IBD in Focus: Causes, Treatment and the Power of Lifestyle

Source: Jeleefstijlalsmedicijn

Author: Dr. Anje te Velde, Biomedical researcher/Immunologist AmsterdamUMC, Tytgat Institute for Liver and Intestinal Research, Scientific advisor Stichting Je Leefstijl Als Medicijn
Author: Victorien Madsen, Project leader IBD Stichting Je Leefstijl Als Medicijn, volunteer Nutritional Therapy for IBD.
Medical-scientific reviewer: Dr. Pieter Stokkers, Gastroenterologist, OLVG, Amsterdam.

Key messages from this article

(reading time 27 minutes):

1. How often IBD occurs: Approximately 0.5 to 1 percent of the population in Western countries has IBD, with increasing numbers worldwide, especially in countries adopting a Western lifestyle, with a peak age between 20 and 30 years.
2. Causes: IBD develops through an interplay of genetic factors, environmental factors, changes in the gut microbiome, and disrupted molecular mechanisms in the immune system.
3. Environmental factors: Diet (especially ultra-processed food), smoking, antibiotic use, and other lifestyle factors influence the risk of IBD and the severity of flare-ups.
4. Treatments: Current medical treatments focus on suppressing inflammation through mesalazine, glucocorticoids, immunosuppressants, monoclonal antibodies, and JAK kinase inhibitors.
5. Nutritional therapies: Various diets such as Exclusive Enteral Nutrition (EEN), Specific Carbohydrate Diet (SCD), IBD Anti-Inflammatory Diet (IBD-AID), Crohn’s Disease Exclusion Diet (CDED), Autoimmune Protocol (AIP), and the Mediterranean diet can help manage IBD.
6. Low-FODMAP: For non-inflammatory symptoms, the Low-FODMAP diet can help reduce IBS-like complaints in IBD patients in remission, by limiting certain fermentable carbohydrates.
7. Malnutrition: Many IBD patients struggle with malnutrition due to reduced appetite, malabsorption, increased loss of nutrients, increased metabolic needs, and dietary restrictions.
8. Physical exercise: Regular, moderate physical exercise improves immune function, reduces inflammation, relieves symptoms, reduces fatigue, and helps with weight management.
9. Stress management: Stress can trigger IBD flare-ups; techniques such as mindfulness, meditation, yoga, and adequate sleep can lower stress levels and reduce inflammation.
10. Smoking: Quitting smoking is crucial for people with Crohn’s disease, as smoking increases the risk of surgeries and disease progression, although the relationship with ulcerative colitis is less clear.

1. Introduction

The increasing prevalence of IBD, such as Crohn’s disease and ulcerative colitis, worldwide emphasizes the need for ongoing research into the underlying mechanisms and effective treatment strategies. In this article, we dive deeper into the world of IBD, examining the causes, symptoms, and treatment options, and discuss the crucial role of lifestyle changes and nutritional therapies, which are increasingly recognized as an essential part of treating this complex condition.

2. What is IBD:

Inflammatory Bowel Disease (IBD) is a collective term for chronic conditions characterized by inflammation in the gastrointestinal tract. The two main forms of IBD are Crohn’s disease and ulcerative colitis. Crohn’s disease can affect any part of the gastrointestinal tract, from the mouth to the anus, and often penetrates into deeper layers of the intestinal wall. Ulcerative colitis, on the other hand, is limited to the large intestine and rectum and primarily affects the innermost layer of the mucous membrane.

In IBD, the immune system reacts incorrectly to the bacteria in the intestines. Normally, the immune system helps maintain a balance between fighting harmful bacteria and leaving beneficial bacteria alone. In people with a predisposition to IBD, this balance is disrupted, causing the immune system to react too strongly to harmless gut bacteria and disturbances of the intestinal wall. This leads to ongoing inflammation in the intestines. Additionally, the body produces extra inflammatory substances, such as TNF-α and interleukins. These substances attract inflammatory cells, which then continue to irritate and damage the intestinal lining. This maintains the inflammation and makes it difficult for the body to heal itself.

The symptoms of IBD vary from person to person, but usually include:

• Persistent diarrhea.
• Abdominal pain,
• Rectal bleeding,
• Weight loss and
• Fatigue.

Periods of “flare-up” and remission often alternate, and symptoms fluctuate. Without proper diagnosis and treatment, IBD can lead to serious complications such as:

• Intestinal obstruction, particularly in Crohn’s disease, where inflammation can narrow the intestines.
• Malnutrition as a result of reduced appetite, poor absorption of nutrients, or restrictive eating habits.
• Fistulas (abnormal connections between organs) and abscesses (localized infections), especially occurring in Crohn’s disease,
• An increased risk of colon cancer, especially with long-term ulcerative colitis.
• Inflammation in other parts of the body, such as the liver, joints, skin, and eyes

A diagnosis of IBD is made after determining the patient’s medical history, physical examination, blood and stool tests, and more importantly, the endoscopic (intestinal examination) and histological (tissue examination) picture. Early diagnosis and effective treatment are essential to keep IBD under control and prevent complications. Nutrition and lifestyle as part of treatment from the first diagnosis can increase the chance of remission and reduce the development of complications (Garcia-Mateo et al., Chicco et al., Rozich et al.).

3. Is IBS the same as IBD?

IBS (Irritable Bowel Syndrome) is a functional disorder of the gastrointestinal tract characterized by chronic abdominal complaints and changes in bowel movements, such as diarrhea, constipation, or a combination of both. In contrast to IBD, IBS does not cause visible inflammation or damage to intestinal tissue.

Although IBS and IBD are different conditions, they can overlap in certain ways:

• Shared symptoms: Both conditions can cause abdominal pain and changes in bowel movements. However, the underlying causes are different: in IBD there is structural damage and inflammation, while this is not the case in IBS.
• Co-existence: 30% of people with IBD who are in remission also receive an IBS diagnosis. (Wieçek et al)
• Misdiagnosis: The early symptoms of IBD can sometimes resemble those of IBS, which can lead to a delay in the correct diagnosis. Tests such as measuring calprotectin or a colonoscopy are essential to distinguish between the two.
• Impact of stress: Stress can worsen the symptoms of both IBS and IBD, but plays a greater role in worsening the symptoms of IBS.

4. How often IBD occurs

Approximately 0.5-1% of people in Western Europe and North America have IBD and this percentage has been increasing in recent years. Also in other countries where a more Western lifestyle has been adopted more recently, the number of people with IBD is increasing. There are studies showing that people who migrate to an area with a high incidence have a higher chance of developing IBD. The age at which most people get IBD is between 20 and 30, and it occurs slightly more often in women (Wang R. et al).

Prevalence (left) and incidence (right) trends from 1990 to 2019. Charts obtained from Global Burden of Disease (GDB) (Diez-Martin et al).

5. Mechanisms and factors contributing to the development of IBD

Why someone develops IBD is not precisely known. Currently, we think that chronic intestinal inflammation can be caused by an interplay of exposure to certain environmental factors, a changed gut microbiome, and genetic susceptibility. From genetic research, among others, risk factors have been defined, generating knowledge about the mechanism of how the immune system goes awry in IBD. (Ananthakrishnan et al.):

• Genetic factors.
• Environmental factors (diet, playing outside as a child, toxic substances, stress, sleep)
• Changes in the microbiome
• Molecular mechanisms

5.1. IBD and Genetic factors

In Crohn’s disease and ulcerative colitis, genetics plays an important role. Much knowledge about this comes from large-scale genetic studies called genome-wide association studies (GWAS). These studies show that IBD is caused by multiple genetic variations, i.e., polygenic conditions. This means that no single gene is responsible, but that different genes together contribute to the risk of IBD (Graham, B, and Xavier R).

From these studies, more than 200 genetic regions (loci) have been identified that are associated with IBD. Some are specific to Crohn’s disease and some specific to ulcerative colitis. This can explain why patients with these diseases sometimes have different symptoms and characteristics. Most of these loci (68%) appear to be involved in both diseases, suggesting they share overlapping inflammatory mechanisms.

Additionally, it appears that many of the genetic variations that occur in IBD also play a role in other autoimmune diseases, such as psoriasis (chronic skin condition) and ankylosing spondylitis (chronic rheumatic condition). This explains why some patients with IBD also experience complaints outside the intestine, such as skin or joint problems. Some of these genes influence the functioning of certain immune cells, such as T-helper cells (Th17) and regulatory T-cells (Treg). A disruption in the balance between these cells can lead to an overactive immune response and chronic inflammation in the intestine (Ramos G.P., et al).

5.2. Environmental factors

Environmental factors play a crucial role in the risk of developing IBD. Diet, smoking, and antibiotic use can influence intestinal inflammation and the composition of the microbiome. The Western diet, particularly a high intake of highly processed foods and a low-fiber diet, can disrupt the intestinal barrier and promote inflammation. Smoking has an ambiguous effect: it worsens Crohn’s disease but appears to have a protective effect against ulcerative colitis. Of course, the benefits of possibly preventing ulcerative colitis do not outweigh the other health risks of smoking. The use of antibiotics can disrupt the gut microbiome and possibly trigger or worsen IBD symptoms.

5.3. Changes in the gut microbiome

The gut microbiome is the collection of billions of bacteria, viruses, fungi, and other microorganisms that live in the intestines. These microbes play an important role in digestion, the immune system, and overall health. A healthy balance of the gut microbiome helps with food digestion, fighting harmful invaders, and reducing inflammation. It plays a crucial role in maintaining gut health. Dysbiosis, or an unbalanced composition of gut bacteria, is associated with the development of IBD. Patients with IBD often show reduced diversity of beneficial bacteria, such as Faecalibacterium prausnitzii, and an increase in potentially harmful species such as Escherichia coli. This microbial imbalance can disrupt the mucosal barrier, activate immune responses, and contribute to chronic inflammation (Pittayanon et al).

5.4. Molecular mechanisms

At the molecular level, various mechanisms contribute to the development of IBD, including for example:

1. Intestinal barrier dysfunction:
   The intestinal epithelial cells are the cells that line the inside of the intestine and form a protective barrier between the intestinal contents and the rest of the body. They help with the absorption of nutrients, prevent harmful substances and bacteria from entering the body, and play a role in the immune system by sending signals during infections or inflammation. Disruption of this barrier allows the passage of bacteria and antigens, which triggers immune responses and inflammation. This is also called leaky gut.
2. Cytokine production:
   Cytokines are small proteins released by cells of the immune system to transmit signals and regulate inflammatory responses. They play an important role in the defense system by activating other immune cells, fighting infections, and promoting wound healing. Some cytokines stimulate inflammation (pro-inflammatory cytokines), while others inhibit inflammation (anti-inflammatory cytokines). Pro-inflammatory cytokines, such as TNF-α, interleukin-1β, and interleukin-6, play a central role in the inflammatory response in IBD. These cytokines promote the recruitment and activation of immune cells, leading to tissue damage and the continuation of inflammation. Inhibiting these cytokines forms the basis of many current treatments for IBD.
3. Oxidative stress:
   During inflammation in the intestines, the body produces extra aggressive oxygen particles, also called reactive oxygen species (ROS). These particles can cause damage to cells and tissues in the intestine. This is called oxidative stress. This damage weakens the intestinal wall, making it easier for bacteria and other harmful substances to enter. This causes the immune system to keep responding and the inflammation not to stop — thus creating a negative vicious cycle.

Diez-Martin, E. et al. , Christensen. C. et al. Ananthakrishnan et al.

Box: The role of the Inflammasome in IBD

To properly understand what goes wrong in the immune system during a chronic intestinal inflammation (and other chronic conditions), we must look at the interaction of DAMPs (Danger Associated Molecular Patterns) and the inflammasome.

a. The immune system is complex and consists of an innate, less specific response and an adaptive, specific response to a pathogen. The adaptive response involves producing antibodies and activating cells that clear pathogens. Three steps are needed for this response: first, dendritic cells present a piece of the pathogen to the immune system. These cells must be activated by danger signals (Danger Associated Molecular Patterns — DAMPs), which can also come from dead cells. After activation, the dendritic cells strengthen the interaction with lymphocytes, which can ultimately clear the pathogen. The third step is producing special messenger proteins that determine the necessary direction of the immune response.


b. DAMPs play a crucial role in the activation of the NLRP3 inflammasome, a protein complex that promotes inflammation by producing IL-1beta, among other things, which causes fever. The inflammasome must be quickly deactivated after fighting infection to prevent tissue damage. Activation occurs in two phases: in the first phase, NLRP3 is prepared in the cell, and in the second phase, when DAMPs are present, the inflammasome is activated.

c. A leaky gut can contribute to diseases because pieces of pathogens, such as lipopolysaccharide (LPS) from gut bacteria, enter the bloodstream. This can activate NLRP3, leading to a chronic inflammatory response. Environmental factors, such as pollution and processed food, can also contribute to the ongoing activation of NLRP3. In people with an unhealthy lifestyle, there is an increased chance of chronic inflammation due to this ongoing activation of the immune system. (Sandys, O. & te Velde A.)

See also The inflammasome and the microbiome, or the science behind eating varied vegetables and fruit

6. Current medical treatment of IBD

In the treatment of IBD, intervention occurs in the inflammatory process that arises from an overactive immune system. It is assumed that this inflammatory process is the result of an abnormal response of the immune system to substances in the intestine. Over the past two decades, various immune-modulating therapies, including biological drugs and small molecules, have become available for the treatment of IBD, with a third of patients achieving long-term remission.

6.1. Mild treatments

The simplest treatments focus directly on reducing inflammation in the intestine:

• Mesalazine: Inhibits the production of prostaglandins, substances that enhance inflammation, in the intestinal mucosa.
• Glucocorticoids (e.g., budesonide): Reduce inflammation by temporarily suppressing the immune system.

Although these agents are effective in controlling inflammation, they do not address the underlying cause.

6.2. Suppression of the immune system

To address the overactive immune response, stronger treatments have been developed.

• Older methods: Drugs such as thiopurines and methotrexate, often in combination with corticosteroids, suppress the immune system in a general way.
• Monoclonal antibodies: In the 1990s, infliximab was introduced, an antibody that specifically blocks the inflammatory protein TNF. This was a breakthrough for patients who did not respond to older treatments. Since then, more monoclonal antibodies have been developed, each targeting specific proteins that are involved in the immune system.

6.3. Challenges with monoclonal antibodies

Monoclonal antibodies are specific proteins made in a laboratory to target a specific molecule in the body. They are designed to support the body’s natural defense system. Although these therapies can be effective, there are some challenges:

• Complexity of the immune system: It is difficult to predict which patient will respond to a specific treatment. Therefore, “trial and error” is often used.
• Evolution of the immune system: Over the course of human evolution, the immune system has developed multiple mechanisms to cause inflammation. If one route is blocked, the body can sometimes use another route. This can lead to reduced effectiveness of the medication or new autoimmune diseases, such as arthritis or psoriasis.

6.4. Newer treatments: JAK kinase inhibitors

Recently, JAK kinase inhibitors have been developed, a new class of drugs that again provide broader immune suppression. Although they are less specific than monoclonal antibodies, they work at a central point in the immune response. This makes them effective, but more side effects can occur, such as infections or immunosuppression-related problems.

Medical treatments often do not yet provide the desired result and do cause many side effects. For many patients, it is a matter of “trial and error” and medication can also decrease in effectiveness over time. Adding nutritional therapies and lifestyle changes can ensure that medication works better and longer, and that less medication is needed and the number of side effects can decrease. (Sahu P. et al, Suskind D.L. et al)

The treatment of IBD is complex and requires careful consideration between effectiveness and possible side effects. The choice of therapy depends on the severity of the disease, the stage, and how a patient responds to previous treatments. Despite progress, challenges remain, and there is continuous search for better and safer treatment methods.

7. What you can do with lifestyle

Lifestyle changes can complement medical treatments for IBD, but they can also significantly contribute to improving symptom control and quality of life. By focusing on nutrition, physical exercise, stress management, sleep, and avoiding harmful habits like smoking, people with IBD can play a more active role in managing their condition. The development of a personalized lifestyle plan, in collaboration with healthcare providers, is crucial for achieving the best possible results in managing IBD.

Integrating the strategies below into daily routines can help to experience fewer flare-ups, relieve symptoms, give a sense of personal control, and improve overall well-being.

The 6 lifestyle pillars

7.1. Nutrition and Diet

Nutrition plays an important role in managing IBD symptoms. There are various nutritional therapies that we describe in more detail later, but there are also some general recommendations that can help prevent the risk of IBD or new flare-ups (Christensen et al.).

• Avoiding ultra-processed food is an important first step in adjusting nutrition. Ultra-processed food includes industrially produced foods with many added sugars, salts, fats, and artificial additives such as soft drinks, cookies, ready-made meals, chips, processed meat, and fast food.
• Identify Trigger Foods: Certain foods can worsen symptoms, such as dairy, high-fiber foods, fatty and spicy dishes. Keeping a food diary can help identify personal triggers.
  In 2019, 200 people with Crohn’s disease or ulcerative colitis anonymously shared their stories at the Voeding Help information point about how they experience that foods and drinks influence complaints such as fatigue, abdominal pain, and bowel problems. This resulted in a clear top 5 of eating less and eating more:
• Balanced dietary pattern: IBD can lead to nutrient deficiencies, so it is important to follow a diet that supports overall health. This includes sufficient proteins, vitamins, and minerals. Consulting a dietitian specialized in IBD can help in creating a personal nutrition plan or starting one of the nutritional therapies described later.
• Probiotics: Probiotics can offer benefits by restoring the balance in the gut microbiome, which is often disrupted in people with IBD. They can help manage inflammation and promote healthy gut function. However, it is important to consult a healthcare provider before starting to use probiotics, as effectiveness can vary between individuals and certain strains may be more beneficial than others.
• Hydration: Adequate hydration is essential for digestive health, especially with diarrhea, which is a common symptom of IBD.
• Mindful eating: Mindful eating is an approach to eating where you are fully aware of the experience of eating and drinking. It involves paying attention to the flavors, smells, textures, and sensations of food, as well as your own hunger and satiety signals. Mindful eating encourages eating without distractions, such as television or phones, and helps develop a healthy relationship with food through more awareness and fewer automatic eating habits (Verma, P. ).

7.2. Regular Physical Activity

Physical exercise offers various benefits for people with IBD. Although disease activity can reduce tolerance for physical exercise, regular, moderate exercise can help manage symptoms. (Severo et al) (Engels et al.)

• Improvement of immune function and reduction of inflammation: Regular physical exercise helps improve immune function and reduces the production of pro-inflammatory cytokines involved in IBD inflammation.
• Improvement of gastrointestinal function: Exercises can relieve symptoms such as bloating, abdominal pain, and constipation. Studies have shown that people with IBD who exercise regularly experience fewer flare-ups and have better symptom control.
• Reduction of fatigue: Fatigue is a common symptom of IBD. Physical activity, especially activities like walking or swimming, can improve energy levels and reduce feelings of exhaustion.
• Weight management: Regular physical exercise helps maintain a healthy weight, which is especially important because obesity is linked to poorer outcomes in IBD. Obesity is associated with a higher risk of relapse and less effective treatments.

7.3. Stress Management

Stress is a known trigger for IBD flare-ups, although the exact role in disease activity is not yet fully understood. Nevertheless, managing stress is essential for better symptom control.

IBD can lead to anxiety and depression-like comorbidities by causing neuroinflammation. (Li et al.)

• Mindfulness and relaxation: Techniques such as meditation, yoga, and deep breathing can help lower stress levels and promote relaxation. These practices not only support emotional well-being but can also reduce inflammation.
• Adequate sleep: Sleep disorders are common in people with IBD, and poor sleep quality can worsen symptoms. It is essential to get a full night’s rest. Creating a calming bedtime routine and limiting screen time before sleep can improve sleep quality.

7.4. Quitting Smoking

Smoking is an important risk factor for the development of Crohn’s disease and can worsen IBD outcomes, such as increasing the risk of surgeries and disease progression. Smoking disrupts the effectiveness of certain treatments and can hinder recovery.

Quitting smoking is one of the most impactful changes that someone with IBD can make to improve their prognosis. Although the relationship between smoking and ulcerative colitis is less clear, and sometimes can even have a positive effect on the disease course, quitting offers numerous benefits for overall health.

7.5. Alcohol and Cannabis Use

The effects of alcohol and cannabis on IBD are still being studied. Some studies suggest that cannabis may reduce the chronic pain associated with IBD without affecting remission, while alcohol can irritate the intestine and trigger flare-ups. Moderation is important and people with IBD should monitor how these substances affect their symptoms.

7.6. Good Social Contacts and Counseling

A strong social network is essential for coping with IBD. Contact with others who understand the challenges of a chronic condition can provide emotional support and practical tips for symptom management. Therapy, including cognitive behavioral therapy (CBT), and group counseling can help manage anxiety and depression, which often accompany chronic diseases like IBD.

7.7. Regular Medical Check-ups

Regular visits to a healthcare provider are necessary to monitor the progress of the disease and adjust the treatment plan as needed. Healthcare professionals can also provide advice on managing symptoms through lifestyle changes and recommend other interventions when needed.\

Sources: Rozich J. et al., Strobel T.M., et al., Nutritional Therapy for IBD , García-Mateo s., et al.

8. Possible nutritional therapies for the treatment of IBD

Although standard treatments for IBD generally mainly involve medication, nutritional therapies are receiving increasing attention due to their role in managing IBD. There are various dietary interventions possible, including Exclusive Enteral Nutrition (EEN), the Specific Carbohydrate Diet (SCD), the IBD Anti-Inflammatory Diet (IBD-AID), the Crohn’s Disease Exclusion Diet (CDED), the Autoimmune Protocol (AIP), and the Mediterranean diet. We highlight the principles, effectiveness, and practical considerations of these diets.

8.1. Exclusive Enteral Nutrition (EEN)

EEN involves consuming exclusively a complete liquid nutrition for a certain period, usually 6-8 weeks, excluding all other foods. This approach is particularly effective in inducing remission in children with Crohn’s disease. Studies show that EEN can reduce inflammation and allow the intestinal wall to heal. However, it can be difficult to maintain this therapy both due to social limitations and due to so-called “taste fatigue,” because there is very limited variation. Recently, a study was also done on a “home-made Whole Foods smoothie” with promising results. This could improve the possibility of adapting to taste, need, and personal tolerances.

8.2. Specific Carbohydrate Diet (SCD)

The SCD focuses on eliminating complex carbohydrates, processed foods, and certain dairy products, while promoting the consumption of simple sugars, fruits, vegetables, and unprocessed meats. The idea is to reduce intestinal inflammation by limiting nutrients that stimulate the growth of harmful gut bacteria. A randomized controlled trial has examined the SCD as induction therapy for children with Crohn’s disease, showing possible benefits in symptom management. Among patients, this diet, which was developed in the early 1970s by Elaine Gottschall, and further researched and applied by David Suskind, MD, at Seattle Children’s Hospital, is popular. However, existing studies are small-scale and more extensive research is needed.

8.3. IBD Anti-Inflammatory Diet (IBD-AID)

The IBD-AID was designed by UMass Medical School Center for Applied Nutrition to influence the gut microbiome and reduce inflammation. It contains elements of the SCD but allows certain grains and emphasizes prebiotic and probiotic foods. The diet is structured in phases, starting with easily digestible foods and gradually expanding to a broader range of foods based on tolerance. Clinical observations show that patients with IBD experience improvements in symptoms and quality of life when following the IBD-AID, although controlled studies are limited.

8.4. Crohn’s Disease Exclusion Diet (CDED)

The CDED is aimed at excluding specific food components that contribute to intestinal inflammation and microbiome disruption, such as certain additives, emulsifiers, and processed foods. Studies regarding CDED show that the diet can be effective in maintaining remission in children with Crohn’s disease. The first studies in adults are also very promising. The diet is often implemented in phases, first combining partial enteral nutrition (liquid food) with solid foods, and then gradually increasing the proportion of solid foods, while symptoms are monitored.

8.5. Autoimmune Protocol (AIP)

The AIP is an elimination diet where potential “triggers” are removed from the diet, including grains, legumes, nightshade vegetables, dairy, and processed foods. The focus is on nutritious, anti-inflammatory foods, such as fatty fish, bone broth, fermented foods (kombucha, kimchi), berries, and leafy greens. After an elimination phase, foods are systematically reintroduced to identify individual sensitivities. Although the AIP is popular for various autoimmune diseases, the scientific evidence for its effectiveness in IBD is limited. More rigorous studies are needed to establish the role of the AIP in IBD management.

8.6. Mediterranean Diet

The Mediterranean diet emphasizes fruits, vegetables, whole grains, legumes, nuts, and olive oil, with moderate consumption of fish and poultry. It thus consists mainly of pure, unprocessed food, with high nutritional value. This diet is known for its anti-inflammatory properties and is associated with a reduced risk of various chronic diseases. There are increasing studies showing that the Mediterranean diet can also have a beneficial effect on inflammatory markers and symptoms in IBD, and support the effect on overall health. However, individual tolerance for high-fiber foods must be considered, especially during active disease phases.

8.7. New diet: Tasty & Healthy

Recently, the results of the ‘Tasty and Healthy diet’ study have been released showing that this diet is effective for Crohn’s disease and easier to maintain than EEN (Exclusive Enteral Nutrition) with better microbiome diversity as a result - the accompanying article has yet to be published, but the results were presented at ECCO 25 and are promising.

8.8. Low-FODMAP (For non-inflammatory symptoms)

Although the primary focus of IBD treatment is on managing inflammation, it is also important to address functional gastrointestinal complaints. Research shows that the Low-FODMAP diet can be effective in reducing IBS (Irritable Bowel Syndrome)-like symptoms, such as bloating, abdominal pain, in IBD patients who are in remission.

The Low-FODMAP diet involves limiting certain carbohydrates, known as fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs). These short-chain carbohydrates are poorly absorbed in the small intestine and can be quickly fermented by gut bacteria. This leads to increased gas production and water retention in the intestines, which can result in bloating and abdominal complaints.

The Low-FODMAP diet is typically completed in three phases:

1. Elimination phase: Foods with a high FODMAP content are completely removed from the diet for 4-6 weeks — examples are onion, garlic, cauliflower, apples, whole grain cereals, and honey. Low-FODMAPs that can be eaten or eaten in moderation are for example: carrot, potato, cucumber, eggs, oatmeal, and eggplant.
2. Reintroduction phase: Specific FODMAPs are gradually reintroduced to identify individual triggers.
3. Personalization phase: A long-term dietary pattern is developed incorporating tolerated foods and avoiding triggers.

Long-term strict adherence to the Low-FODMAP diet is discouraged, as this can have a negative impact on the gut microbiome.

8.9. Practical Considerations

When considering nutritional therapies for IBD, it is essential to tailor dietary interventions to disease activity, nutritional status, and personal preferences. Collaboration with healthcare providers, including gastroenterologists and dietitians, is essential and ensures that dietary adjustments are safe and nutritious. Regular monitoring and adjustments can help maintain remission and improve quality of life.
The visual guide from voedingleeft and the IBD Nutrition Navigator from Nutritional Therapy for IBD can help healthcare providers and patients jointly determine which nutritional therapy or dietary adjustments best fit the patient with IBD.

Sources: Reznikov et al., Magen-Rimon R., et al., Christensen C., et al., Manski S. et al., Sigall Boneh R., et al., Naik R.G., et al., Suskind D.L., et al., Więcek M., et al.

**Box: Malnutrition in IBD **

Malnutrition is a common complication in people with inflammatory bowel diseases (IBD), such as Crohn’s disease and ulcerative colitis. Malnutrition does not always mean that someone eats too little. It mainly means that someone gets too few or the wrong nutrients. Inflammation can disrupt the absorption and processing of nutrients, leading to various health problems.(Massironi et al)
Patients with Crohn’s disease typically develop a disrupted nutritional status over a longer period, while patients with ulcerative colitis often show a sudden and severe nutrient deficiency during an acute, severe flare-up of the disease. (Balestrieri et al.)

Factors contributing to malnutrition in IBD:
* Reduced appetite: Inflammation and discomfort in the digestive tract can lead to loss of appetite, making it difficult to get enough calories and nutrients.
* Malabsorption: Damage to the intestinal wall from inflammation can impair the absorption of nutrients from food, resulting in deficiencies of vitamins, minerals, and other essential nutrients.
* Increased loss of nutrients: Chronic diarrhea and inflammation can lead to increased loss of nutrients through stool. Blood loss can lead to iron deficiency.
* Increased metabolic needs: During active inflammatory periods, the body has an increased metabolism, leading to a higher need for nutrients that is difficult to meet through diet alone.
* Dietary restrictions: Some people with IBD avoid certain foods based on symptoms and disease activity, which can limit nutrient intake.
* Certain medications can also affect the absorption of nutrients.


**Malnutrition can cause additional complications such as: **
* Weight loss
* Fatigue
* Muscle wasting
* Reduced immune function
* Delayed healing ability
* Reduced bone health.

It is essential for patients with IBD to work closely with their healthcare professional to prevent malnutrition. Working with a registered dietitian can help create a balanced diet that meets the specific needs and tolerances of the individual. Additionally, blood tests can detect nutrient deficiencies and nutritional supplements can be recommended to improve nutritional status.

**Special nutritional advice before and after IBD surgery: **
Before and immediately after surgery in IBD patients, it is especially important to ensure that nutritional status is optimized. According to the ESPEN Guidelines, it is recommended to assess patients at high risk for a disrupted nutritional status. For patients undergoing a planned surgery for Crohn’s disease, it has been shown that at least 4 weeks of exclusive enteral nutrition (liquid food) improves nutritional status and reduces intestinal inflammation. Additionally, optimizing nutritional status before surgery increases the chance of a successful surgery and reduces the chance of complications(ESPEN Guidelines and Nutritional Therapy for IBD)

9. How to successfully get started with lifestyle changes

Living with IBD can be quite a challenge in itself, so adjusting diet and lifestyle can sometimes seem like an impossible task. Below are some practical strategies to successfully get started with lifestyle changes, so you can still maintain a sense of overview and control.

9.1. Start with small steps

Making big changes all at once can be overwhelming and difficult to maintain. Therefore, choose small, achievable steps. Choose whether it’s easier for you to follow the rules of one special nutritional therapy, or whether you prefer to start with one change per week, such as eliminating certain processed foods. Or perhaps you want to start with short daily relaxation exercises. Small successes help to stay motivated and make the transition to a healthier lifestyle easier.

9.2. Work with a professional

A dietitian, coach, or other healthcare provider can offer support in making the right choices and setting realistic goals. They can help create a plan that fits your specific situation and takes into account your medical background. Moreover, regular appointments can provide extra motivation and accountability to persevere.

A recent study, supported by the Voeding Leeft foundation, compares standard care with a multimodal lifestyle intervention. This study, supervised by a dietitian and a lifestyle coach, with a focus on healthy diet, stress reduction, sleep, and exercise, shows that fatigue in IBD patients in remission significantly improved through the multimodal lifestyle intervention. Loveikyt R,. et al.

9.3. Keep a diary

By keeping a food and symptom diary, you gain insight into how certain habits affect your body. Note what you eat, how you feel, how much you exercise, and other relevant factors such as stress and sleep. This can help recognize patterns and better understand which adjustments work for you. A diary can also provide valuable information for conversations with your healthcare provider.

9.4. Set realistic goals

It is important to set concrete and achievable goals. Instead of saying: “I want to live healthier,” you can formulate specific goals such as: “I will walk 20 minutes three times a week” or “I will drink an extra glass of water every day this week.” By making goals measurable and achievable, you increase the chance of success and stay motivated.

9.5. Build a supportive network

Lifestyle changes are easier to maintain when you receive support from family, friends, or peers. Discuss your goals with people around you and ask for support where needed. Participation in a patient association or online community, such as our IBD and Lifestyle group, can also help to share experiences and stay motivated.

9.6. Be patient and kind to yourself

Change takes time, and there will be moments when things don’t go as well. That’s normal and no reason to give up. Accept that there may be setbacks and focus on the progress you have already made. Celebrate small successes and give yourself the space to adjust where needed.

By making adjustments step by step, working with professionals, and keeping good track of what works, you can sustainably improve your lifestyle and better cope with IBD.

10. Conclusion

Although medical treatments, such as immune-modulating therapies and biological drugs, play a crucial role in managing IBD, their effectiveness is often insufficient or only temporary. It is clear that a holistic approach that includes lifestyle adjustments and nutrition alongside medication is essential for achieving optimal results.

Nutritional therapies, such as the Specific Carbohydrate Diet (SCD), the IBD Anti-Inflammatory Diet (IBD-AID), the Crohn’s Disease Exclusion Diet (CDED), and the Mediterranean diet, offer promising possibilities to support gut health and reduce inflammation. However, it is crucial that these diets are adapted to the individual needs and tolerances of each patient, preferably under proper guidance from a healthcare professional.

Additionally, other lifestyle adjustments, including regular physical exercise, stress management, and avoiding harmful habits, can reduce symptoms and significantly improve quality of life.

The future of IBD management lies in a holistic approach that takes into account the unique needs and circumstances of each patient and optimally combines medication, lifestyle, and nutrition.

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What are the options for IBD treatment with lifestyle?

There are various non-medicinal approaches for IBD treatment, including nutritional therapies such as the Specific Carbohydrate Diet (SCD), IBD Anti-Inflammatory Diet (IBD-AID), Crohn's Disease Exclusion Diet (CDED), and the Mediterranean diet. Additionally, regular physical exercise, stress management (such as mindfulness and yoga), adequate sleep, and avoiding smoking help manage symptoms. These approaches are complementary to medical treatments.

Which diet works best for IBD?

There is no universal diet for all IBD patients. Various nutritional therapies show positive results, including Exclusive Enteral Nutrition (EEN), the Specific Carbohydrate Diet (SCD), IBD Anti-Inflammatory Diet (IBD-AID), Crohn's Disease Exclusion Diet (CDED), Autoimmune Protocol (AIP), and the Mediterranean diet. The optimal choice depends on individual factors such as disease type, personal tolerances, and circumstances. Guidance from a specialized dietitian is essential.

What is the difference between IBS and IBD in terms of symptoms?

Although IBS (Irritable Bowel Syndrome) and IBD (Inflammatory Bowel Disease) can have similar symptoms such as abdominal pain and changes in bowel movements, the crucial difference is that IBD involves visible inflammation and tissue damage in the intestine, while IBS is a functional disorder without structural damage. IBD also presents symptoms like rectal bleeding, weight loss, and fatigue. About 30% of IBD patients in remission also receive an IBS diagnosis.

What are the main causes of IBD development?

IBD develops through a complex interplay of factors: genetic predisposition (more than 200 genetic regions have been identified), environmental factors (such as Western diet, smoking, antibiotic use), a disrupted gut microbiome (dysbiosis), and molecular mechanisms such as intestinal barrier dysfunction and overproduction of pro-inflammatory cytokines. Together, these factors lead to an overreaction of the immune system to normally harmless gut bacteria.

How can I improve my lifestyle with IBD?

Improve your lifestyle with IBD by: 1) Making small, achievable changes, 2) Working with professionals such as dietitians or IBD coaches, 3) Keeping a symptom and food diary, 4) Setting realistic goals, 5) Building a supportive network through family or patient associations, and 6) Being patient and kind to yourself. Focus on regular physical exercise, stress management, adequate sleep, quitting smoking, and dietary adjustments.

How can I prevent malnutrition with IBD?

Malnutrition in IBD can be prevented by: 1) Regular monitoring of your nutritional status through blood tests, 2) Working with a dietitian for a balanced nutrition plan that fits your tolerances, 3) Using nutritional supplements for deficiencies, and 4) In case of severe malnutrition, temporary exclusive enteral nutrition may be considered. Be alert to signs of malnutrition such as unwanted weight loss, fatigue, muscle weakness, and reduced immunity.