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Existing dietary guidelines for Crohn’s disease and ulcerative colitis

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Existing dietary guidelines

for Crohn’s disease and
ulcerative colitis
Expert Rev. Gastroenterol. Hepatol. 5(3), 411–425 (2011)

Amy C Brown†1,
S Devi Rampertab2 and
Gerard E Mullin3
1
Department of Complementary &
Alternative Medicine, John A Burns
School of Medicine, University of
Hawaii at Manoa, 651 Ilalo Street,
MEB 223, Honolulu, HI 96813, USA
2
Division of Gastroenterology,
Penn State Hershey Medical Center,
PA, USA
3
Johns Hopkins School of Medicine,
The Johns Hopkins Hospital, MD, USA
†
Author for correspondence:
Tel.: +1 808 692 0907
amybrown@hawaii.edu
Patients with inflammatory bowel disease (IBD) often question their doctors about diet. The
objectives of this article are to provide clinicians with existing dietary advice by presenting the
dietary information proposed by medical societies in the form of clinical practice guidelines as
it relates to IBD; listing dietary guidelines from patient-centered IBD-related organizations; and
creating a new ‘global practice guideline’ that attempts to consolidate the existing information
regarding diet and IBD. The dietary suggestions derived from sources found in this article include
nutritional deficiency screening, avoiding foods that worsen symptoms, eating smaller meals at
more frequent intervals, drinking adequate fluids, avoiding caffeine and alcohol, taking
vitamin/mineral supplementation, eliminating dairy if lactose intolerant, limiting excess fat,
reducing carbohydrates and reducing high-fiber foods during flares. Mixed advice exists regarding
probiotics. Enteral nutrition is recommended for Crohn’s disease patients in Japan, which differs
from practices in the USA.
Keywords : Crohn’s disease • diet • dietary supplements • enteral nutrition • inflammatory bowel disease
• nutrition • parenteral nutrition • ulcerative colitis

Although physicians are not always taught infor-
mation about diet and inflammatory bowel
disease (IBD) in their training or through their
professional associations, registered dietitians may
also not be adequately prepared to present dietary
information to patients with IBD. Based on our
previous review of the literature on diet and
Crohn’s disease (CD), it appears that a large gap
exists in translating research-based dietary knowl-
edge to clinical practice for the IBD population [1] .
Creating evidence-based dietary recommenda-
tions for people with IBD is an un­addressed need.
These patients need up-to-date dietary clinical
practice guidelines that will, if possible, best serve
to reduce the risk of nutritional deficiency and
possibly reduce their symptoms.
The current state of the art is that various clini-
cal practice guidelines for IBD patients exist, but
many are sparse on dietary ­recommendations,
and vary by origin.
The objectives of this article are to:
• Collectively present the dietary information
relating to IBD in the form of clinical practice
guidelines proposed by medical societies;
• List the ‘informal dietary guidelines’ suggested
by patient-centered IBD-related associations;
• Create a new ‘global practice guideline’ that
incorporates the current clinical practice
guidelines and informal dietary recommenda-
tions into one consolidated set of guidelines;
• Comment on existing nutrition guidelines for
IBD and recommend future research.
Clinical practice guidelines
The current recommendations of the American
Dietetic Association (ADA), clinical practice
guidelines from selected medical organizations
and a few informal dietary recommendations are
now briefly summarized.
The American Dietetic Association
The ADA [101] is the world’s largest organization of
food and nutrition professionals, and their online
Nutrition Care Manual (available by subscription)
lists the majority of diets recommended for various
medical conditions [102] . Only general guidelines
are provided for IBD listed in Box 1,���������������
with an accom-
panying table of recommended foods (Table 1) and
foods that are not ­recommended (Table 2) .
The American College of Gastroenterology
The American Journal of Gastroenterology pub-
lished the American College of Gastroenterology

www.expert-reviews.com 10.1586/EGH.11.29 © 2011 Expert Reviews Ltd ISSN 1747-4124 411

 Review Brown, Rampertab & Mullin

mentioned that no difference in efficacy exists between elemental

Box 1. General inflammatory bowel disease
guidelines from the American Dietetic Association.
• Eat small meals or snacks every 3 or 4 h
• Use low-fiber foods when you have symptoms (recommended
foods chart: Table 1). You can slowly reintroduce small amounts
of whole-grain foods and higher-fiber fruits and vegetables one
at a time when symptoms improve
• Drink enough fluids (at least eight cups each day) to avoid
dehydration
• Eat foods with added probiotics and prebiotics
• Use a multivitamin
• During periods when you don’t have symptoms, include whole
grains and a variety of fruits and vegetables in your eating plan.
Start new foods one at a time, in small amounts
© 2010 American Dietetic Association. Reprinted with permission from [101].
(ACG) Practice Guidelines for CD [2] and ulcerative colitis
(UC) [3] .
Crohn’s disease
The only mention of nutrition for patients with CD is “no pla-
cebo-controlled trials of nutritional therapy for active CD have
been performed.” They report that corticosteroids are more
effective than enteral nutrition to induce remission in active
CD patients, but that more than 50% of corticosteroid acute
users become ‘steroid dependent’ or ‘steroid resistant’. It is also
and polymeric diets, and the only appropriate use of enteral diets
is as an ­adjunctive therapy to support a patient’s nutrition [2] .
Ulcerative colitis
The dietary information for patients with UC is more sparse. It
states, with the exception of patients with significant nutrition
depletion, total parenteral nutrition showed no benefit, and may
even deprive colonic enterocytes of short-chain fatty acids [3] .
The online ACG consumer guide information sheets [103]
­provide more information on diet and suggest:
• Lactose-intolerant individuals should avoid milk or milk prod-
ucts or use those to which lactase enzyme has been added;
• A low-roughage diet is recommended for those experiencing
diarrhea after meals;
• Patients can often eat a reasonably unrestricted diet.
World Gastroenterology Organization practice guidelines
Compared with other clinical practice guidelines, those from
the World Gastroenterology Organization (WGO) provide the
most comprehensive dietary advice to IBD patients [4] . Diet
and lifestyle considerations are part of the WGO global guide-
lines  [4] . Although they state that the impact of diet is poorly
understood, they add that “dietary changes may help reduce
symptoms in CD and UC.” Their guidelines, provided in Box 2 ,

Table 1. American Dietetic Association ‘recommended’ foods for inflammatory bowel disease.
Food group Recommended foods Notes
Milk and dairy Buttermilk Choose lactose-free products if you have lactose intolerance. Lactose
products Evaporated, skimmed, powdered or low-fat milk intolerance causes symptoms after drinking regular milk or eating
Yogurt foods from milk. Symptoms include diarrhea, nausea, stomach pain
Cheeses (low-fat) and bloating
Ice cream (low-fat) Choose yogurt with live, active cultures (see food label)
Sherbet
Meats and other Tender, well-cooked meats, poultry, fish, eggs
protein foods and soy prepared without added fat
Smooth nut butter
Grains Bread, bagels, rolls, crackers, cereals and pasta Choose grain foods with less than 2 g of fiber per serving (see
made from white or refined flour food label)
Vegetables Most well-cooked vegetables without seeds See Table 2 for vegetables to avoid if you have diarrhea or
Potatoes without skin abdominal pain
Lettuce
Strained vegetable juice
Fruits Fruit juice without pulp (except prune juice) Choose canned fruit in juice or light syrup. Heavy syrup has lots of
Ripe banana or melons sugar, which may make diarrhea worse.
Most canned, soft fruits See Table 2 for foods to avoid if you have diarrhea or abdominal pain
Peeled apple
Fats and oils Limit fats and oils to less than eight teaspoons per day
Beverages Water Drinking beverages with sugar or corn syrup may make
Decaffeinated coffee diarrhea worse. Very sweet juices may also have this effect
Caffeine-free tea
Soft drinks without caffeine
Rehydration beverages
© 2010 American Dietetic Association. Reprinted with permission from [101].

412 Expert Rev. Gastroenterol. Hepatol. 5(3), (2011)

 Existing dietary guidelines for Crohn’s disease & ulcerative colitis Review

focus on the reduction of symptoms (CD

and UC), reduction of inflammation (CD),
­probiotics and supplements.
The American Society for Parenteral
& Enteral Nutrition
The American Society for Parenteral and
Enteral Nutrition (ASPEN) guidelines,
divided by adult and pediatric patients in
Box 3, suggest that all IBD patients should
receive nutrition screening to determine
which patients require formal nutrition
­intervention [5] .
Table 2. American Dietetic Association ‘foods to avoid’ for
inflammatory bowel disease.
Food group Foods to avoid
Milk and dairy Whole milk, half-and-half, cream, sour cream
products Yogurt with berries, orange or lemon rind, or nuts
Ice cream (unless low-fat or nonfat)
Meats and other Fried meats, including sausage and bacon
protein foods Luncheon meats, such as bologna or salami
Hot dogs
Tough or chewy cuts of meat
Fried eggs
All dried beans, peas and nuts
Chunky nut butters

The European Society for Clinical
Nutrition & Metabolism
In 2006, the European Society for
Parenteral and Enteral Nutrition (ESPEN)
published enteral nutrition guidelines for
IBD patients [6] . Van Gossum et al. stated
that malnutrition occurs in 20–85% of
CD patients, and the highest risk group
is patients with the disease in their small
intestines [7] . Selected dietary guidelines for
enteral and parenteral nutrition from both
publications are highlighted in Box 4.
The Japanese Society for Pediatric
Gastroenterology, Hepatology
& Nutrition
The authors of ‘Guidelines for the treat-
ment of CD in children,’ published in
Pediatrics International, the official journal
of the Japan Pediatric Society, provide their
guidelines in Box 5 [8] .
Grains Whole-wheat or whole-grain breads, rolls, crackers or pasta
Brown rice and wild rice
Cereals made from whole grain
Any grain foods made with seeds or nuts
Vegetables Beets, broccoli, Brussels sprouts, cabbage, sauerkraut, cauliflower,
corn, greens (spinach, mustard, turnip and collards), lima beans,
mushrooms, okra, onions, parsnips, peppers, potato skins and
winter squash
Fruits All raw fruits except peeled apples, ripe bananas and melon
Canned berries, canned cherries
Dried fruits, including raisins
Prune juice
Fats and oils Do not have more than eight teaspoons a day
Beverages Beverages with caffeine, such as coffee, tea, cola and some
sport drinks
Alcoholic drinks
Avoid sweet fruit juices and soft drinks or other beverages made with
sugar or corn syrup if they make diarrhea worse
Other Sugar alcohols (sorbitol, mannitol and xylitol) cause diarrhea in some
people. These ingredients are often found in sugarless gums and
candies, and some medications
© 2010 American Dietetic Association. Reprinted with permission from [101].

Informal dietary recommendation The National Digestive Diseases

Several informal sources of dietary information for patients with
IBD exist through the Crohn’s & Colitis Foundation of America,
The National Digestive Diseases Information Clearinghouse and
Medline Plus. These public recommendations are now briefly
provided in the following sections.
Information Clearinghouse
The National Digestive Diseases Information Clearinghouse, a
service of the National Institute of Diabetes and Digestive and
Kidney Diseases (NIH) lists no recommendations concerning
diet for UC, but Box 7 lists suggestions for those with CD [105] .

Crohn’s & Colitis Foundation of America Medline Plus

The leading IBD nonprofit association in the USA suggests on their
website that “there is no single diet for everyone with IBD,” and that
“dietary recommendations must be individualized” [104] . However,
they add that, “what you eat may go a long way toward reducing
symptoms and promoting healing.” The Specific Carbohydrate
Diet, popularized in Elaine Gottschall’s lay book, ‘Breaking the
Vicious Cycle’, is mentioned as being only supported by patient
testimonials, but “bottom line, it may be worth a try.” Patients are
recommended to limit their salt intake during corticosteroid treat-
ment because salt worsens fluid retention. If there is a stricture, Box 6
provides suggestions to avoid cramping or contractions.
The website providing information from the National Library of
Medicine, the NIH and other government agencies and health-
related organizations provides more detailed information for IBD
patients (Box 8) [106,107] .
Global IBD dietary clinical practice guideline
Many of the aforementioned dietary recommendations have
identical or similar content, with some degree of variation. In
order to consolidate the information into a concise summary,
Table 3 was created by the authors to provide a summary of existing
guidelines. This is an educated summary of existing guidelines

www.expert-reviews.com 413
 Review Brown, Rampertab & Mullin

Box 2. World Gastroenterology Organization clinical practice guidelines for inflammatory bowel disease
concerning diet.
• During disease activity, decrease the amount of fiber
• Dairy products can be maintained unless not tolerated
• A high-residue diet may be indicated in cases of ulcerative proctitis (disease limited to rectum where constipation is more of a problem)
• Limited data suggest that reducing dietary fermentable oligosaccharides, disaccharides and monosaccharides, and polyols may reduce
symptoms of IBD
Diet and lifestyle considerations may reduce inflammation in CD, specifically:
• A liquid diet, predigested formula or nothing by mouth may reduce obstructive symptoms
• An exclusive enteral diet can settle inflammatory disease, especially in children
Probiotics:
• IBD may be caused or aggravated by alterations in gut flora
• There is no evidence that probiotics are effective in either UC or CD; however:
– Escherichia coli Nissle 1917 is not inferior to 5-aminosalicylic acid
– VSL#3 (combination of eight bacterial strains) reduced flares of pouchitis (a post-ileoanal pouch procedure for UC)
Supplements:
• Nutritional supplementation for those with malnutrition or during periods of reduced oral intake
• Vitamin/mineral supplementation for all
• Vitamin B12 and vitamin D for those that who are deficient
• Steroid users should receive calcium and vitamin D supplementation
• Chronic iron-deficiency anemia should be treated with parenteral iron if oral iron is not tolerated
CD: Crohn’s disease; IBD: Inflammatory bowel disease; UC: Ulcerative colitis.
Adapted from [4].

and no attempt has been made to explore the scientific basis for an actual oral diet. The topics of nutritional deficiency screening,
these recommendations. diet and enteral and/or parenteral nutrition are now briefly dis-
cussed in light of the aforementioned existing dietary guidelines
Commentary on existing IBD dietary guidelines for patients with IBD.
Overall, the subject of diet and IBD embodies both nutrient
deficiencies, as well as the role diet may play in reducing IBD Nutritional deficiency screening
symptoms. The former has more concrete data, whereas the latter Nutritional deficiency for patients with IBD is well described in the
has not been well investigated. literature, but only the ESPEN has recommended nutritional defi-
The literature becomes difficult to decipher at times because ciency screening in this patient population [7] . A diseased GI tract
‘nutritional therapy’, a broad term covering all types of nutrition, can potentially compromise nutrient status, especially with regards
is often used in the medical literature to define enteral and/or to nutrient absorption, healing and/or growth in children. Primary
parenteral nutrition in relationship to IBD, and rarely describes problems related to CD include mal­absorption, malnutrition,
Box 3. American Society for Parenteral and Enteral Nutrition clinical practice guidelines for inflammatory
bowel disease concerning diet.
Adult practice guidelines for IBD from ASPEN include [8] :
• Enteral nutrition should be used in CD patients requiring specialized nutrition support
• Parenteral nutrition should be reserved for those patients with IBD in whom enteral nutrition is not tolerated
• Fistula-associated CD – a brief course of bowel rest and parenteral nutrition is recommended
• Perioperative specialized nutrition support is indicated for those who are severely malnourished and for those in whom surgery can be
safely postponed
• Specialized nutrition support and bowel rest should not be used as primary therapies for either UC or CD
Pediatric practice guidelines for IBD patients provided by ASPEN include:
• Enteral nutrition should be given to children with growth retardation to help induce a growth spurt
• Enteral nutrition should be used as an adjunct to medical therapy in those who are unable to maintain their nutrition status through
oral intake
• Parenteral nutrition should be used in children who are unable to maintain normal growth and development on enteral nutrition or a
standard diet
ASPEN: American Society for Parenteral and Enteral Nutrition; CD: Crohn’s disease; IBD: Inflammatory bowel disease; UC: Ulcerative colitis.
Adapted from [5].

414 Expert Rev. Gastroenterol. Hepatol. 5(3), (2011)

 Existing dietary guidelines for Crohn’s disease & ulcerative colitis Review

Box 4. The European Society for Clinical Nutrition and Metabolism clinical practice guidelines for
inflammatory bowel disease concerning diet.
Crohn’s disease:
• Enteral nutrition is indicated for the prevention and treatment of undernutrition, improving growth in children, quality-of-life
improvements, acute-phase therapy, perioperative nutrition and maintenance of remission in chronic active disease
• Enteral nutrition is the sole therapy in adults during the acute phase when corticosteroid treatment is not feasible
• For enteral therapy, use oral supplements up to 600 kcal/day with food intake, and then tube feeding if higher intakes are necessary.
Continuous tube feeding is better than bolus, owing to a lower complication rate
• Whole proteins are preferred as free amino acid- or peptide-based formulas are not recommended
• Parenteral nutrition is usually combined with oral/enteral food unless there is continuing intra-abdominal sepsis or perforation
• Undernourished CD patients may benefit from parenteral nutrition
• Despite encouraging experimental data, insufficient data exist to recommend glutamine, n-3 fatty acids or other pharmaconutrients
• Vitamin B12 deficiencies are well documented, especially if the distal ileum is affected by CD or resectioned. In these patients,
serum B12and folate should be measured annually
• Correct nutrient deficiencies with vitamin/mineral supplementation
Ulcerative colitis:
• Unlike CD, both enteral and parenteral nutrition do not serve as primary therapies in UC, where nutritional deficiencies are not as
common compared with CD. Enteral nutrition is only for patients with undernutrition or inadequate intake
• Parenteral nutrition should only be used in those with UC who are malnourished or at risk of becoming malnourished before or after
surgery because they cannot tolerate food or an enteral feed
• Bowel rest should not be provided through the use of parenteral nutrition during acute inflammatory periods
• Parenteral and enteral nutrition are not recommended for the maintenance of remission
• Iron-deficient anemia due to blood loss occurs in 80% of UC patients
• Correct nutrient deficiencies with vitamin/mineral supplementation
CD: Crohn’s disease; UC: Ulcerative colitis.
Adapted from [6].

reduced dietary intake, weight loss, increased resting energy expend- 125 pediatric IBD patients were questioned about diet, 90% of
iture during flares, growth retardation in children, and the need for the CD patients and 71% of the UC patients revealed that they
adequate bowel rest, hydration and food sensitivity screening [1] . had altered their diets since diagnosis [17] . Approximately 73%
In support of ESPEN’s practice guidelines, these potential prob- of these reported that their dietary changes alleviated symptoms
lems indicate that it is in the patient’s best interest to be screened of abdominal pain, diarrhea and flatulence.
for primary nutritional problems, with referral to a registered Unfortunately, IBD patients often ask questions about diet
dietitian to arrange a treatment plan and follow-up. Table 4 pro- without receiving instruction or referral to a registered dietitian.
vides a general checklist of these nutrition-related problems that For example, when CD patients were asked if diet altered their
may exist in CD patients [9–16] . Patients with UC are also prone to symptoms, 78% (n = 21 out of 27), replied ‘yes’ [18] . However, only
nutritional deficiency, especially since iron-deficient anemia due 15% of these patients (n = 4 out of 27) received a dietary referral.
to blood loss occurs in up to 80% of these patients. Currently, many IBD patients continue to receive minimal dietary
instruction, despite clinical practice guidelines and emerging
Dietary supplements research suggesting that dietary changes may ameliorate symptoms.
Many of the dietary guidelines indirectly addressed nutritional defi- In terms of existing guidelines for dietary modifications, three
ciency by suggesting a daily vitamin/mineral supplement with phy- suggested limiting dairy if lactose intolerant, two suggested lim-
sician guidance. Special consideration should be given for vitamin D iting excess fat, one indicated decreasing excess carbohydrates,
and the the other fat soluble vitamins A, E
and K, as well as other nutrients, such as vita- Box 5. Japanese Society for Pediatric Gastroenterology, Hepatology
min C, vitamin B12, folate, calcium, mag- and Nutrition clinical practice guidelines for inflammatory bowel
nesium, iron, zinc and copper. IBD patients disease concerning diet.
who are prescribed corticosteroid medica- • Total enteral nutrition (elemental formula) and oral mesalazine are used together as the
tions should be informed of the increased primary therapy during the onset and active stage of the disease
risk for osteoporosis and should receive • Total parenteral nutrition with oral mesalazine is reserved for children having
­calcium and vitamin D supplementation. serious illnesses
• Corticosteroids should not be used until at least 1 week after starting total parenteral
Diet for IBD nutrition, and then additional amounts used if the child does not respond to total
No diet currently exists for patients with parenteral nutrition
IBD. This is problematic because when Adapted from [8].

www.expert-reviews.com 415
 Review Brown, Rampertab & Mullin

a try. However, this is apart from their

Box 6. Crohn’s & Colitis Foundation of America dietary suggestions
dietary suggestions provided for patients
for inflammatory bowel disease patients with strictures of
­experiencing bowel strictures.
the bowel.
The malabsorption and compromise of
• Low-fiber diet or special liquid diet may be beneficial digestive enzymes on an inflamed GI tract
• Restrict intake of certain high-fiber foods, such as nuts, seeds, corn, popcorn and may contribute to the small number of
various Chinese vegetables studies in the literature suggesting some
• Minimize ‘scrappy’ foods, such as raw fruits, vegetables, seeds, nuts and corn hulls success of the Specific Carbohydrate Diet.
• Eat smaller meals at more frequent intervals This popular dietary regimen described
• Reduce the amount of greasy or fried foods in Elaine Gottschall’s book, ‘Breaking
• Limit consumption of milk or milk products if you are lactose intolerant the Vicious Cycle’, is largely supported
Adapted from [106]. by testimonials.
The diet was originally created by a
and five suggested avoiding high-fiber foods, especially during renowned pediatrician to treat celiac disease and needs to be clini-
flares. The question of whether or not to use probiotics continues cally tested in people with IBD. It is essentially an elimination
to be debated. diet in disguise that limits dairy, gluten and processed foods. It
is unique in also limiting saccharides, except the easily absorbed
Reducing dairy monosaccharides, which are allowed. The purpose of removing
The prevalence of lactose malabsorption is significantly greater in dietary disaccharides and polysaccharides (starches) is to inhibit
patients with CD involving the small bowel than it is in patients the growth of microorganisms in the intestines, their resulting
with CD involving the colon or UC [19] . Symptoms of IBD and overgrowth and therefore the possible side effects of gas, bloating
lactose intolerance often overlap, so it seems prudent to avoid and abdominal pain.
lactose-containing foods if there is an intolerance. Another possibility we suggest is that an inflamed intestinal
wall in the duodenal region would compromise the digestive
Reducing fat enzymes of not only lactose, but also other disaccharides, and
Some patients with IBD react to excess dietary fat and perhaps perhaps even the enzymes for proteins and fats.
this is where the recommendation is derived. Few research stud-
ies are available to support or refute such a recommendation. Elimination diet
The topic needs further investigation because patients with mal­ Although not mentioned in any of the dietary guidelines, the
absorption may be at risk of not obtaining their necessary essential use of an elimination diet in patients with CD has some weak
fatty acids. Perhaps saturated fats should be limited, with more of support in the literature. Brown and Roy’s previous review of
an emphasis on more healthy fat intakes. diet and CD revealed a higher rate of food allergies in patients
with IBD [1] . For example, a survey by Ballegaard et al. observed
Reducing carbohydrates that more than half of their IBD subjects were affected by food
Only the WGO mentioned “limited evidence suggests reduc- sensitivities. They reported food intolerances occurring in 14%
ing carbohydrates” [4] . The Crohn’s and Colitis Foundation (n = 70) of their healthy controls, compared with 66% (n = 53)
of America mentions the Specific Carbohydrate Diet as only of CD subjects and 64% (n = 77) of those with UC (n = 75).
being supported by testimonials, but that it might be worth The most commonly reported symptoms in this study were

Box 7. The National Digestive Diseases Information Clearinghouse dietary suggestions for people with
Crohn’s disease (none exist for ulcerative colitis).
Crohn’s disease:
• Decreased appetite can affect nutrition needed for good health and healing
• Diarrhea and poor absorption of necessary nutrients may occur
• No special diet has been proven effective for preventing or treating CD, but it is very important that people who have CD follow a
nutritious diet and avoid any foods that seem to worsen symptoms
• There are no consistent dietary rules to follow that will improve a person’s symptoms
• People should only take vitamin supplements based on their doctor’s advice
• Foods such as bulky grains, hot spices, alcohol and milk products may increase diarrhea and cramping
• The doctor may recommend nutritional supplements, especially for children whose growth has been slowed. Special high-calorie liquid
formulas are sometimes used for this purpose
• A small number of patients may need to be briefly fed intravenously (through a small tube inserted into the vein of the arm)
CD: Crohn’s disease.
Adapted from [105].

416 Expert Rev. Gastroenterol. Hepatol. 5(3), (2011)

 Existing dietary guidelines for Crohn’s disease & ulcerative colitis Review

abdominal pain, meteorism (drum-like

Box 8. Medline Plus dietary suggestions for people with Crohn’s
distention of the abdomen caused by gas in
disease and ulcerative colitis.
the abdomen or intestines), diarrhea and
flatulence. The most frequently symptom- Crohn’s disease [106] :
provoking foods were vegetables (40%), • No specific diet has been demonstrated to improve or worsen the bowel inflammation
fruit (28% – apple, strawberries and cit- in CD. However, eating a healthy amount of calories, vitamins and protein is important
to avoid malnutrition and weight loss. Specific food problems may vary from person
rus fruits), milk (27%), bread (23%), meat
to person
(25% – beef and smoked meat) and ­others
• Certain types of foods may worsen diarrhea and gas symptoms, especially during times
(38%) [20] .
of active disease. Suggestions for diet during periods when symptoms are
Not all IBD patients are afflicted with present include:
food allergies. The majority do react to – Eat small amounts of food throughout the day
foods so perhaps they should be tested for – Drink lots of water (frequent consumption of small amounts throughout the day)
food allergies and food intolerances. This – Avoid high-fiber foods (bran, beans, nuts, seeds and popcorn)
may also apply more for patients with CD – Avoid fatty, greasy or fried foods and sauces (butter, margarine and heavy cream)
in the duodenum, rather those afflicted in – If your body does not digest dairy foods well, limit dairy products
the colon or patients with UC. Allergy tests – Avoid or limit alcohol and caffeine consumption
are not always reliable, so perhaps a 2-week
• People who have a blockage of the intestines may need to avoid raw fruits and
trial elimination diet would determine if
vegetables. Those who have difficulty digesting milk sugar (lactose) may need to avoid
symptoms improve. This dietary method is milk products
cost-effective and such regimens have been • Ask your doctor about extra vitamins and minerals you may need:
provided to animals [21] . – Iron supplements (if you are anemic)
– Calcium and vitamin D supplements to help keep your bones strong
Reduced fiber during flares (active disease – Vitamin B12 to prevent anemia
states, fistulas or strictures)
Ulcerative colitis [107] :
Reducing high-fiber foods during symp- Certain types of foods may worsen diarrhea and gas symptoms, especially during times of
toms appears to have generated the most active disease. Dietary suggestions include:
support in the dietary guidelines. It may be • Eat small amounts throughout the day
important to communicate to IBD patients • Drink lots of water (frequent consumption of small amounts throughout the day)
that high-fiber foods are not recommended, • Avoid high-fiber foods (bran, beans, nuts, seeds and popcorn)
especially for those with CD, during flares • Avoid fatty, greasy or fried foods and sauces (butter, margarine and heavy cream)
or in the presence of active disease states, • Limit milk products if you are lactose intolerant. Dairy products are a good source of
fistulas or strictures. There appears to be a protein and calcium
tendency among the dietary guidelines to • Avoid or limit alcohol and caffeine consumption
restrict foods such as raw fruits, raw veg- CD: Crohn’s disease.
etables, beans, bran, popcorn, seeds, nuts,
corn hulls, whole grains, brown rice and semi-elemental diets, which consist of partially hydrolyzed nutri-
wild rice. Although not mentioned, raw salads would also fall ents, or elemental diets containing completely hydrolyzed nutri-
into this category. ents broken down into their smallest units of digestion, such as
Even lower in fiber and easier to absorb are enteral feedings, amino acids, monosaccharides, fatty acids, vitamins and miner-
which may be considered during periods of exacerbation, mal­ als [22] . The nutrients are fed into the body through either the gut
absorption or inadequate nutrient intake. These enteral feed- (enteral) or vein (parenteral). There appears to be no difference
ings are preferred over parenteral with the exception of some in efficacy between elemental diets (n = 188) and nonelemental
cases of extreme malabsorption or complications, such as fis- diets (semi-elemental or polymeric diet; n = 146) for CD patients,
tulas. Patients with CD may benefit from learning that their according to researchers conducting a Cochrane meta-ana­lysis of
symptoms may be temporarily alleviated during these times if ten trials [23] .
placed on an enteral diet, and that in some cases they may even Enteral nutrition is considered to be a first-line therapy for
avoid surgery. adults with CD in Japan because it places patients in remission,
after which they start the ‘slide method’ in which a low-fat
Enteral nutrition for CD diet slowly replaces the elemental diet [24] . The ‘half-elemental
It appears that the majority of research supporting ‘nutrition’ diet therapy’ is fed during the night through a nasogastric
and IBD has previously focused on enteral nutrition, sometimes tube while the patient is at home and consuming a low-fat diet
inaccurately referred to as ‘diet’. Enteral nutrition (polymeric, (20–30  g) during the day [9] . Insurance plans often dictate
semi-elemental and elemental) are liquid diets consisting of whether or not a particular treatment plan is pursued, and
nutrients broken down into their smaller units. Polymeric diets Japan’s national health insurance plan covers enteral nutrition
contain intact nutrients that are more palatable and cheaper than for CD [24] .

www.expert-reviews.com 417
 Review Brown, Rampertab & Mullin

Table 3. A ‘global’ clinical practice guideline summarizing dietary advice for inflammatory bowel disease
patients created by combining current clinical practice guidelines and informal dietary suggestions into
one (not all suggestions are in agreement or based on evidence-based research).
General diet
IBD No special diet has been proven to be effective for preventing or treating CD symptoms or inflammation, but it is very important
that people who have CD follow a nutritious diet, and avoid malnutrition, weight loss and any foods that seem to worsen
symptoms. Specific food problems may vary from person to person‡‡,§§
Decreased appetite can affect nutrition needed for good health and healing†
Eat smaller meals at more frequent intervals†,††,§§
CD Certain types of foods may worsen diarrhea and gas symptoms, especially during times of active disease §§
Fiber or grains
IBD Decrease fiber consumption during disease activity, especially whole-grain products, bran, beans, brown rice, wild rice, nuts,
corn, corn hulls, popcorn, seeds, raw fruits and certain vegetables†,‡,††,‡‡
A special liquid diet may be beneficial††
During periods of no symptoms, slowly reintroduce high-fiber foods one at a time in small amounts†
Those with blocked intestines may need to avoid raw fruits and vegetables‡‡
Vegetables & fruits
IBD During diarrhea and abdominal pain†:
Recommended Avoid
Well-cooked vegetables Potatoes with skins or potato skins
Strained vegetable or fruit juices Vegetables or fruits with seeds
Canned or soft fruits Corn and corn products
Peeled apple, ripe banana or melon Raw greens, beets, broccoli, Brussels sprouts, cabbage, sauerkraut,
cauliflower, lima beans, mushrooms, okra, onions, parsnips, peppers and
winter squash
Most raw and dried fruits (see exceptions on left)
Canned berries or cherries
Prune juice
Dairy
IBD Dairy products can be maintained unless not tolerated‡
Limit intake of milk and milk products if you do not digest dairy foods well, or are lactose intolerant†,††,‡‡,§§
If tolerated, fermented foods, such as yogurt (choose live cultures) and certain low-fat cheeses, may be allowed†
If tolerated, nonfat, skimmed or low-fat milk products over higher fat versions
Fat
IBD Avoid fatty, greasy or fried foods and sauces (butter, margarine and heavy cream)††,§§
During diarrhea or abdominal pain, keep fat intake below eight teaspoons per day†
CD: Crohn’s disease; IBD: Inflammatory bowel disease; UC: Ulcerative colitis.
© 2011 Amy Brown.
Adapted from:
Clinical practice guidelines:
†
American Dietetic Association (ADA).
‡
World Gastroenterology Organization (WGO).
§
American Society for Parenteral and Enteral Nutrition (ASPEN).
¶
European Society for Clinical Nutrition and Metabolism (ESPEN).
#
Japanese Society for Pediatric Gastroenterology, Hepatology and Nutrition.
Informal dietary suggestions:
††
Crohn’s & Colitis Foundation of America.
‡‡
National Digestive Diseases Information Clearinghouse.
§§
Medline Plus.

418 Expert Rev. Gastroenterol. Hepatol. 5(3), (2011)

 Existing dietary guidelines for Crohn’s disease & ulcerative colitis Review

Table 3. A ‘global’ clinical practice guideline summarizing dietary advice for inflammatory bowel disease
patients created by combining current clinical practice guidelines and informal dietary suggestions into
one (not all suggestions are in agreement or based on evidence-based research) (cont.).
Carbohydrates
IBD Limited evidence suggests reducing carbohydrates – dietary fermentable oligosaccharides, disaccharides and monosaccharides,
and sugar alcohols (erythritol, sorbitol, xylitol and so on, as used in sugarless products) ‡
Meats or protein foods
IBD Well-cooked meats without added fat†
Avoid high-fat meats – fried, processed (hot dogs and luncheon meats), bacon or sausage†
Avoid dried beans and peas†
Avoid nuts. Choose smooth over chunky nut butters†

Beverages
IBD During diarrhea and abdominal pain†:
Recommended Avoid
Drink lots of water (frequent consumption of small High sugar drinks
amounts throughout the day)†,§§ Sweet juices
Caffeine†,§§
Alcohol§§,‡‡
Sugar alcohols (erythritol, sorbitol and so on)
Probiotics
IBD IBD may be caused or aggravated by alterations in gut flora‡
Eat foods with added probiotics and prebiotics. Ask for advice†
There is no evidence that probiotics are effective in either UC or CD; however, Escherichia coli Nissle 1917 is not inferior to
5-aminosalicylic acid, and VSL#3 (combination of bacterial strains ) reduced flares of pouchitis (a post-ileoanal pouch procedure
for UC) ‡
Dietary supplements
IBD Vitamin/mineral supplementation for all†,‡ or at least in those with malnutrition or during periods of reduced oral intake‡,¶. Ask for
physician’s advice‡‡,§§
Vitamin B12 (to prevent anemia) and vitamin D (for bones) for those that who are deficient‡
Steroid users should receive calcium and vitamin D supplementation‡
Iron supplements if you are anemic. Chronic iron-deficiency anemia should be treated with parenteral iron if oral iron is
not tolerated‡
CD Diarrhea and poor absorption of necessary nutrients may occur‡‡
UC Iron-deficient anemia due to blood loss occurs in 80% of UC patients¶
Liquid meals (enteral nutrition) for adults
IBD A liquid diet, predigested formula or nothing by mouth may reduce obstructive symptoms‡
CD: Crohn’s disease; IBD: Inflammatory bowel disease; UC: Ulcerative colitis.
© 2011 Amy Brown.
Adapted from:
Clinical practice guidelines:
†
American Dietetic Association (ADA).
‡
World Gastroenterology Organization (WGO).
§
American Society for Parenteral and Enteral Nutrition (ASPEN).
¶
European Society for Clinical Nutrition and Metabolism (ESPEN).
#
Japanese Society for Pediatric Gastroenterology, Hepatology and Nutrition.
Informal dietary suggestions:
††
Crohn’s & Colitis Foundation of America.
‡‡
National Digestive Diseases Information Clearinghouse.
§§
Medline Plus.

www.expert-reviews.com 419
 Review Brown, Rampertab & Mullin

Table 3. A ‘global’ clinical practice guideline summarizing dietary advice for inflammatory bowel disease
patients created by combining current clinical practice guidelines and informal dietary suggestions into
one (not all suggestions are in agreement or based on evidence-based research) (cont.).
Liquid meals (enteral nutrition) for adults (cont.)
CD Enteral nutrition is the sole therapy in adults during the acute phase when corticosteroid treatment is not feasible¶
For enteral therapy, use oral supplements up to 600 kcal/day with food intake, and then tube feeding if higher intakes are
necessary. Continuous tube feeding is better than bolus, owing to a lower complication rate¶
Whole proteins are preferred as free amino acid- or peptide-based formulas are not recommended¶
Enteral nutrition for adult CD patients requiring specialized nutrition support§
Liquid meals (enteral nutrition) for children
IBD An exclusive enteral diet can settle inflammatory disease, especially in children‡
Enteral nutrition should be given to children with growth retardation to help induce a growth spurt§,‡‡
Enteral nutrition should be used as an adjunct to medical therapy in those who are unable to maintain their nutrition status
through oral intake§
Total enteral nutrition (elemental formula) and oral mesalazine is used together as the primary therapy during the onset and
active stage of the disease #
CD Enteral nutrition is indicated for the prevention and treatment of undernutrition, improving growth in children, quality-of-life
improvements, acute phase therapy, perioperative nutrition and maintenance of remission in chronic active disease¶
Vein feeding (parenteral nutrition)
IBD Parenteral nutrition should be reserved for those patients with IBD in whom enteral nutrition is not tolerated §
Parenteral nutrition should be used in children who are unable to maintain normal growth and development on enteral nutrition
or a standard diet§
Total parenteral nutrition with oral mesalazine is reserved for children who have serious illnesses #
Corticosteroids should not be used until at least 1 week after starting total parenteral nutrition, and then additional amounts
used if the child does not respond to total parenteral nutrition #
CD Parenteral nutrition is usually combined with oral/enteral food unless there is continuing intra-abdominal sepsis or perforation¶
Undernourished CD patients may benefit from parenteral nutrition¶,‡‡
Despite encouraging experimental data, insufficient data exist to recommend glutamine, n-3 fatty acids or
other pharmaconutrients¶
Vitamin B12 deficiencies are well documented, especially if the distal ileum is affected by CD or resectioned. In these patients,
serum B12 and folate should be measured annually ¶
Correct nutrient deficiencies with vitamin/mineral supplementation¶
Fistula in CD – a brief course of bowel rest and parenteral nutrition is recommended §
UC Unlike CD, both enteral and parenteral nutrition do not serve as primary therapies in UC, where nutritional deficiencies are not as
common compared with CD. Enteral nutrition is only for patients with undernutrition or inadequate intake¶
Parenteral nutrition should only be used in those with UC who are malnourished or at risk of becoming malnourished before or
after surgery because they cannot tolerate food or an enteral feed¶
Bowel rest should not be provided through the use of parenteral nutrition during acute inflammatory periods¶
Parenteral and enteral nutrition are not recommended for maintenance of remission¶
CD: Crohn’s disease; IBD: Inflammatory bowel disease; UC: Ulcerative colitis.
© 2011 Amy Brown.
Adapted from:
Clinical practice guidelines:
†
American Dietetic Association (ADA).
‡
World Gastroenterology Organization (WGO).
§
American Society for Parenteral and Enteral Nutrition (ASPEN).
¶
European Society for Clinical Nutrition and Metabolism (ESPEN).
#
Japanese Society for Pediatric Gastroenterology, Hepatology and Nutrition.
Informal dietary suggestions:
††
Crohn’s & Colitis Foundation of America.
‡‡
National Digestive Diseases Information Clearinghouse.
§§
Medline Plus.

420 Expert Rev. Gastroenterol. Hepatol. 5(3), (2011)

 Existing dietary guidelines for Crohn’s disease & ulcerative colitis Review

Table 4. Primary nutritional problems related to Crohn’s disease.

Potential nutritional Description
problems
Malabsorption Inflammation, ulceration or surgery can compromise digestion and absorption
Malnutrition Affects 65–75% of CD patients [9] and may include protein-losing enteropathy, iron-deficient anemia†,
calcium, folic acid, iron, zinc, vitamin D, vitamin K and vitamin B12 [10] . Diarrhea may affect zinc, potassium
and magnesium. Steatorrhea compromises absorption of calcium‡, zinc, magnesium and copper [11] .
Dietary supplements are warranted, coupled with yearly routine evaluation of serum B12 and
vitamin D levels
Reduced dietary intake Fear of abdominal pain from consuming food, anorexia, strictures and fistulas can all contribute to
malnutrition [12]
Weight loss Anorexia and malnutrition contributes to weight loss in 65–75% of patients [9,13]
Increased resting energy Caloric requirements can increase during flares [14]
expenditure
Reduced growth Decreased linear growth that may be expressed in adulthood, and delayed puberty occur in 40–50% of
children [15]
Osteopenia 40–50%‡ [12]
Osteoporosis 5–36% [12]
Lack of bowel rest Interferes with the ability of the bowel to heal itself
Dehydration Due to chronic diarrhea. Lack of hydration can lead to kidney stones
Possible food sensitivities due May trigger inflammation, contribute to symptoms and exacerbate any intestinal damage
to allergens and intolerances
Anemia may be due to iron, vitamin B12 and iron deficiencies. Iron deficiency is the main cause of anemia occurring in up to 80% of UC patients [16].
†
‡
Osteopenia may be due to protein, calcium and vitamin D deficiencies.
CD: Crohn’s disease.
© 2011 Amy Brown.

In the USA, clinical practice guidelines do not appear uniform
in their recommendations for enteral therapy. The ACG states,
“corticosteroids are more effective than enteral nutrition to induce
remission in active CD patients,” while the WGO indicates, “An
exclusive enteral diet can settle inflammatory disease, especially
in children.”
The difference between the USA and Japan in the use of enteral
therapy appears to be based on a meta-analysis of six trials (15 eli-
gible trials were found) by Zachos et al., stating that corticosteroids
are more effective than enteral nutrition [23] . In terms of pediatric
patients, Dziechciarz et al.’s. meta-ana­lysis of seven out of 11 ran-
domized clinical ­trials demonstrated similar efficacy for enteral
nutrition compared with corticosteroids  [25] . In Japan, Matsui
et al. concluded from their review that enteral nutrition used as
a primary therapy results in maintaining remissions with lower
adverse reactions, fewer complications and surgeries, and lower
mortality rates than patients not receiving enteral n ­ utrition [26] .
The corticosteroid over enteral nutrition conclusion appears
controversial. Smith mentioned that the exclusion of two large
trials due to concomitant use of other medications in the steroid
arm resulted in both enteral nutrition and steroids having equal
efficacy [24] . In addition, only a few meta-analyses averaging ten
trials or less, exist in the literature. However, our informal litera-
ture search found approximately 36 clinical trials investigating
the use of enteral nutrition in CD patients  [1] . Taken alone and
without comparison to corticosteroids, the majority (86% [30
out of 35]) of these studies resulted in beneficial effects of enteral
nutrition to CD patients [27–56] , while the remaining 14% (five
out of 35) had mixed results [57–61] .
Despite the inconsistent recommendations of enteral nutrition
use mentioned in clinical practice guidelines, the serious side
effects of corticosteroids (especially stunted growth in pediatric
patients) make enteral therapy the recommended treatment in the
USA for children with active CD. It is also recommended for adults
suffering from malnutrition or corticosteroid ­complications [9] .
There are also positive indications that enteral therapy may be a
viable option for some CD patients, at least temporarily. Possible
benefits exist in the form of improved remission and relapse rates,
mucosal healing, hospitalization rates, biochemical values and
nutritional status.
Remission & relapse rates
Researchers sometimes use 3–5 weeks of enteral therapy to place
approximately 85% of their CD subjects into remission prior to
being treated by an experimental drug or diet [62,63] . CD patients
(aged 7–71 years) requiring hospitalization were placed on an
elemental diet (Vivonex®) for 4 weeks and achieved a 92% (22
out of 24) remission rate [64] . Despite a Cochrane review stating
that there was no difference between elemental diet types [23] ,
75% (12 out of 16) of CD patients on an elemental diet (Vivonex)
went into remission compared with only 36% (5 out of 14) on a
polymeric diet (Fortison™). Corticosteroid-resistant IBD cases

www.expert-reviews.com 421
 Review Brown, Rampertab & Mullin

may respond to elemental therapy. Axelsson and Jarnum gave
31 subjects on high-dose prednisone therapy for 1–4 weeks an
elemental diet, resulting in 44% (15 out of 31) remission [62] .
Remission maintenance rates were measured among 61 patients
induced into remission with drugs [50] . After 1, 2 and 4 years,
remission rates were 94, 63 and 63% in the group receiving home
elemental enteral hyperalimentation (HEEH), 75, 66 and 66%
in the group receiving HEEH and drugs, 63, 42 and 0% in the
group receiving drugs, and 50, 33 and 0% in the group receiving
no maintenance therapy, respectively. These researchers concluded
that “elemental diet therapy was effective not only for the induction
of remission, but also for the maintenance of remission in CD” [50] .
Mucosal healing
Enteral therapy may contribute to mucosal healing, which is one
of the latest therapeutic goals in the management of IBD. Several
studies have demonstrated that enteral nutrition allows the GI
tract to heal [27,65–68] . Elemental diets have been reported to sig-
nificantly improve lactulose/l-rhamnose permeability ratios [69]
and cytokine production [70] , suggesting mucosal healing. An
oral polymeric diet (CT3211; Nestle, Vevey, Switzerland) fed to
29 pediatric patients with CD for 8 weeks resulted in complete
clinical remission in 79% of the participants [39] . The clinical
response to the oral polymeric diet was associated with muco-
sal healing and a downregulation of mucosal pro­inflammatory
cytokine mRNA in both the terminal ileum and colon [39] . The
healing of gut inflammatory lesions occurred in 74% (14 out
of 19) of CD pediatric patients receiving an oral polymeric for-
mula compared with 33% (six out of 18) of subjects on cortico­
steroids [68] . Berni Canani also noted that 65% (26 out of 37) of
their pediatric CD patients had improvement in mucosal inflam-
mation compared with 40% (four out of ten) in the corticosteroid
group [67] . In addition, complete mucosal healing was observed
in 19% (seven out of 37) subjects in the enteral group, compared
with none of those receiving corticosteroids.
Enteral therapy may contribute to mucosal healing owing to
decreased fecal bacterial concentrations [71] and/or decreased
­antigen uptake reducing the risk of an inflammatory response.
Hospitalization rates
Enteral nutrition was also recently reported to decrease hospital-
ization rates [72] .
Biochemical values
A total of 28 malnourished CD patients provided with oral nutri-
tion experienced significantly increased serum proteins, creatinine
height index and circulating T lymphocyte numbers, while serum
orosomucoid levels dropped significantly, suggesting that disease
activity was reduced [73] . Sedimentation rate and renal urea excre-
tion decreased in certain IBD patients consuming an elemental
diet [62] . In 17 pediatric patients with CD in their small intes-
tines, linear growth (assessed from height velocity over 6 months)
was significantly greater in the children receiving an elemental
diet [74] .
Nutritional status
Enteral formulas are available to address the insufficient nutrient
intake and growth failure related to IBD in pediatric patients [75] .
Malnutrition is common in IBD due to decreased food intake, mal-
absorption, increased nutrient loss, increased energy requirements
and drug–nutrient interactions [76] . In pediatric patients, weight
loss occurs in up to 85% of those with CD and 65% of those with
UC. Approximately 15–40% of IBD pediatric patients ­experience
growth failure, which is more common in CD than UC.
It may be inaccurate to suggest that ‘nutritional therapies
(enteral nutrition) do not work’ based on the aforementioned
data. They may work as well as pharmaceutical intervention with-
out the side effects. The major problems of enteral nutrition are
patient compliance, their limited duration of use and the 60%
relapse rate that occurs after discontinuation. Other problems
to consider are that elemental diets are liquid, so possible side
effects of this treatment are osmolarity diarrhea, abdominal dis-
tension, colic, cholelithiasis and pneumonia (due to pulmonary
­aspiration) [77] .
Perhaps the decision of whether or not to use enteral therapy
should involve the patient with CD. Such patients should at
least be made aware that enteral therapy is an option available to
them, especially during manageable flares or when considering
certain surgeries. Makola provides a list and cost comparison of
28 elemental, semi-elemental and polymeric formulations [78] .
Expert commentary
More research is needed to elucidate the evidence-based,
dietary-related clinical practice guidelines for patients with IBD.
Suggested research topics include, but are not limited to:

Key issues
• Based on the above review of the current existing dietary guidelines for inflammatory bowel disease (IBD), we suggest the following
regarding nutrient deficiencies, as well as the role diet may play in reducing IBD symptoms.
• Screen all IBD patients for nutritional deficiencies, especially children, and make the appropriate nutrition counseling referrals. Consider
suggesting a vitamin/mineral supplement and or specific nutrient supplementation based on individual patient history.
• Overall dietary suggestions may include to eat smaller, more frequent meals, consume sufficient liquids (especially water), decrease
excess saturated fat, decrease excess sugars (especially disaccharides and polysaccharides) and decrease high-fiber foods during flares.
• Educate IBD patients about possible food sensitivities, and suggest that a 2-week, trial elimination diet may aid in their detection.
Inform Crohn’s disease patients that dietary surveys often list casein and gluten as the top two food offenders.
• Educate Crohn’s disease patients about enteral or oral elemental supplementation options that may alleviate flares, reduce
hospitalization rates and increase the possibility of remission.

422 Expert Rev. Gastroenterol. Hepatol. 5(3), (2011)

 Existing dietary guidelines for Crohn’s disease & ulcerative colitis Review

• Researching the benefit of utilizing enteral nutrition during
flares on reducing hospitalization, medication and surgical rates;
• Quantifying rates of lactose intolerance and other disaccharide,
lipase, pancreatic elastase and protease deficiencies in IBD
patients through stool and hydrogen breath testing;
• Clinically testing elimination diets for effectiveness, if any, in
reducing symptoms of CD, UC and irritable bowel ­syndrome.
Five-year view
We suggest that there is sufficient information to date to incor-
porate nutritional screening for all IBD patients, act proactively
against nutrient and growth deficiencies, and to provide the
dietary suggestions in Table 3 to patients inquiring about diet.
The relatively unexplored area of diet and IBD will remain a work
in progress that will continue to be revised as new research and
clinical practice experiences emerge.
Financial & competing interests disclosure
This research was made possible by a grant from the Broad Medical Research
Program of The Broad Foundation. Amy Brown is CEO of Natural Remedy
Labs, LLC. The authors have no other relevant affiliations or financial
involvement with any organization or entity with a financial interest in or
financial conflict with the subject matter or materials discussed in the
­manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.

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