Culinary Medicine for IBD
By Carrie Dennett, MPH, RDN
Vol. 25 No. 9 P. 30
Leveraging Food and Nutrition to Improve Patient Outcomes
Culinary medicine blends the art of cooking and the act of eating with the science of medicine, and interest in this field has grown alongside interest in the relationship between food and health. Much of culinary medicine’s focus is on teaching meal planning and cooking skills to treat or reduce the risk of major lifestyle-related chronic diseases, such as CVD, type 2 diabetes, and cancer, as well as on weight control. However, culinary medicine may have applicability to other health concerns, including those that have less research pointing to specific dietary practices, and one specific reason cited for the rise in interest in culinary medicine is dissatisfaction with conventional medical approaches to chronic disease.1 Both of those factors apply to inflammatory bowel disease (IBD).
IBD is an umbrella term for disorders that cause chronic inflammation of the gastrointestinal (GI) tract, with the two most common forms including Crohn’s disease and ulcerative colitis. IBD affects more than 6 million people worldwide, about 3 million of those in North America.2 One of the many downsides of developing any health problem centered on the digestive system is that it affects what patients can eat to minimize uncomfortable and often embarrassing symptoms. But the stakes are higher with structural GI disorders like IBD than they are with functional GI disorders such as irritable bowel syndrome (IBS)—even though culinary medicine is more likely to address IBS. IBD and IBS have some symptoms in common, such as abdominal pain, diarrhea, and urgent bowel movements, but IBD can permanently harm the intestines and increase the risk of colon cancer.
While the causes of IBD aren’t fully understood, it’s thought that in genetically susceptible individuals, an interaction between environmental triggers, the gut microbiome, and an inappropriate reaction of the immune system leads to chronic bowel inflammation. Despite recent advances in medical management of IBD, many patients only achieve partial control of their disease, falling short of clinical remission. Because growing evidence is finding that diet may be a key environmental factor in both the onset and progression of the disease, dietary adjustments may improve patients’ response to treatment, helping reduce specific symptoms as well as overall inflammation.3
Finding more effective interventions is crucial because IBD-related inflammation can contribute to weight loss and malnutrition due to loss of appetite, decreased food intake, elevation of resting energy expenditure, and increased muscle catabolism. Other IBD-related factors, such as mouth ulcers, diarrhea, bowel resections, and nutrient malabsorption, also contribute to the development of malnutrition. When IBD patients develop malnutrition, they may experience prolonged hospitalization, be more likely to need surgery, and have a greater risk of infection and other postoperative complications, including death.3
IBD doesn’t present the same way in all patients, so personalizing advice about which foods to eat and how to prepare them may be an important factor in helping patients make sustainable dietary changes that may improve nutritional status while reducing gut inflammation and abdominal symptoms—thereby improving quality of life. This is where culinary medicine may be more beneficial than simply telling patients what foods to avoid.
“Rather than focusing on which foods to avoid, I prefer to target foods to add into the diet,” says Therezia Alchoufete, MS, RD, LDN, a consultant for the Crohn’s & Colitis Foundation’s Gut Friendly Recipes (www.crohnscolitisfoundation.org/gutfriendlyrecipes), an interactive collection of more than 500 recipes that were vetted by Alchoufete and other RDs, who specialize in IBD. “This gives the patient access to more variety, better nutrition, and hopefully a better quality of life. Having recipes available to guide patients helps to reenforce this strategy with real examples.”
Building Patient Confidence
Though the ideal dietary pattern for IBD patients can help manage inflammation and symptoms while reducing the risk of malnutrition, this isn’t an easy solution. Unfortunately, while the evidence base on a handful of “IBD diets” has grown, often there’s disagreement between diets regarding what foods are allowed or not allowed, which can lead to frustration and confusion among patients. In some cases, the list of permitted foods is short, which can decrease optimal nutrition and make long-term adherence challenging due to the tediousness of a restrictive diet.3 As it is, there’s already a high prevalence of food avoidance and restrictive dietary behaviors among IBD patients, partly due to diet misinformation. A 2021 scoping review found that 28% to 89% of participants avoid foods believed to trigger or worsen symptoms, and 41% to 93% engage in other forms of restrictive eating, such as avoiding eating for fear of fecal incontinence and being unable to find a bathroom.4
A 2020 qualitative study in which researchers interviewed 28 patients with IBD found that the disease had a profound impact on their food-related quality of life. The complex relationship between food and IBD, with patients typically trying to avoid some foods to prevent triggering symptoms while needing to seek out specific foods that might help them prevent or manage symptoms, can negatively impact their personal, professional, and social lives. Being uncertain if and how certain foods affect their symptoms (ie, does a food cause a flare, exacerbate a flare, or have no effect at all) reduces enjoyment of eating, creates a fear of eating, and makes social occasions stressful because of possible pain after eating and the need to be near a bathroom. Complying with restrictions caused by actual or perceived food triggers can make food shopping and preparation feel like more of a burden (ie, reading food labels carefully, having fewer foods to choose from, preparing separate meals at home, not being able to eat the food at some restaurants or gatherings) and can create problems at home, work, and in social situations. And that’s before factoring in the need for careful planning of activities to make sure a bathroom is nearby.5
Building patient confidence in how foods affect their symptoms can help them also reclaim joy in eating, reduce food fears, and increase adherence to a treatment plan. “In my experience, an understanding of food options can help patients with IBD feel more confident and secure when preparing meals,” Alchoufete says. “We can modify food components and textures to help patients reduce flare symptoms as well as prevent future symptoms. This also can help patients reduce fears surrounding food and eating and potentially improve their overall quality of life if meal preparation has become a burden. Having recipe resources for patients with IBD, in addition to medical nutrition therapy with an IBD-focused registered dietitian, can really make a difference in the care of a patient.”
Seattle chef Joel Gamoran, author of Cooking Scrappy and creator of the free livestreaming cooking show “Homemade” (homemadecooking.com), was diagnosed with ulcerative colitis six years ago. It wasn’t a big surprise, as he has a strong family history of the disease and has watched loved ones struggle with it for decades. But he still found himself wondering and worrying about what he could eat. You might think that having a chef’s cooking skills would make it easier to navigate a necessary diet change, but that’s not necessarily the case.
“Our best strengths are always our biggest weaknesses,” Gamoran says. “All I do all day is think about food. And then I’m supposed to navigate that a different way.” He says he found it difficult until he teamed up with the Crohn’s & Colitis Foundation and began to understand what he could eat and what was best for his body. Gamoran ended up partnering with the foundation to develop Gut Friendly Recipes.
One source of conflicting or misinformation, and an area where culinary medicine may help, is in educating IBD patients about the role of fiber. Although dietary fiber intake is safe in IBD patients if overt GI obstruction has been excluded, it’s a food component that often is avoided due to increased abdominal symptoms or the fear of developing them. Preliminary evidence suggests that dietary fiber can alter the gut microbiome, improve IBD symptoms, balance inflammation, and enhance health-related quality of life.6,7 An IBD-related focal point for culinary medicine may be to educate patients about types of beneficial fiber they can integrate into meals and teach cooking methods that can make fiber tolerable.
For example, Gamoran says people with IBD may tolerate eating farro or other whole grains but find that eating wheat flour affects their digestion. Like many people with IBD, he had to get creative to be able to tolerate cruciferous vegetables. “It’s really hard for me to eat coleslaw, but if I braise cabbage with a little chicken stock, that goes well,” he says. Many Gut Friendly Recipes suggest cooking vegetables for longer or peeling off skins, if needed, to make them more digestible. “Experiment. Try the salad, and if that doesn’t work for you, try chopping the salad really fine. If that still doesn’t work, then add a squeeze of lemon and let it wilt down.”
Culinary Medicine Resources
While much of the education on culinary medicine is geared toward the biggest lifestyle-related chronic diseases and to developing teaching kitchens and cooking demonstrations,8 these things aren’t available to all patients, whether due to geography or income or because their disease isn’t common enough to be a focal point for culinary medicine. The Culinary Medicine Specialist Board’s Health meets Food culinary medicine program (CulinaryMedicine.org), which partners with more than 55 medical schools, residency programs, and nursing schools, includes an optional module on IBS, IBD, and gastroesophageal reflux disease in its Certified Culinary Medicine Specialist Curriculum. The University of Massachusetts Chan Medical School’s Center for Applied Nutrition offers group cooking classes based on the Anti-Inflammatory Diet for IBD.
This is where websites such as Gut Friendly Recipes can bridge the access gap. The site, which launched at the beginning of 2023, is still in its first phase. Currently, registered users can save favorite recipes and create meal plans. Phase 2 will include more cooking videos and personalization options. Catherine Soto, senior director of patient education and support for the Crohn’s & Colitis Foundation, says the site will continue to grow to include not just more recipes but more recipes that represent a variety of cultural food traditions. Not only is this a useful, supportive tool for patients, but RDs who want to offer cooking demonstrations or kitchen skills training to their IBD patients also may find it informative.
As with the overall field of culinary medicine, dietary recommendations for IBD aren’t one size fits all. Culinary medicine is most closely aligned with the Mediterranean diet, which research suggests may be useful for some patients with IBD.8 Currently, Gut Friendly Recipes supports the Crohn’s Disease Exclusion Diet and the Specific Carbohydrate Diet, both of which have the strongest evidence base for helping to manage IBD and reduce symptom flare-ups, as well as the Mediterranean diet and the low-FODMAP diet. The site will evolve to meet the also-evolving science on the connection between IBD and diet. “The biggest question we receive at the foundation is ‘What should I eat?’” Soto says. “We would love to be at the point where we can say, ‘This one diet,’ but we’re not at that point. That’s part of the complexity of this disease. Diet does have a role to play in IBD, there’s more research needed to understand it.”
Gamoran says he also gets the “What can you eat?” question frequently. “I see it as, ‘What can you not eat.’ When you get diagnosed with anything, I think it’s like, ‘Oh God, what do I have to change?’ But there’s a million ways you can go with this.” He says learning how to cook—then teaching people how to get behind the stove—has been his calling. “I want to give people that confidence and those tools. If people want to take care of their health, they have to cook. Just being able to have that arrow in your quiver is important. It doesn’t matter if you’re dealing with Crohn’s or colitis or not.”
People living with IBD still can do the things they love, Soto says. “You might have to navigate things along the way, but we want you to find what works for you. There’s some science that shows us that certain diets may be helpful, and within that you may have choices,” she says. Ultimately, she adds, it’s about learning which foods you can tolerate and meeting your nutritional needs.
“Nutrition research in IBD has come a long way in recent years, and we still have so much more to learn,” Alchoufete says. “It’s so important to individualize medical nutrition therapy for each patient and recognize the important role food can play in each person’s life—medically, functionally, culturally, emotionally, and so much more,” she continues. “I think Gut Friendly Recipes will be a well utilized tool in many patient’s toolboxes. We discuss these tools as a way to tackle challenges that each patient faces, and plans are developed that are individualized to patients’ needs. As their dietitian provides guidance on meal preparation or food selections, having Gut Friendly Recipes available can complement this education and allow a customized meal plan to be developed, or simply provide the patient with more diet variety to help them understand how to build their plate.”
— 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.
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