How to eat well with Inflammatory Bowel Disease

Inflammatory Bowel Disease (IBD) is more than just a medical diagnosis. It’s a journey with many challenges. Understanding how to eat well with Inflammatory Bowel Disease is one of them. The real task lies in managing the day-to-day challenges and knowing what to eat, what to avoid, and how to achieve a balance that doesn’t disrupt your well-being.

If you or a loved one has IBD, you might already be familiar with the role certain foods play in either easing or increasing symptoms. IBD can affect your diet in so many ways. When you are feeling well, you may be able to eat most foods and this is the time to focus on eating well.

The two most common forms of IBD are Crohn’s Disease and Ulcerative Colitis. Both have periods of flare-ups and remission. This article focuses on eating well during remission and will cover the following:

The difference between Crohn’s Disease and Ulcerative Colitis
Complications of IBD
Tips for eating a healthy diet with IBD
Identifying food triggers
The importance of drinking enough fluid
Why eating fruit and vegetables is important and how you can eat this with IBD
Vitamins and minerals
Looking at food intolerances
Are there any special diets for IBD?

Crohn’s disease vs Ulcerative Colitis: A quick recap

IBD is an umbrella term to describe conditions characterised by chronic inflammation within the digestive tract. People with IBD may experience symptoms such as abdominal pain, fatigue, and frequent or urgent bowel movements.

Crohn’s disease can affect any part of the digestive tract, from the mouth to the anus, whereas ulcerative colitis affects the large bowel and anus. Because of the locations of these conditions, they can affect digestion in different ways.

For instance, when there is inflammation in the small bowel (Crohn’s disease), the usual reabsorption of water and the absorption of water, vitamins and other nutrients such as minerals, carbohydrates, fat and protein are prevented. This can lead to diarrhoea and urgent bowel movements.

For more information of IBD, getting diagnosed and treatment, read: An overview of Inflammatory Bowel Disease (IBD) and its treatment.

Complications of IBD

Malabsorption and losses of vital nutrients

Due to inflammation, absorbing vital nutrients may become difficult. The nutrients affected will depend on where the inflammation is. If the inflammation is in the small bowel, carbohydrates, protein, fats, vitamins and mineral absorption may be affected. This can lead to malnutrition and weight loss. The larger the area of inflammation, the bigger the risk of malabsorption.

People with Ulcerative colitis will have less issues with malabsorption of nutrients because the small bowel is not affected.

Poor appetite

Appetite is often affected and can lead to weight loss and poor intake.

Low bone density and risk of developing osteoporosis

Not getting enough Calcium through the diet can increase the risk of low bone density or developing osteoporosis. Poor absorption of calcium, low vitamin D intake and low levels of physical activity can cause low levels.

Inflammation and long term use of steroids can also affect bone density.

Bowel strictures and obstruction:

Some people with Crohn’s disease can develop strictures in the small bowel due to chronic inflammation. Strictures are narrowing of the bowel wall due to scar tissue which can make it difficult for food to travel through. It can even get blocked.

High fibre foods, such as fruit and vegetables can get blocked and cause pain, bloating or nausea.

In this instance, a low fibre diet or even a blended or liquid diet may be better tolerated. If the stricture is due to inflammation only, then medication can help, but if it is due to scar tissue, surgery may be needed to open up the obstruction.

Do you have a stricture and not sure if you have to adapt your diet? Please speak to your doctor to refer you to you a Dietitian. A Dietitian can guide you through this.

So, how do you manage to eat well with Inflammatory Bowel Disease?

Tips for eating well with Inflammatory Bowel Disease

1. Eat a balanced diet

A balanced diet includes protein, carbohydrate, good fats, vitamins and minerals. This can be achieved by eating a variety of food and aiming for diversity in the diet.

Protein

Protein is essential for building and repairing.

Protein rich food also provides B vitamins, vitamin E, iron, zinc, magnesium and other nutrients. Good sources of protein are meat, seafood, beans, dairy, eggs, nuts and seeds.

Most of these should be easy to tolerate, but some people may have a problem tolerating seeds and nuts, particularly if having a flare up or narrowing of the bowel.

People with IBD need to increase their protein intake during times of inflammation and when recovering from inflammation. If you eat meat and chicken, it is best to choose low fat or leaner options, because the extra fat can lead to poor absorption and make your symptoms worse. Focus on high protein sources such as oily fish (tuna and salmon) that are high in omega 3 fatty -acids and try some nut butters.

Carbohydrates

Grains such as rice, wheat, quinoa are high in carbohydrates, but you will also find carbohydrates in fruit and starchy vegetables, legumes (beans and peanuts) and dairy. Carbohydrates provide energy to the body.

Fat

Olive oil, avocado butter and other oils contain fat. Fat is used by the body for energy storage, insulation and protection of vital organs.

Getting enough calories

This can be difficult for someone with IBD, particularly when having a poor appetite. Your calorie needs may even increase during active inflammation. Keep an eye on your weight. When you notice your weight dropping, increase your calories slightly by 250 – 500 calories per day or work with a dietitian to help you maintain your body weight.

Sometimes, eating well with IBD can feel like an impossible task, because when you feel at your worst and don’t feel like eating, it is also the time you need more and getting this balance right can be hard.

Some ideas to increase your calories:

Eat small, more frequent meals throughout the day
Add in a smoothie or a shake in-between meals or at night
Add nutrient-dense foods such as avocado, cheese or olive oil to food
Use nut butters to increase protein and calorie intake

Eating with IBD is very individual. You may find that you struggle to tolerate some foods, while others do not have the same problem. It is important to understand what foods you can and cannot tolerate. This is referred to as your individual food triggers.

If you do struggle with symptoms you can try these basic steps first to see if this helps:

1. Eat smaller meals, but eat more frequently

Small, frequent meals can help the digestive system not to get overwhelmed and can lead to smoother digestion, reduce the risk of triggering a flare-up, and provide steady energy throughout the day.

Include snacks that are easy on the gut, like bananas or rice cakes to help maintain this regular eating pattern.

2. Eat in a relaxed atmosphere, not when answering stressful work emails

When you eat when stressed, blood flow away from the gut and can create problems with digestion.

3. Reduce the amount of greasy and fatty food

Fatty foods are difficult to digest and can lead to malabsorption. This will trigger uncomfortable symptoms such as diarrhoea.

4. Understand your food triggers

To eat well with IBD, understanding your food triggers can be helpful, but not always easy, especially when everyone with IBD will have their own individual triggers.

How you tolerate certain food will also depend on what is going on with your IBD. For example: if you are having a flare, you may need to reduce fibre and other foods that may aggravate your symptoms, but when you are in remission, these foods may not be a problem anymore.

It is also possible to have IBS and not have active disease, but still struggle with functional symptoms such as bloating, excess flatulence, constipation or diarrhoea. These symptoms can be very similar to IBS and may have its own triggers.

Do not randomly cut out entire food groups as you could be missing out on essential nutrients. Start with the basics as I explain in my Symptoms and Trigger tracker to give you a start.

A Dietitian can guide you through the process of identifying any triggers and ensure your diet remains balanced and healthy and can also be reassuring to know you have support during this process.

2. Stay hydrated

Drinking plenty of fluids are important to prevent dehydration from losses due to frequent diarrhoea. Water helps digestion and potentially prevent constipation.

Some medications prescribed for IBD can be hard on the kidneys, or they might have side effects that can be reduced with proper hydration. Drinking water can support kidney function and help process and eliminate these medications from the body.

IBD can sometimes interfere with the proper absorption of nutrients in the intestines due to inflammation. Water is crucial in ensuring that soluble vitamins and minerals get adequately absorbed.

So, staying well hydrated is important, but the type of fluids matters.

The Best beverages to try:

Water is the best choice
oral rehydration solutions can be helpful when there’s significant electrolyte loss due to diarrhoea (4 cups of water, ¼ tps salt, 6 teaspoons of sugar or maple syrup, squeeze of lemon, lime of orange)
Broth

On the other hand avoid these if they give you a problem:

Sugary beverages (juices, sodas, sports drinks)

The excess sugar can cause diarrhoea, because the sugar pulls more water into the gut. Dilute sports drinks and fruit juices as this may be less sugary.

Ice cold liquids

Very cold liquids can cause cramping.

Caffeinated drinks such as tea and coffee

Caffeine acts as a gut stimulant. This can increase diarrhoea, but will not cause inflammation.

Alcohol

Alcohol can dehydrate the body.
Some alcoholic drinks may contain certain sugars that can worsen symptoms.
Avoid alcohol during a flare up and also if this is a particular trigger for you.
Can be in moderation if not a trigger for you.

Check your urine to see if you are drinking enough. It should be clear and light yellow. Eating foods with high water content such as melons will also provide liquid.

DON’T: drink with a straw as this can introduce air into your gut, which can give excess gas and discomfort.

DO: drink slowly and sip throughout the day.

3. Diversity is key

Diversity of plants such as fruit, vegetables and grains is important for a healthy gut and optimal health. Tolerance of fruits and vegetables can vary among people with IBD.

When all is calm and you have no symptoms or strictures, most fruit and vegetables should be tolerated, but when there is a disease flare up, it may be easier to select fruit and vegetables that are easier to digest.

Removing the skin and seeds can help as well as cooking vegetables until tender.

If you find that you have difficulty tolerating high fibre foods then the following can be easier:

1. Eat low fibre fruit

Banana
Cantaloupe melon
Honeydew melon
Cooked fruit
Canned fruit in juice or light syrup

2. Cook your vegetables

Remove the skin and seeds
Avoid cruciferous vegetables (such as cauliflower, cabbage, kale, bok choy, broccoli, brussels sprouts, green leafy vegetables
Try: Asparagus tips, potatoes, squash, well-cooked carrots and vegetable stock

What about Grains

Grains are a good source of fibre, B vitamins and minerals such as iron, magnesium and selenium. Generally wholegrains are better for us, because the process of refining these grains removes valuable iron, B vitamins and fibre. Sometimes, wholegrains are not well tolerated in people with IBD.

Examples of grains are: wheat, rice, oats and barley and are used to make bread, pasta, oatmeal and breakfast cereals.

When all is well, try to include. Start with only a small amount and gradually increase as you tolerate it, but reduce or even avoid during a flare up (when you are symptomatic). This is because refined grains will be easier to tolerate.

Examples of refined grains are:

Peeled potatoes
White sourdough bread
White bread
White pasta
White rice
Oatmeal (refined porridge)

But fibre is essential for health and digestion. There are two types of fibre: soluble and insoluble.

Soluble fibre dissolves in water and forms a gel in your intestines. It adds consistency and form to your stool and can be helpful when you have watery bowel movements. Good examples of soluble fibre are canned fruit, peeled fruit, bananas, cooked oats, lentils, beans, peas, potatoes and squash.

Insoluble fibre does not dissolve in water and can be more difficult to digest. It pulls water into your gut and sweeps food through more quickly. Because of this action, insoluble fibre may aggravate IBD symptoms by causing more bloating, more gas, diarrhoea and pain.

Insoluble fibre is also more likely to get stuck in strictures. It is found in the skins fruit and vegetables, fruit with seeds, whole nuts, whole seeds, wheat bran, whole grains, brown rice, quinoa, corn and leafy vegetables.

Most foods have a combination of soluble and insoluble fibre. Cooking vegetables until tender, removing the seeds and peeling vegetables and fruit will help reduce the insoluble fibre.

A word on Vitamins & Minerals

When you eat well with Inflammatory Bowel Disease and have a well balanced diet, you should get all the essential vitamins and minerals you need. Unfortunately IBD can interfere and lead to potential deficiencies.

The following nutrients should get checked regularly:

folic acid, vitamin B12, vitamin D, iron, zinc, magnesium and selenium.

During times when you are not eating well and think you may have nutritional deficiencies, speak to your doctor in the first instance. Your doctor can test your levels and advise on an appropriate dose of supplementation.

Vitamin D

Taking a Vitamin D supplement daily will help with calcium absorption. The dose will depend on your baseline level and whether you already have a deficiency or not. When you had a blood test done, discuss supplementation with your doctor. If you have any concerns with your dietary intake and would like support to balance your intake given your limitations with IBD, a Dietitian can help.

Calcium

Getting enough calcium is very important for people with IBD. Eat 3-4 servings of calcium rich foods per day to meet your calcium requirements without the need of a supplement. Good sources of calcium include

Milk (regular, lactose free, calcium-fortified almond or soy milk)
Yoghurt
Cheese
Calcium fortified orange juice
Tinned fish
Kale
Collard greens and Tofu

For men and women over 19 years of age, 1000mg of calcium per day is recommended. This is particularly important if you take corticosteroids.

For more information on calcium sources, check out this Fact Sheet from the British Dietetic Association:

What about food intolerances?

It is possible to be in remission of IBD and still have functional bowel symptoms such as bloating, cramping, pain and altered bowel movements (constipation or diarrhoea) as found in IBS.

Some people with IBD find digesting lactose, which is the sugar in milk and milk products, difficult. Lactose intolerance may lead to cramping, abdominal pain, gas, bloating and diarrhoea. A small amount of milk can usually be tolerated if you are lactose free.

If you suspect you struggle with Lactose, your doctor can refer you for a Hydrogen breath test to confirm and your Dietitian can offer advice on alternatives to ensure you do not loose out on essential nutrients. Please do not randomly cut out food groups without confirmation. There is a risk that you may not get the nutrients you need.

FODMAPs can sometimes cause issues with bloating, pain, and changes in stool consistency.

The low FODMAP diet, which has been developed as a tool to support people with IBS in identifying food triggers, can also be helpful for people with IBD. It is recommended not to do this diet on your own but to have the support of a trained dietitian. Read this blog, before you start the low FODMAP diet.

Is there a specific IBD diet?

At this moment in time, there is not a specific diet recommended for IBD. The overarching goal is to eat a healthy, well-balanced diet. IBD and food is very individual and it is more important to understand what foods give you trouble and how to balance your diet so you can eat well when you are able and adjusting your diet as needed during a flare up.

Eating during a flare-up

When you’re in a flare-up, you might not feel like eating much. But it is still important to get enough energy and nutrients. This booklet from www.crohnsandcolitis.org.uk provides a good summary.

In short, if your appetite is low.

Include foods that are high in protein such as: eggs, dairy, meat, fish, pulses, beans, or nut butters.
Choose easy to digest fibres for example: well-cooked, peeled vegetables, bananas, melons, or fruit juice.
Soups and smoothies can be a very helpful way of getting your nutrients when you find you are struggling to eat full meals as they are easier to digest.
If dairy makes your symptoms worse, try dairy alternatives with added calcium, like oat, nut, rice or soy products.

As you start to feel better, try to get back to a balanced diet. Slowly re-introduce any foods that made your symptoms worse during the flare up.

If you find you always have symptoms, ask your doctor to refer you to a Dietitian for support.

Conclusion

Eating with IBD is a journey of discovering what works for you. There is no one size fits all, but there are some things to keep in mind when planning your meals. Eating a balanced diet is the ultimate aim, but due to issues with inflammation, flare-ups and tolerances, your diet may have to be adjusted to meet your needs.

You are not alone in this journey. Lean on your healthcare team for support. We are here to help.

Christel Lyell is a Registered Dietitian in the UK with over 25 years experience. Having worked in the NHS for over 20 years, Christel is now working privately, specialising in Gut Health and Irritable Bowel Disease.

Christel is passionate about helping people with digestive discomfort confidently manage their condition and get their gut back on track through simple and sustainable steps. After all, life is complicated enough, no need to complicate the diet too.

If you have a question about this post or your digestive health, please feel free to get in touch by email or book a free introductory call.

References:

Gibson PR, Shepherd SJ. Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. Journal of Gastroenterology and Hepatology. 2010;25(2):252-258.
Lomer MCE, Parkes GC, Sanderson JD. Review article: lactose intolerance in clinical practice—myths and realities. Alimentary Pharmacology & Therapeutics. 2008;27(2):93-103.
Hou JK, Lee D, Lewis J. Diet and inflammatory bowel disease: review of patient-targeted recommendations. Clinical Gastroenterology and Hepatology. 2014;12(10):1592-1600.
Vagianos K, Bector S, McConnell J, Bernstein CN. Nutrition assessment of patients with inflammatory bowel disease. JPEN Journal of Parenteral and Enteral Nutrition. 2007;31(4):311-319.
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 Feb;36(1):336-377. doi: 10.1111/jhn.13054. Epub 2022 Jul 21. PMID: 35735908; PMCID: PMC10084145.
Lamb CA, Kennedy NA, Raine T, et al British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults Gut 2019;68:s1-s106.
National Institute for Health and Care Excellence (2019) Crohn’s Disease: Management (NG129). Available at https://www.nice.org.uk/guidance/ng129
National Institute for Health and Care Excellence (2019). Ulcerative Colitis: Management (NG130). Available at https://www.nice.org.uk/guidance/ng130/resources/ulcerative-colitis-management-pdf-66141712632517