Today’s Dietitian
Vol. 28 No. 2 P. 30
Inflammatory bowel disease (IBD) is a group of chronic, relapsing immune-mediated diseases that affects an estimated 2.4 to 3.7 million Americans.1 IBD triggers the immune system to attack healthy cells,2 and the most common type is ulcerative colitis, which damages the inner lining of the colon and rectum. The next most common type is Crohn’s disease, which can affect the entire GI tract, from mouth to anus, inflaming areas of the intestine walls and causing patches of damage that can extend all the way through the intestinal wall.1,3
IBD symptoms include abdominal pain and cramping, chronic diarrhea or constipation, bowel urgency, and rectal bleeding. Loss of appetite, fatigue, and weight loss may also occur.4 Diagnosis is based on family history, physical exam, and diagnostic tests,5 and medication is the frontline treatment for reducing inflammation or suppressing the immune response. If drug therapy is unsuccessful, surgery to remove affected areas of the intestines may be necessary. However, surgery generally does not lead to long-term remission.6,7 This has led to a closer look at the role of nutrition therapy, especially with growing patient interest in nonpharmacologic approaches to managing their disease.
A consensus statement released last fall by the European Crohn’s and Colitis Organisation (ECCO)8 looked at the body of evidence for dietary therapies for inducing and maintaining remission. It joins similar statements from other organizations, such as the American Gastroenterological Association (AGA),9 the International Organization for the Study of Inflammatory Bowel Disease (IOIBD),10 and the British Dietary Association (BDA)11 to provide evidence-based recommendations to guide clinical practice, noting that the role of diet in the management of IBD has evolved beyond adjustment for nutritional needs and is now applied as therapy to influence disease activity and complications. Food components can affect both the function of the intestinal epithelial barrier and the composition of the intestinal microbiota, which could modulate the immune system’s inflammatory response.12,13 However, the lack of prior clear dietary recommendations has meant that many IBD patients have experienced unnecessary and unhelpful dietary restrictions.
One of ECCO’s first recommendations was that all IBD patients should have access to a dietitian experienced with IBD. “It was nice to see a larger consensus acknowledge the role of a dietitian in helping improve health outcomes and quality of life for IBD patients,” says Ashley Hurst, MS, RD, LD, owner of The Crohn’s & Colitis Dietitians in Sugar Land, Texas. However, New York-based Brittany Rogers, MS, RDN, CSDH, CPT, founder of Romanwell, a virtual telehealth insurance-based group practice, says she would like to see the acknowledgement of the importance of IBD dietitians appear not just in nutrition-focused statements but also in medical guidelines. “I think that’s where we would probably get more referrals.”
Enteral and Parenteral Nutrition
Exclusive enteral nutrition (EEN) and partial enteral nutrition (PEN) have long been used in the treatment of management of IBD. There was strong consensus that EEN is effective for inducing remission in children and adults with mild-to-moderate Crohn’s disease, and that PEN could be similarly effective when provided in higher volumes (at least 50% of total intake). The authors recommended standard enteral (polymeric) formulas because they are as effective as elemental and semielemental formulas.
Research also supports at least two weeks of EEN for Crohn’s disease patients awaiting surgery and might reduce inflammation and even prevent the need for surgery. Four weeks of preoperative nutrition can reduce the risk of postoperative complications, and most evidence points to four weeks of EEN, or 10 days of oral nutritional supplementation if EEN isn’t feasible. The authors did not find sufficient data to define the optimal preoperative nutrition care for patients with ulcerative colitis.
Dietitians can also consider PEN for maintaining remission in Crohn’s disease, alone or as an adjunct to medical therapy, with evidence suggesting the best efficacy when PEN makes up more than 35% of daily energy requirements. However, details of optimal duration and psychological impact of long-term PEN are unknown.
The Crohn’s disease exclusion diet (CDED)—a three-phase diet that starts with removing foods that may negatively impact the gut microbiome and intestinal barrier integrity14—with PEN is also recommended for induction of remission in children and could be considered in adults with mild-to-moderate Crohn’s disease. However, the evidence is insufficient to support CDED without PEN as induction therapy for Crohn’s disease, or CDED for maintenance of remission of Crohn’s disease.
“I do feel like this strengthens the recommendations for EN, PEN, and CDED for Crohn’s,” Rogers says. “I haven’t had a lot of patients who want to do EEN, but I have had a lot more patients over the past year or two be interested in the CDED with PEN, and PEN on its own.”
However, based on insufficient evidence, the ECCO authors could not recommend using EEN, PEN or the CDED for ulcerative colitis. “There’s really not a lot of research on diet for ulcerative colitis patients,” Rogers says. “Maybe EEN would be just as effective. We just have no idea.” She attributes the research gap to the fact that many more Crohn’s disease patients will eventually need surgery. Estimates are up to 80% of Crohn’s disease patients and around 30% of ulcerative colitis patients.15
Given the risk of harm, the authors don’t recommend using total parenteral nutrition for induction or maintenance of remission of IBD, even though there is evidence that it can be effective as induction therapy for IBD, particularly for Crohn’s.
Dietary Patterns
One area the ECCO guidelines diverges from the AGA and BDA guidelines is related to the Mediterranean diet. The ECCO authors concluded that there is insufficient evidence to recommend the Mediterranean diet to induce remission of IBD, but it could be considered for maintenance of remission in ulcerative colitis as an adjunct to medical therapy. This surprised both Rogers and Hurst.
“The AGA guidelines recommended the Mediterranean diet for all patients with IBD. So, this was kind of a step back because they [ECCO] basically said we have insufficient evidence for Crohn’s. I feel like we do have enough research,” Rogers says, adding that the ECCO recommendation goes against what many dietitians are already doing in practice.
“We know that studies on the diet over six months showed improvements in inflammatory markers, disease activity, and improved quality of life for IBD patients, as noted by the AGA guidelines,” Hurst says.
The statement authors noted that most evidence for dietary interventions in IBD is of low quality, with few studies measuring endoscopic, radiological, or biochemical endpoints, or the durability of any observed responses. Accordingly, they did not recommend use of the specific carbohydrate diet, the low microparticle diet, food-specific IgG-guided diets, gluten-free diets, the Crohn’s Disease TReatment-with-EATing (CD TREAT) diet, the Autoimmune Protocol diet, the IBD-Anti-Inflammatory Diet, the 4-strategies-to-SUlfide-REduction (4 SURE diet), or the ulcerative colitis exclusion diet.
They also did not recommend the low FODMAP diet for maintenance of remission of IBD. However, in patients in remission who have IBS-like symptoms, the diet is recommended for symptom management.
Overall, in the absence of a specific dietary intervention, the ECCO consensus is that people with IBD—and those who want to prevent it—follow the same healthy eating guidelines recommended for the general population. The authors noted this generally means high consumption of fruits, vegetables, whole grains, nuts and seeds, legumes, and fish and low consumption of red meat, processed meats, and high-sugar foods and beverages. They noted that ultraprocessed food intake is associated with the development of Crohn’s disease but not ulcerative colitis.
Food Components and Dietary Supplements
The authors said that while there’s enough evidence to recommend reducing intake of red and processed meat for maintenance of remission in ulcerative colitis patients, there’s not enough evidence to support eliminating cow’s milk protein as an adjunct induction therapy. They also stated there is no consistent evidence to support recommendations on the use of low- or high-fiber diets as induction or maintenance therapy for IBD, although the authors did note that increased dietary fiber is associated with lower risk of developing IBD.
Hurst felt the consensus on fiber is important. “I still see so many patients being told that they cannot have fiber because they have IBD and this is simply not the case. It’s holding many people back from seeing improvements and is often leading people closer to malnutrition, which we already know can impact medication response.”
On the flip side, the authors wrote that evidence is lacking to recommend fiber supplements or prebiotics, which Rogers found frustrating. “They talk about psyllium husk and other soluble fiber supplements not being helpful for induction of remission or maintenance of remission, but, practically, it’s something I use with almost all my IBD patients for symptom management. It feels like a huge gap that they’re not actually calling that out and talking about.” Two supplements that may be helpful for ulcerative colitis are curcumin, which is the main active component of turmeric, and QingDai, a plant-based compound also known as indigo naturalis. Curcumin could be used as an adjunct therapy to the anti-inflammatory medication mesalamine (5-aminosalicylic acid) for induction of remission in mild-to-moderate ulcerative colitis, and on its own for maintenance of remission. However, the optimal formulation, duration, and dose are unclear. QingDai could be used with or without curcumin as an adjunct for induction of remission of mild-to-moderate ulcerative colitis, but not maintenance. Due to potential toxicity of both supplements, medical supervision is advised.
Although higher blood levels of the omega-3 fatty acid DHA are associated with lower risk of IBD, there’s not enough evidence to recommend taking omega-3 supplements for induction or maintenance of remission. Similarly, there’s insufficient evidence to recommend vitamin D or glutamine supplements.
Malnutrition and Nutrition Assessment
Assessment of dietary intake in people with IBD is recommended, as dietary restriction is common—especially during disease flare-ups—often resulting in inadequate energy and nutrient intake. The malnutrition and sarcopenia (involuntary loss of skeletal muscle) that can result are associated with poor clinical outcomes in IBD.
Because BMI does not accurately represent body composition in people with IBD, the ECCO authors recommended including additional assessments of body composition, muscle function, or both. They also recommend monitoring micronutrient levels, ideally during remission, because levels may be falsely altered during active disease. Based on current evidence, risk of deficiency is greatest for vitamin D, folate, iron, and vitamin B12 in Crohn’s disease patients who’ve had an ileal resection. Dietary intake of iron and vitamin C is often low in people with IBD, and dietary calcium intake is often below recommendations for optimal bone health, so assessment of dietary intake of these nutrients is recommended.
Despite the acknowledgement of dietary restriction among IBD patients, other than a brief mention of disordered eating there’s no discussion of co-occurring disordered eating and eating disorders, despite how common it is. “Research suggests up to 93% of patients with IBD have some sort of disordered eating,” Rogers says, adding that this is most often restrictive eating, but she has a patient who was purging because of the GI symptoms related to his Crohn’s. “His Crohn’s actually led to the eating disorder. And then he had feelings of guilt and shame, and there’s so much guilt and shame in this population anyway. They should make some sort of statement about what to do with those patients.”
Evidence Gaps and Future Directions
The authors noted the many evidence gaps, and that advancing diet-focused IBD research would be facilitated by increasing the numbers of research dietitians, as well as financial support. Hurst and Rogers agree there are gaps in the overall body of research on diet and IBD—Rogers says she particularly wants to see more research on microscopic colitis and on fistulas and strictures in Crohn’s disease patients—but also feel that the ECCO consensus missed some additional marks.
“I don’t feel that this consensus speaks to the whole body of research around IBD,” Hurst says. “It is also quite conflicting with other clinical updates from the AGA and the IOIBD guidelines. The article also tends to be very binary with regards to how successful the discussed treatments are but doesn’t acknowledge the full spectrum of markers of success by acknowledging the different types of remission—symptom relief, inflammation relief, endoscopic/histological improvements.”
Rogers says she has many patients who want to be medication free, which she struggles with because she herself has IBD and knows how debilitating a symptom flare can be. “I personally believe let’s do all the evidence-based interventions to keep you in remission for as long as you possibly can. But I try to put my own thoughts aside. And the reality is if they don’t get help from me, then they’re going to get help from the internet or someone who’s going to give them information that’s not evidence based. So, we don’t have enough research on the Med diet for induction of remission in ulcerative colitis, but if someone’s going to do a restrictive diet that has no research, then the Med diet is better for them than that.”
She says that when there’s limited research, she may share that with her patients in the interest of informed consent. “For instance, EEN has been researched in a subpopulation of ulcerative colitis patients who are acutely severe and hospitalized. It showed some benefit and was a randomized controlled trial, but it was just one study. Should we never use that with those patients when we don’t have any other dietary options? I think we should use all the tools that we have in our toolbox when it is a high-quality study and it’s not going to cause any harm.”
Hurst says she’s happy that there’s more conversation about IBD nutrition therapy and the importance of having a dietitian experienced in IBD on the care team. “However, if this were my first time reading up on IBD nutrition, I’d personally walk away feeling like there wasn’t a lot I could do for my patients when in reality, many patients with IBD are already very restricted, skipping meals to avoid triggering symptoms, and showing signs of malnutrition,” she says. “With upwards of 75% of IBD patients experiencing malnutrition at some point, this is an area where dietitians can really be of assistance. Treating malnutrition, staying on top of nutrients and helping patients expand their limited diets through texture modification and other tools is incredibly helpful to their quality of life and improving the chance of remission. For those looking for guidance, I’d recommend also adding the IOIBD guidelines and ESPEN16 guidelines.”
— Carrie Dennett, MPH, RDN, is the nutrition columnist for The Seattle Times, owner of Nutrition By Carrie, and author of Healthy for Your Life: A Non-Diet Approach to Optimal Well-Being.
References
1. Lewis JD, Parlett LE, Jonsson Funk ML, et al. Incidence, prevalence, and racial and ethnic distribution of inflammatory bowel disease in the United States. Gastroenterology. 2023;165(5):1197-1205.
2. Vuyyuru SK, Kedia S, Sahu P, Ahuja V. Immune-mediated inflammatory diseases of the gastrointestinal tract: beyond Crohn’s disease and ulcerative colitis. JGH Open. 2022;6(2):100-111.
3. IBD facts and stats. Centers for Disease Control and Prevention website. https://www.cdc.gov/inflammatory-bowel-disease/php/facts-stats/index.html. Updated June 21, 2024. Accessed October 16, 2025.
4. When to take stomach pain and other GI issues seriously. Crohn’s and Colitis Foundation website. https://www.crohnscolitisfoundation.org/patientsandcaregivers/what-is-ibd/symptoms. Accessed October 18, 2025.
5. How is IBD diagnosed? Crohn’s and Colitis Foundation website. https://www.crohnscolitisfoundation.org/patientsandcaregivers/what-is-ibd/diagnosing-ibd. Accessed October 18, 2025.
6. Cai Z, Wang S, Li J. Treatment of inflammatory bowel disease: a comprehensive review. Front Med (Lausanne). 2021;8:765474.
7. IBD treatment options for long-term symptom relief. Crohn’s and Colitis Foundation website. https://www.crohnscolitisfoundation.org/blog/ibd-treatment-options-long-term-symptom-relief. Published July 29, 2025. Accessed October 19. 2025.
8. Svolos V, Gordon H, Lomer MCE, et al. European Crohn’s and Colitis Organisation consensus on dietary management of inflammatory bowel disease. J Crohns Colitis. 2025;19(9):jjaf122.
9. Hashash JG, Elkins J, Lewis JD, Binion DG. AGA clinical practice update on diet and nutritional therapies in patients with inflammatory bowel disease: expert review. Gastroenterology. 2024;166(3):521-532.
10. Levine A, Rhodes JM, Lindsay JO, et al. Dietary guidance from the international organization for the study of inflammatory bowel diseases. Clin Gastroenterol Hepatol. 2020;18(6):1381-1392.
11. Lomer MCE, Wilson B, Wall CL. British Dietetic Association consensus guidelines on the nutritional assessment and dietary management of patients with inflammatory bowel disease. J Hum Nutr Diet. 2023;36(1):336-377.
12. Ruemmele FM. Role of diet in inflammatory bowel disease. Ann Nutr Metab. 2016;68 Suppl 1:32-41.
13. Knight-Sepulveda K, Kais S, Santaolalla R, Abreu MT. Diet and inflammatory bowel disease. Gastroenterol Hepatol (N Y). 2015;11(8):511-520.
14. Sigall Boneh R, Westoby C, Oseran I, et al. The Crohn’s disease exclusion diet: a comprehensive review of evidence, implementation strategies, practical guidance, and future directions. Inflamm Bowel Dis. 2024;30(10):1888-1902.
15. Khoudari G, Mansoor E, Click B, Alkhayyat M, Saleh MA, Sinh P, Katz J, Cooper GS, Regueiro M. Rates of intestinal resection and colectomy in inflammatory bowel disease patients after initiation of biologics: a cohort study. Clin Gastroenterol Hepatol. 2022;20(5):e974-e983.
16. Bischoff SC, Bager P, Escher J, et al. ESPEN guideline on clinical nutrition in inflammatory bowel disease. Clin Nutr. 2023;42(3):352-379.