD.  What we do know is that genetics play a role but it is not all down to genetics.  People with a particular set of genes may be more likely to develop IBD.  Scientific research also suggests that interactions between genetics, the environment or environmental factors, microbial agents, and the immune system all contribute to the development of IBD.  But more research is needed and, fortunately, is underway.

Nutrition and IBD

Given the nature of IBD and the impact it has on the GI tract (gut),  it is not surprising that nutrition is a hot topic for people with IBD.  Everything we eat and drink passes through the GI tract, we absorb nutrients and water from the GI tract so conditions which affect the gut, can impact on nutrition and vice versa.  Nutrition can be affected by IBD, particularly during active episodes, and nutrition can play a role in the management of IBD.  Scientific studies tell us that people with IBD often change their diets; for example, two thirds of people with IBD restrict their dietary intake, omitting certain foods or food groups, which can, in some instances, lead to an increased risk of weight loss and, potentially, malnutrition. 

Malnutrition and IBD have been consistently linked together. Research has found that malnutrition can affect up to 85% of people with IBD.  Reasons for this include reduced oral intake particularly during active periods of disease.  This can be due to many factors such as decreased hunger, self-imposed food restrictions and reduced pleasure associated with food Other reasons also include altered nutrient absorption which means food is no longer absorbed as effectively because of the inflammation along the GI tract due to the conditions. Altered bowel motions can result in an increase in stool output which results in nutrients from food being inadequately absorbed. In instances where malnutrition arises, there can, in some people, be an increased risk of other conditions such as osteoporosis and a reduced quality of life. A well balanced diet can help reduce the risk of malnutrition as well as vitamin and mineral deficiencies which have been reported in some people with IBD. 

As mentioned, it is important to note that this article is focused on general dietary advice and is not meant to replace tailored nutrition advice specific to an individual.  For such tailored advice should be provided by a suitably qualified healthcare professional such as a dietitian or general practitioner.  This is particularly important during an 'active' period.  What we will focus on is general healthy eating advice for optimum health and wellbeing during remission of IBD.  In our work with ISCC we recently run a focus group with people living with IBD.  During the focus group we gathered questions about nutrition and this article will respond to the questions raised.

Despite much research in the area, the simple answer is we do not fully understand what causes IBD.  What we do know is that genetics play a role but it is not all down to genetics.  People with a particular set of genes may be more likely to develop IBD.  Scientific research also suggests that interactions between genetics, the environment or environmental factors, microbial agents, and the immune system all contribute to the development of IBD.  But more research is needed and, fortunately, is underway.

Nutrition and IBD

Given the nature of IBD and the impact it has on the GI tract (gut),  it is not surprising that nutrition is a hot topic for people with IBD.  Everything we eat and drink passes through the GI tract, we absorb nutrients and water from the GI tract so conditions which affect the gut, can impact on nutrition and vice versa.  Nutrition can be affected by IBD, particularly during active episodes, and nutrition can play a role in the management of IBD.  Scientific studies tell us that people with IBD often change their diets; for example, two thirds of people with IBD restrict their dietary intake, omitting certain foods or food groups, which can, in some instances, lead to an increased risk of weight loss and, potentially, malnutrition. 

Malnutrition and IBD have been consistently linked together. Research has found that malnutrition can affect up to 85% of people with IBD.  Reasons for this include reduced oral intake particularly during active periods of disease.  This can be due to many factors such as decreased hunger, self-imposed food restrictions and reduced pleasure associated with food Other reasons also include altered nutrient absorption which means food is no longer absorbed as effectively because of the inflammation along the GI tract due to the conditions. Altered bowel motions can result in an increase in stool output which results in nutrients from food being inadequately absorbed. In instances where malnutrition arises, there can, in some people, be an increased risk of other conditions such as osteoporosis and a reduced quality of life. A well balanced diet can help reduce the risk of malnutrition as well as vitamin and mineral deficiencies which have been reported in some people with IBD. 

As mentioned, it is important to note that this article is focused on general dietary advice and is not meant to replace tailored nutrition advice specific to an individual.  For such tailored advice should be provided by a suitably qualified healthcare professional such as a dietitian or general practitioner.  This is particularly important during an 'active' period.  What we will focus on is general healthy eating advice for optimum health and wellbeing during remission of IBD.  In our work with ISCC we recently run a focus group with people living with IBD.  During the focus group we gathered questions about nutrition and this article will respond to the questions raised.

Food has been implicated in the development of IBD although research is limited on the extent and relationship between food and IBD. What we do know is that as countries move away from more traditional diets to, what is known as a 'Westernised diet' these countries see the rates of IBD increase. Compared to a more traditional diets which are predominately  plant based, there has been a shift in recent years to a Westernised diet which is high in calories, fat and sugar, soft drinks and food additives along with processed food items such as processed meats which are high in saturated fat and preservatives 2. From these findings it is recommended that heavily processed food items high in saturated fat and preservatives are reduced.

It is important to remember that each individual is unique and no one food or nutritional component has been consistently found to trigger IBD symptoms. However, alcohol, caffeinated drinks e.g. tea and coffee, spicy foods, foods high in fat or fried food can potentially trigger gut symptoms in some people so limiting or removing these items may be advisable.  It may be helpful to keep a dietary and symptom diary to identify foods that cause or worsen symptoms 2 .

Promoting Health: The importance of diet

Good nutrition is not only important in the context of IBD but it is also vital for overall health and well-being. A growing body of scientific research has examined the relationship between an individual’s eating pattern and their risk of developing chronic disease including diabetes and heart disease 3. This research has found a consistent link between what and how a person eats and their overall health and wellbeing. The focus of this article is to provide you with healthy eating advice not only surrounding IBD but also nutritional guidance that will promote overall health.  It is not intended to replace tailored dietary advice provided to individual patients nor is it specific to active episodes of IBD where more tailored advice may be required.  So, eating for health and wellbeing, let’s find out what this means. 

There is so much information on what a healthy diet is and in today's social media world there are often mixed messages about what healthy eating actually entails. A healthy balanced diet is recommended for those with, and without, IBD. So what exactly is a healthy balanced diet? A healthy balanced diet is one that provides adequate nutrition to maintain health and wellbeing. Recommendations from science and public health policies suggest that a diet should reflect the key nutrients which include protein, fat and carbohydrates. Protein is important for maintaining muscle, growth and repair and is essential for the immune system. Key sources include fish, meat, legumes such as beans and lentils along with nuts and cheese. 

The second major nutrient group is fat.  Fats are a major energy source for the body but also provide an essential structural component in our cell membrane. Despite these essential functions fats are often described in the media as being ‘bad for us’ but this is not the complete story. Fats derived from animal products such as red meats, fatty and or processed meats as well as full fat milk and cheese are generally considered to be ‘bad fats’, or more scientifically, saturated fats.  Saturated fats are associated with increased cholesterol which can lead to heart disease.  Good fats, otherwise known as, unsaturated fats, are derived from plant based sources such as olive oil, rapeseed oil, avocados, nuts, and have lots of health promoting properties.  For example, scientific studies have shown they play a role in protection against heart disease.  When considering a healthy balanced diet, the recommendations are to choose unsaturated or plant-based oils and fats (e.g. olive oil, plant oil butter alternatives) rather than animal-based fats (e.g. butter lards and processed meats).  

Lastly, carbohydrates are the third main nutrient group and are an important source of energy and B-vitamins in the diet.  Carbohydrates are largely derived from grains so common sources in the diet include bread, pasta, cereals as well as potatoes.  Refined grains such as white pasta, white bread have a lower fibre content than whole-grain or wholemeal versions, so if tolerated, whole-grain or wholemeal options are recommended due to the higher fibre levels.  However, fibre can be an issue for people with IBD so it is important to keep an eye on symptoms to see if you can tolerate the higher fibre alternatives.  Now that we have discussed the common food groups, let’s consider how we can achieve a healthy balanced diet to promote health and wellbeing.

There is no magic trick when it comes to achieving a healthy diet but the good news is that the Irish healthy eating guidelines offer support to achieve a healthy diet.  These healthy eating guidelines are illustrated in the Food Pyramid below and further information can be obtained from the Food Safety Authority of Ireland. The Food Pyramid describes the foods needed for a healthy body and for protection against disease.  It also provides guidance on the types and amounts of food and drinks needed for optimum health.

The Food Pyramid is made up of six levels representing different food groups, only five of these levels are required as part of a healthy balanced diet. The levels are grouped together according to foods containing similar nutrients. The shape of the food pyramid indicates how much of each food a person needs to eat starting at the base of the pyramid 3. 

At the base of the pyramid are fruits and vegetables.  For a healthy balanced diet, a minimum of five portions of fruit and vegetables should be consumed daily along with a variety of different vibrant colours.  Fruits, vegetables and salads are rich in protective nutrients as they contain lots of vitamins and minerals, they are also rich sources of fibre. One portion from this food tier is equal to a whole piece of a medium sized fruit e.g. 1 apple, if the fruit is smaller for example a mandarin orange or kiwi one portion is the same as two of these,  or 1 large slice of melon or pineapple, with vegetables one portion is roughly half a cup of vegetables. 

The next level on the pyramid contains the wholemeal cereal breads, potatoes, pasta and rice tier. Between 3-5 portions of these foods are recommended for a healthy diet but this can be increase depending on activity levels. For example, in very active males aged between 19-50 years  5-7 portions from this tier may be required. One portion from this food group is the equivalent to half a cup of dried porridge oats or muesli, 2 slices of wholemeal bread, 1 medium potato or 1 cup of cooked pasta or rice.  Wholegrain and wholemeal options are recommended but, as previously mentioned, in people with IBD, the higher fibre content may be problematic.  If you are unable to tolerate whole grain options, try wholemeal options and if issues persist you may need to try white-options e.g. white bread, white rice. Track your symptoms using a dietary diary available on the ISCC website. 

Next on the pyramid is the milk yoghurt cheese level.  This level represents food/drinks high in calcium which is important for bone health. Guidelines recommend 3 servings per day.  A  serving being equivalent to one disposable water cup of milk, a pot of yoghurt or a small match-box size of cheese. Low fat options are recommended as they contain just as much calcium but are lower in saturated fat.  Yoghurts with seeds or grains add an extra boost of fibre but again should be consumed as tolerated in people with IBD. 

The meat, poultry, fish, eggs, beans and nuts group on the pyramid is defined by the protein content and two servings per day is recommended.  One serving of meat or fish  is approximately the width and depth of an individual  palm, 2 eggs, or three quarters of a cup of beans, peas or lentils. Unprocessed lean cuts of meat are an excellent source of protein and also provide the richest source of iron available. This is because the iron found in red meat is also known as haem iron which is easily absorbed in the body so people experiencing anaemia (low iron, which can occur in IBD) may benefit from red meat. Guidelines recommend red meat such as beef two to three times a week.  Chicken and turkey have a lower level of available iron but are good sources of lean protein and are lower in saturated fat. Two to three portions per a week is recommended.  Fish is another important source of protein and oily fish which  is a great source of vitamin D, important for bone health and oily fish are a great source of unsaturated fats which can protect against heart disease. One portion of oily fish (e.g. mackerel, salmon) is recommended weekly along with a portion of white fish (e.g. cod, haddock). Plant-based foods often contain lower levels of protein but are increasing in popularity and include tofu, soy-based products, lentils, beans, chickpeas and nuts.  Plant-based protein sources can also contain iron but it is in a form that is more difficult for the body to absorb. Vitamin C helps to increase the absorption of non-haem iron so a practical tip is to consume plant-based protein with vitamin C-rich foods e.g. orange juice and green leafy vegetables. Eggs and nuts are also sources of protein and can be included as part of a healthy balanced diet. 

Fats spreads and oils should be used sparingly. Lower fat options are a practical alternative and cooking methods such as baking and steaming foods instead of frying are practical and easy switches to make.  Also, choosing healthier plant based fats such as rapeseed or olive oil rather than animal fats such as butter and lard is another step one can include in a healthy balanced diet. 
 
The top tier of the food pyramid is made up of foods and drinks high in fat, sugar and salt which are not required as part of a healthy balanced diet. These foods and drink are often what we consider ‘treat items’ and, as the name suggests, should be consumed sparingly and not part of daily eating habits.  Foods and drinks for this level of the pyramid are generally high in calories, fat particularly saturated (bad) fat, sugar and salt, all the nutrients linked to poor health outcomes such as obesity and high blood pressure.  

Regarding fluid intake, it is important that we include adequate fluid intake to maintain hydration.  Two litres of fluids daily, preferably water, is recommended to prevent dehydration but, depending on activity levels more may be required. Alcohol, as mentioned, can cause gut symptoms in people both with and without IBD.  Alcohol should be consumed in line with government recommendations https://alcoholireland.ie/alcohol-and-you/guidelines/ and in those with IBD it is important to consider the impact of intake against gut symptoms.  

To summarise, a healthy balanced diet is important for good health and wellbeing and guidance on how to achieve a healthy balanced diet is supported by the Health Ireland Food Pyramid.  Diversity of the diet is important, both from a nutrition perspective but also from an enjoyment perspective.  A balanced diet includes food and drinks from all the major food groups, when choosing fruits and vegetables think colour, the greater the colour the more nutrients you consume.  Nutrients such as calcium, iron and fibre are important, particularly for people with IBD but consider your foods and drinks carefully – and keeping a dietary diary can help identify items that you tolerate well or not.  A healthy balanced diet is recommended for health and wellbeing but is also allows you to enjoy your food.  

This dietary advice is based on the national guidelines for healthy eating. For further information on the Food Pyramid visit the Food Safety Authority Ireland website Food Safety Authority Ireland Food Pyramid.

The Food Pyramid is made up of six levels representing different food groups, only five of these levels are required as part of a healthy balanced diet. The levels are grouped together according to foods containing similar nutrients. The shape of the food pyramid indicates how much of each food a person needs to eat starting at the base of the pyramid 3. 

At the base of the pyramid are fruits and vegetables.  For a healthy balanced diet, a minimum of five portions of fruit and vegetables should be consumed daily along with a variety of different vibrant colours.  Fruits, vegetables and salads are rich in protective nutrients as they contain lots of vitamins and minerals, they are also rich sources of fibre. One portion from this food tier is equal to a whole piece of a medium sized fruit e.g. 1 apple, if the fruit is smaller for example a mandarin orange or kiwi one portion is the same as two of these,  or 1 large slice of melon or pineapple, with vegetables one portion is roughly half a cup of vegetables. 

The next level on the pyramid contains the wholemeal cereal breads, potatoes, pasta and rice tier. Between 3-5 portions of these foods are recommended for a healthy diet but this can be increase depending on activity levels. For example, in very active males aged between 19-50 years  5-7 portions from this tier may be required. One portion from this food group is the equivalent to half a cup of dried porridge oats or muesli, 2 slices of wholemeal bread, 1 medium potato or 1 cup of cooked pasta or rice.  Wholegrain and wholemeal options are recommended but, as previously mentioned, in people with IBD, the higher fibre content may be problematic.  If you are unable to tolerate whole grain options, try wholemeal options and if issues persist you may need to try white-options e.g. white bread, white rice. Track your symptoms using a dietary diary available on the ISCC website. 

Next on the pyramid is the milk yoghurt cheese level.  This level represents food/drinks high in calcium which is important for bone health. Guidelines recommend 3 servings per day.  A  serving being equivalent to one disposable water cup of milk, a pot of yoghurt or a small match-box size of cheese. Low fat options are recommended as they contain just as much calcium but are lower in saturated fat.  Yoghurts with seeds or grains add an extra boost of fibre but again should be consumed as tolerated in people with IBD. 

The meat, poultry, fish, eggs, beans and nuts group on the pyramid is defined by the protein content and two servings per day is recommended.  One serving of meat or fish  is approximately the width and depth of an individual  palm, 2 eggs, or three quarters of a cup of beans, peas or lentils. Unprocessed lean cuts of meat are an excellent source of protein and also provide the richest source of iron available. This is because the iron found in red meat is also known as haem iron which is easily absorbed in the body so people experiencing anaemia (low iron, which can occur in IBD) may benefit from red meat. Guidelines recommend red meat such as beef two to three times a week.  Chicken and turkey have a lower level of available iron but are good sources of lean protein and are lower in saturated fat. Two to three portions per a week is recommended.  Fish is another important source of protein and oily fish which  is a great source of vitamin D, important for bone health and oily fish are a great source of unsaturated fats which can protect against heart disease. One portion of oily fish (e.g. mackerel, salmon) is recommended weekly along with a portion of white fish (e.g. cod, haddock). Plant-based foods often contain lower levels of protein but are increasing in popularity and include tofu, soy-based products, lentils, beans, chickpeas and nuts.  Plant-based protein sources can also contain iron but it is in a form that is more difficult for the body to absorb. Vitamin C helps to increase the absorption of non-haem iron so a practical tip is to consume plant-based protein with vitamin C-rich foods e.g. orange juice and green leafy vegetables. Eggs and nuts are also sources of protein and can be included as part of a healthy balanced diet. 

Fats spreads and oils should be used sparingly. Lower fat options are a practical alternative and cooking methods such as baking and steaming foods instead of frying are practical and easy switches to make.  Also, choosing healthier plant based fats such as rapeseed or olive oil rather than animal fats such as butter and lard is another step one can include in a healthy balanced diet. 
 
The top tier of the food pyramid is made up of foods and drinks high in fat, sugar and salt which are not required as part of a healthy balanced diet. These foods and drink are often what we consider ‘treat items’ and, as the name suggests, should be consumed sparingly and not part of daily eating habits.  Foods and drinks for this level of the pyramid are generally high in calories, fat particularly saturated (bad) fat, sugar and salt, all the nutrients linked to poor health outcomes such as obesity and high blood pressure.  

Regarding fluid intake, it is important that we include adequate fluid intake to maintain hydration.  Two litres of fluids daily, preferably water, is recommended to prevent dehydration but, depending on activity levels more may be required. Alcohol, as mentioned, can cause gut symptoms in people both with and without IBD.  Alcohol should be consumed in line with government recommendations https://alcoholireland.ie/alcohol-and-you/guidelines/ and in those with IBD it is important to consider the impact of intake against gut symptoms.  

To summarise, a healthy balanced diet is important for good health and wellbeing and guidance on how to achieve a healthy balanced diet is supported by the Health Ireland Food Pyramid.  Diversity of the diet is important, both from a nutrition perspective but also from an enjoyment perspective.  A balanced diet includes food and drinks from all the major food groups, when choosing fruits and vegetables think colour, the greater the colour the more nutrients you consume.  Nutrients such as calcium, iron and fibre are important, particularly for people with IBD but consider your foods and drinks carefully – and keeping a dietary diary can help identify items that you tolerate well or not.  A healthy balanced diet is recommended for health and wellbeing but is also allows you to enjoy your food.  

This dietary advice is based on the national guidelines for healthy eating. For further information on the Food Pyramid visit the Food Safety Authority Ireland website Food Safety Authority Ireland Food Pyramid.

Fibre is a type of carbohydrate that is neither digested or absorbed in the small intestine but it moves down to the large intestine (the colon) where it is ‘eaten’ (metabolised) by our gut microbiota.  The gut microbiota includes trillions of microbes that live in our gut and play an important role in our health including an important role in our immune system.  

Dietary fibre is usually found in fruits, vegetables, legumes and wholegrains. It can be divided into either insoluble or soluble fibre. Soluble fibre helps to control blood sugar and cholesterol levels it includes foods such as oats, fruits, carrots, beans, lentils and pulses.  Insoluble fibre  is needed to maintain a healthy bowel function, it basically add ‘bulk’ to the stool.  It is found in wholegrains, bran, flaxseed, the skins of fruit and vegetables, nuts and seeds. 

Some individuals with IBD may find fibre can trigger gut symptoms but often is it a particular type of food that causes the symptoms rather than fibre per se.  Dietary fibre is an important source of energy and can help regulate bowel function preventing constipation. If you find it difficult to tolerate fibre rather than eliminating all fibre-containing foods containing try to include more soluble sources of fibre (e.g. oats, apples, carrots, citrus fruits) rather than insoluble fibre.  Other practical ways to increase your fibre intake but possibly reduce symptoms includes removing the skin from vegetables, cooking vegetables well and juicing fruits and vegetables will reduce the insoluble fibre.  Stewing or peeling fruits can also help.  Nuts and seeds, wholegrain breads are packed full of fibre but an individual tolerance of these may vary and you may find it helpful to keep a dietary diary to see which fibre sources you tolerate.  Also, consider the amount, start with small amounts and gradually increase.  Even a little goes a long way.  See the swap system below for some ideas. 

Red Meat and IBD

People with IBD often report that they regularly restrict red meat as it is perceived to worsen gut symptoms. Some studies have associated a high consumption (greater than two portions of red meat per week) with the development of IBD but there is currently no evidence to support the finding that red or processed meats increase the time between remission and active episodes of IBD5 . However, health eating guidelines recommend limiting processed meats and choosing lean sources of red meat twice a week. If you experience worsening gut symptoms with red meat consider reducing the frequency or amount you eat.  Alternatively, consider excluding and choosing lean alternatives such as chicken, fish or plant-based alternatives such as tofu. If you do decide to exclude red meat, do consider including other sources of iron in your diet as red meat is an important source of iron which can be a nutrient of concern in some people with IBD.  Iron-rich alternatives include dark, green leafy vegetables (e.g. spinach), potatoes, string beans, tofu.  

Alcohol – uh oh gut trouble...

Alcohol is known as a gut irritant, especially if consumed in high quantities.  That goes for people with and without IBD.  In people with IBD, alcohol can aggravate symptoms.  Some research has reported that sulphites which are commonly used in the processing of alcohol have been found to exacerbate symptoms in UC. However, there is no definitive evidence to suggest alcohol can trigger symptoms of IBD but consumption should be limited to tolerance.  If you experience a worsening of symptoms, reduce or eliminate.  And in those that can tolerate alcohol, it should be consumed in line with government policy.  

Fruit and Vegetables – Eat the Rainbow

Fruit and vegetables are part of healthy diet. They are low in calories but high in vitamins, minerals and fibre and a huge array of literature has consistently shown that greater intakes of fruit and vegetables are associated with better health outcomes. However, people with IBD often report fruit and vegetables to be problematic and some people can eliminate all fruits and vegetables due to a fear of aggravating symptoms. However, rather than restricting a whole food group, particularly a food groups that offers lots of important nutrients, identifying which fruits and or vegetables that are tolerated is key.  Using a dietary diary can be one way to monitor symptoms response to fruit and vegetables.
 
Other practical tips include:

1. Cooking vegetables well or pureeing vegetables can increase the tolerability of them.  For example, steamed and pureed spinach which can be eaten as part of a meal of included in, for example, an omelette.  Raw vegetables can be more problematic than cooked vegetables in some people. 
2. Avoiding vegetables with a high insoluble fibre content e.g. celery.
3. Choosing fruit and vegetables with greater soluble fibre e.g. carrots, turnips sweet potatoes and parsnips this can help to be minimize GI symptoms. 
4. Peeling fruit and vegetables e.g. peeled apples, pears, peaches.
5. A word about garlic and onions.  These vegetables can sometimes cause gut issues with people without IBD and especially those with a more ‘sensitive gut’.   Tracking and monitoring your intake of garlic and onions and symptoms may be useful.  If you experience symptoms, try reduce the amount or frequency of consumption or remove as needed.  Ultimately, including a variety of different fruit and vegetables whilst avoiding or minimising gut symptoms is key.  Now that we have looked at specific nutrients, let's address some questions that are commonly raised by people with IBD.

In our recent conversation with ISCC members the questions of a specific diet for IBD was raised.  Simply put, there is no specific diet that people with inactive IBD should follow*.  However, there is evidence that a Western style diet, which is typified by higher intakes of processed meats, fast food, high fat intake, and conversely lower intakes of fruits, vegetables, and fibre, is implicated in the development of IBD as well as other conditions including heart disease and cancer.  What we do know from the evidence is that a healthy balanced diet is important for those with and without IBD and a healthy, balanced diet is associated with better health outcomes overall.  Emerging scientific evidence has indicated a Mediterranean diet, which is associated with lots of positive health effects, could be beneficial for people with IBD.  There is emerging evidence for a low FODMAP diet in some patients with IBD. More details on these diets are given below.

*People with an active episode of IBD may be advised by their healthcare professional to follow a particular diet.  The above information is specific to inactive IBD.   

A Mediterranean Diet

A Mediterranean diet is a diet defined as a high intake of plant-based foods, unrefined cereals, fruit, vegetables, legumes, olive oil a moderate to high consumption of fish and dairy products along with a lower consumption a red meats, processed meats and saturated fatty foods such as pastries and foods containing large quantities of sugar. Some research has suggested that a Mediterranean style diet is associated with an improved quality of life and reduced disease activity in Crohn’s Disease and there is lots of evidence to suggest a Mediterranean diet is associated with good health overall.  

Low FODMAP diet 

A Low FODMAP diet is a therapeutic diet typically used in the treatment of irritable bowel syndrome (IBS).   Although a low FODMAP diet is not an established  treatment option for IBD, emerging evidence has shown some promising findings that a low FODMAP diet may help to reduce gut symptoms in people with both IBD and IBS. A low FODMAP diet is a very restrictive diet which should be done in collaboration with a registered dietitian to ensure that your diet is healthy and as varied as possible throughout the process. This restrictive diet is not recommended without dietetic guidance and has the potential to increase the risk of malnutrition and or nutritional inadequacies if undertaken without dietetic support.  For more information, seek advice from a registered dietitian.  It is not recommended that people implement this diet without support from a registered dietitian or healthcare professional.

Vegetarian or plant-based diets

There is currently no compelling evidence in support of a vegetarian diet in IBD.  If you choose to become vegetarian it is important to understand food and identify areas of concern.  In IBD nutrients such as iron, calcium, vitamin D among others can be low.  These nutrients can also be low in vegetarian and particularly vegan diets so it is important to carefully consider the adequacy of a vegetarian or vegan diet.  If you are considering removing meat from your diet  consider substituting meat or meat products with plant-based protein alternatives such as beans, lentils, chickpeas, tofu, soya alternatives and nuts. 

Iron rich sources should also be included and can include lentils beans, peas, dark green leafy vegetables such as spinach, cabbage and broccoli, dried fruits such as figs, apricots, raisins eggs, and cereals fortified with iron . 

The amount of calcium and vitamin D in plant sources is not as readily available when compared to animal sources,  so choosing fortified milk and calcium set tofu to increase the calcium content of your diet and fortified  cereals containing vitamin D can help rich the calcium and vitamin D targets.  If you think your diet may be lacking in these nutrients, a multi-vitamin can be considered to supplement.  

Meal Patterns and Portions

Large meals can cause gut symptoms in many people, both with and without IBD.  A practical strategy to minimise symptoms can be tracking your meal patterns and portion sizes.  People with IBD may find that reducing the size of meals and having smaller but more frequent meals can be helpful in terms of managing symptoms.  

Exploring the relationship between the timing of meals and symptoms can also be worth considering.  Whilst there is a lack of research on the impact of meal timings and IBD symptoms some patients find it helpful to change the timing of their meals.  For instance, some individuals may find their symptoms are worse in the mornings, whereas others may find symptoms are worse in the evenings. A food and symptom diary can help you keep track of your symptoms, food and drink intake and identify the best timing of meals for you. If the mornings are more problematic for you, try having a lighter breakfast in the morning and more substantial meals as the day goes on.  Another benefit of keeping a food and drink diary is you may be able to identify certain foods that could be causing more symptoms for you.    Remember that each individual may vary, what works for one person may not be what works for you.  

Emerging Evidence: Diet and IBD

The area of diet and IBD is a very active area of research and while no formal recommendations yet exist there are several active areas of research that are being explored.  For example, the role of emulsifiers in IBD. Emulsifiers are food additives which are added to a food to stabilise the consistency of food items; they prevent the separation of oil and water helping to prolong the shelf life, improve the appearance and mouth feel of a food when eaten. Studies so far, although very small in size, suggest that emulsifiers may contribute to an increase in inflammation along the GI tract which could trigger symptoms and so it has been suggest that some individuals with IBD may find it beneficial to reduce foods containing dietary emulsifiers6 .  These studies have focused predominantly on emulsifiers which do not occur naturally in foods such as lecithin commonly found in chocolate, xanthan gum found in mayonnaise and carrageenan found in flavoured milks, iced coffee and dairy based ice cream. But before you drop the tub of mayo, remember this is a new area of research and no definitively conclusions can be drawn. 

Probiotics

Probiotics have been defined by the World Health Organisation as “live microorganisms which, when administered in adequate quantities, confer health benefits to the host”. In more simple terms an organism which is really any living structure such as a plant bacteria fungus or animal that is either consumed through a capsule or naturally through certain foods such as Greek yoghurt, kefir or kombucha when eaten these foods may have beneficial effects on the digestive system.   

Can Probiotics Help Maintain Inactive IBD?  

Naturally occurring probiotics found in fermented foods have been part of the human diet for centuries and were initially produced to preserve foods, improve flavor, and eliminate toxins, now many people are incorporating fermented foods in their diets because they contain probiotics which have a positive effect on heart and digestive health. Kefir is a fermented dairy product which has been shown to have a positive effect on bloating and overall general digestive symptoms period 7.  There is currently no evidence to support the use of probiotics in the remission or maintenance of inactive Crohn’s disease. In mild to moderate Ulcerative colitis some early-stage evidence suggests that some specific probiotics may help prolong remission.  These probiotics that have shown a small benefit include  Escheria Coli Nissle 1917 or VSL #3 which are available over the counter in a capsule form.  

Prebiotics 

Prebiotics are carbohydrates which promote the growth of good bacteria in the gut. They occur naturally in many foods such as oats, garlic, onions, leek, asparagus, bananas, apples and bran and can be consumed as part of a healthy balanced diet. Scientific research has found no link between prebiotics and a reduction in active episodes of IBD but research is ongoing within this area so watch this space!

Food Safety Authority Ireland Food Pyramid  

Cox, S.R., Lindsay, J.O., Fromentin, S., Stagg, A.J., Mccarthy, N.E., Galleron, N., Ibraim, S.B., Roume, H., Levenez, F., Pons, N., Maziers, N., Lomer, M.C., Ehrlich, S.D., Irving, P.M., and Whelan, K., 2020. Effects of Low FODMAP Diet on Symptoms, Fecal Microbiome, and Markers of Inflammation in Patients With Quiescent Inflammatory Bowel Disease in a Randomized Trial. Gastroenterology, 158 (1), 176–188.e7.

Irish Nutrition and Dietetic Association

British Dietetic Association Vegetarian, Vegan and Plant Based Diet. Food Fact Sheet.

References 

Irish Society For Colitis and Crohn’s What Is IBD. 2021 Available from: https://iscc.ie/facts/what-is-ibd/ 

https://iscc.ie/facts/what-is-ibd/ Rizzello F, Spisni E, Giovanardi E, Imbesi V, Salice M, Alvisi P, et al.. Implications of the Westernized Diet in the Onset and Progression of IBD. Nutrients [Internet] 2019;11(5):1033. Available from: https://dx.doi.org/10.3390/nu11051033

Roseboom T, De Rooij S, Painter R. The Dutch famine and its long-term consequences for adult health. Early Human Development 2006;82(8):485–91.

Food Safety Authority Ireland Food Pyramid Healthy Eating Guidelines (2019) https://www.fsai.ie/science_and_health/healthy_eating.html

Albenberg L, Brensinger CM, Wu Q, Gilroy E, Kappelman MD, Sandler RS, et al.. A Diet Low in Red and Processed Meat Does Not Reduce Rate of Crohn’s Disease Flares. Gastroenterology 2019;157(1):128–36.e5.

Bancil AS, Sandall AM, Rossi M, Chassaing B, Lindsay JO, Whelan K. Food Additive Emulsifiers and Their Impact on Gut Microbiome, Permeability, and Inflammation: Mechanistic Insights in Inflammatory Bowel Disease. Journal of Crohn's and Colitis 2021;15(6):1068–79.

 Yilmaz I, Dolar ME, Ozpinar H. Effect of administering kefir on the changes in fecal microbiota and symptoms of inflammatory bowel disease: A randomized controlled trial. The Turkish Journal of Gastroenterology [Internet] 2020;30(3):242–53. Available from: https://dx.doi.org/10.5152/tjg.2018.18227

Instead of eliminating whole food groups it is important to consider how to adapt and incorporate other food alternatives into the diet. By incorporating similar food items this will minimise nutritional deficiencies and will help you to achieve an overall healthy balanced diet.  Here is a simple swap system  of some simple alternative suggestions that can be made. The food items in red are items that are often associated with aggravating IBD symptoms while the foods in green are similar alternative foods which may be better tolerated.

Download the sample swap system