Nutrition and Vitamins
“Don’t eat anything your great-great-grandmother wouldn’t recognize as food…There are a great many foodlike items in the supermarket your ancestors wouldn’t recognize as food (Go-Gurt? Breakfast-cereal bars? Nondairy creamer?); stay away from these.” – Michael Polin, author
If you’ve ever suffered a particularly bad Crohn’s or colitis episode, you already know what it feels like to eat and eat and yet not feel like you are absorbing any of the nutrients from your food. Fortunately, the proper diet gives you an excellent chance of fixing the malabsorption problems associated with IBD.
As you explored foodrx.org, you may have wondered why we put so much emphasis on the topic of eating right and supplementing with vitamins. The answer is really two-fold. First, the food we take into our body directly impacts the symptoms we feel from our IBD. Secondly, individuals with IBD commonly suffer from nutritional deficiencies, which can have implications for our health.
While researchers continue to explore the causes and contributing factors of IBD, the pressing issue for patients currently living with the disease is getting the nutrients their bodies need. Many people with IBD have vitamin and mineral deficiencies, which could be due to loss of appetite, reduced absorption by the colon, and chronic diarrhea. Some medications may also limit the availability of important nutrients in the body. For example, sulfasalazine reduces the body’s ability to absorb folate (folic acid), and corticosteroids can reduce calcium, potassium, and vitamin C and D levels.
Making sure you get enough nutrients is a crucial part of treating IBD. For a list of vitamin supplements we recommend, please see our page on Nutritional Supplements. The list below highlights some of the important nutrients for individuals living with IBD.
Now it’s a not-so-carefully-guarded secret that many of us who volunteer at the Food Rx Project are nerds when it comes to our interest in science. We enjoy digging into the research and understanding what it means for those of us living with IBD. And there have been some really interesting preliminary research studies into what environmental factors may actually contribute to the development of IBD.
Some studies have suggested factors such as tobacco use, the consumption of cow’s milk (particularly at a young age), and the consumption of a diet high in sugars and refined carbohydrates may actually be contributing factors to the development of IBD in genetically predisposed individuals.[1,2,3,4,5,6,7,8,9,10,11,12] Conversely, a diet high in fruits and vegetables was shown in one study to be negatively correlated with the onset of IBD. Just another reason to put down that cigarette, and pick up some carrot sticks instead.
There is a great deal of interest today in the use of probiotics as a therapy for people with IBD. Several studies have indicated that taking probiotics can help reduce the symptoms of IBD. Probiotics are live microorganisms that are similar to beneficial microorganisms usually found in the human gut. Probiotics are frequently referred to as “friendly bacteria” or “good bacteria,” in that it is speculated that they help balance the microbial balance of the intestinal flora. Probiotics are sold to consumers mainly in the form of dietary supplements. A few common groups of probiotics are Lactobacillus, Bifidobacterium, Streptococcus, nonpathogenic E. coli, and Saccharomyces boulardii (S. boulardii differs from the others in that it is a yeast, not a bacteria).
Interestingly, there have been numerous in vitro (performed in a controlled environment, such as a Petri dish) and in vivo (performed on a living organism) studies that suggest probiotics have numerous effects that could benefit individuals with IBD. These benefits might include:
Given the considerable public, media, and scientific interest in the use of probiotics to modulate intestinal health, many patients with IBD have elected to add these supplements to their nutritional program. But are these products worth your time and money? While the initial evidence is certainly encouraging, there are still many unanswered questions about probiotics.
For one thing, many of the tests that have demonstrated the benefits of probiotics have been performed in vitro or have used mice and rats. While these models are extremely valuable in helping scientists understand how a disease or therapy may act in a human being, our bodies are undeniably more complex. Therefore, it is not uncommon for treatments that show a great deal of promise in animal models to fall somewhat short of expectations when applied to humans.
That said, the studies performed to date on mice show a range of impressive benefits.  These benefits have included an improvement in mucosal barrier function (Lactobacillus reuteri tested with a colitis model in mice), a general reduction in colitis activity (Lactobacillus salivarius, Lactobacillus salivarius in conjunction with Bifidobacterium infantis, Lactobacillus plantarum, in separate colitis models in mice[24,25,26]), and the prevention of colitis recurrence (Lactobacillus GG tested with a colitis model in rats). Additionally, studies involving VSL#3 – a “mega” mixture of 4 lactobacilli strains (including Lactobacillus acidophilus), 3 bifidobacteria strains, and 1 strain of 1 strain of Streptococcus salivarius – yielded impressive results, including the significant reduction of colitis and the associated inflammation in rats. 
The challenge for researchers has been generating similar results when the studies moved to human subjects. While a number of probiotic strains (including Lactobacillus, E. coli, Bifidobacterium, Saccharomyces boulardii, and the VSL#3 mixture) have shown great promise in helping people with ulcerative colitis, the results from studies on Crohn’s patients have been mixed at best. [21,22] On the balance, the research seems to demonstrate that probiotics appear to work better for ulcerative colitis than they do on Crohn’s disease.
At least four randomized, placebo controlled studies conducted in the last six years on ulcerative colitis patients have yielded positive results for strains of Bifidobacterium breve, Lactobacillus acidophilus, Bifidobacterium longum, and VSL#3. In each case, the probiotic outperformed the placebo in inducing and maintaining remission. [29,30,31,32] In contrast, the studies for Crohn’s disease have been somewhat disappointing. While some smaller studies on Lactobacillus for Crohn’s patients showed improvements in gut immunological function and remission induction, most of the larger placebo controlled studies over the last eight years have failed to substantiate the efficacy of probiotics for this disease. In fact, some of the very researchers who carried out the previously successful trials of Lactobacillus for patients with Crohn’s found that in larger patient populations the results were negative. In the face of these seemingly contradictory results, the researchers speculated that perhaps the usefulness of probiotics in Crohn’s patients is in inducing remission, rather than maintaining it. 
So where exactly do we stand on the question of whether priobiotics are effective in treating IBD? It is certainly fair to say that there is considerable experimental evidence (from both in vitro and in vivo studies) showing great potential for the use of probiotics to treat IBD. However, we need more randomized, controlled studies to determine the correct preparations, dosage, and duration of treatment. At this point, the use of probiotics for ulcerative colitis appears encouraging, particularly for preparations utilizing Lactobacillus and VSL#3. Crohn’s disease, it would seem, is a bit of an unknown. While some strains of probiotics initially inspired hope, recent tests have consistently disappointed. While it is unlikely that a patient with Crohn’s will do any harm by taking a probiotic, it is unclear at this point as to whether they will derive any clinical benefit.
Food Rx recommends patients with IBD at least try a probiotic containing Lactobacillus acidophilus to see if you experience a benefit. If you are beginning a form of dietary modification at the same time – such as the Specific Carbohydrate Diet (SCD) – we recommend waiting a couple weeks to introduce the probiotics. We also suggest gradually increasing the dosage, not to exceed 3 billion cells per day. As a note, the compound VSL#3, which has been the focus of a number of successful studies, is also available commercially. We currently do not recommend the patented VSL#3 formulation, because it contains maltose and cornstarch as product additives, which are expressly prohibited on the SCD. For a list of probiotics we recommend, please see our page on Nutritional Supplements.
Omega-3 fatty acids are polyunsaturated fats found in foods and also commercially available as dietary supplements (usually in capsule or oil form). They are important for a number of functions in the body, and are known for having anti-inflammatory properties. Large concentrations of Omega-3 fatty acids are found in seafood, as well as nuts, vegetable oils, seeds, and green leafy vegetables.
There has been interest in determining whether or not patients with IBD should be adding Omega-3 supplements to their therapy regimen. The theory is that these fatty acids may reduce disease activity in Crohn’s disease and ulcerative colitis when used with standard medical therapies. It has been speculated that these supplements induce a reaction in the body that inhibits proinflammatory cytokine gene expression. In other words, they may reduce the inflammation in your gut.
So far the evidence of a clinical benefit to these supplements has been mixed. In March of 2010, Rajendran et al. published an article that reviewed some of the research to date on the use of Omega-3 in the treatment of IBD. The report highlighted the fact that while a number of studies have shown that Omega-3 fatty acids appear to help induce remission in Crohn’s and ulcerative colitis, other studies have failed to demonstrate any link between the supplements and disease improvement.  In June of 2010, Turner et al. released a meta-analysis of 9 randomized controlled trials studying maintenance of remission in patients with IBD. While there appeared to be a statistically significant benefit for Crohn’s patients, the authors signaled the clinical benefit may not have been particularly significant. For ulcerative colitis, there didn’t appear to be a significant difference in relapse between patients who did and did not use Omega-3 supplements.
The authors of these studies believe that more research into the effectiveness of these Omega-3 supplements is warranted. There have been enough studies with positive results to believe that these products could be an effective addition to an IBD therapy regimen. At this point, though, we simply don’t have enough evidence to make a determination as to how effective a therapy this could be. But that shouldn’t stop you from trying an Omega-3 supplement to see if it works for you. While the jury may be out on how they impact IBD, numerous studies have demonstrated that these fatty acids are effective in reducing several cardiovascular disease risk factors and may help with some aspects of rheumatoid arthritis. [36,37] For this reason alone, it may be wise to consider adding an Omega-3 oil to your daily nutrition regimen.
When it comes to understanding the relationship between the food we eat and one’s health and wellness, nobody in the game is more knowledgeable than the people at Food As Medicine. This professional training arm of the Center for Mind-Body Medicine is responsible for educating MDs, DOs, NDs, Nurses, and health practitioners from across the globe on the subject of how the food we eat impacts our health and helps fend off disease. The program, started 9 years ago, was designed to enable healthcare professionals to offer their patients nutritional therapies for chronic illness and to bring nutrition into the center of the medical school curriculum.
Jo Cooper is a friend of ours here at the Food Rx Project. Ms. Cooper is a Senior Program Manager at Dr. James S. Gordon’s Center for Mind-Body Medicine. She is the Director of Nutrition Programs, which includes the highly regarded Food As Medicine program. Ms. Cooper also operates one of the best blogs in the business specifically dedicated to how food and nutrition help heal the body. We highly recommend you take a moment to visit her site, where you can learn more about the topic of food as therapy for disease. Please also check out the Food As Medicine blog at: foodasmedicine.cmbm.org. Please note, though, that content on her blog may not always be consistent with the advice on Food Rx, as her blog addresses more than IBD.
Next Section: Nutritional Supplements
 Lucendo, A. et al. Importance of nutrition in inflammatory bowel disease. World J Gastroenterol. 2009; 15(17): 2081-2088.
 Binder JH, et al. Intolerance to milk in ulcerative colitis. A preliminary report. Am J Dig Dis. 1966; 11: 858-864.
 Lerner A, et al. Serum antibodies to cow’s milk proteins in pediatric inflammatory bowel disease: Crohn’s disease vs. ulcerative colitis. Acta Paediatr Scand. 1989; 78: 81-86.
 Knoflach P, et al. Serum antibodies to cow’s milk proteins in ulcerative colitis and Crohn’s disease. Gastroenterology. 1987; 92: 479-485.
 Martini, GA et al. Increased consumption of refined carbohydrates in patients with Crohn’s disease. Klin Wochenschr. 1976; 54: 367-371.
 Miller, B et al. Sugar consumption in patients with Crohn’s disease. Verh Dtsch Ges Inn Med. 1976; 82 Pt 1: 922-924.
 Reif, S et al. Preillness dietary factors in inflammatory bowel disease. Gut 1997; 40: 754-760.
 Mayberry, JF et al. Increased sugar consumption in Crohn’s disease. Digestion. 1980; 20: 323 326.
 Geerling, BJ et al. Nutrition and inflammatory bowel disease: an update. Scand J Gastroenterol Suppl. 1999; 230: 95-105.
 Thornton, JR et al. Smoking, sugar, and inflammatory bowel disease. Br Med J (Clin Res Ed). 1985; 290: 1786-1787.
 Husain, A et al. Nutritional issues and therapy in inflammatory bowel disease. Semin Gastrointest Dis. 1998; 9:21-30.
 Panza, E et al. Dietary factors in the aetiology of inflammatory bowel disease. Ital J Gastroenterol. 1987; 19: 205-209.
 Russel, MG et al. Modern life’ in the epidemiology of inflammatory bowel disease: a case control study with special emphasis on nutritional factors. Eur J Gastroenterol Hepatol. 1998; 10: 243-249.
 García-Manzanares Vázquez de Agredos, A. et al. Soporte nutricional en la enfermedad inflamatoria intestinal. Manual de Nutrición y Metabolismo. Madrid: Díaz de Santos, 2006: 333-348.
 The American Cancer Society. Colorectal Cancer: Can colorectal cancer be prevented? 2010.
Colon and Rectum Cancer.
 University of Maryland Medical Center. Crohn’s disease. 2010. http://www.umm.edu/altmed/articles/crohns-disease-000043.htm.
 Tilg, H. et al. Gut, inflammation and osteoporosis: basic and clinical concepts. Gut. 2008; 57: 684-694.
 McClain, C. et al. Zinc deficiency: a complication of Crohn’s disease. Gastroenterology. 1980; 78: 272-279.
 Kruis W. et al. Zinc deficiency as a problem in patients with Crohn’s disease and fistula formation. Hepatogastroenterology. 1985; 32: 133-134.
 National Center for Complementary and Alternative Medicine. An Introduction to Probiotics.
 Guandalini S. Update on the role of probiotics in pediatric inflammatory bowel disease: experimental basis for the theoretical use of probiotics in IBD. Expert Rev Clin Immunol. 2010; 6(1):47-54.
 Sheil B., et al. Probiotic effects on inflammatory bowel disease. J. Nutr. 2007; 137(3): 819S-824S.
 Madsen K., et al. Lactobacillus species prevents colitis in interleukin 10 gene-deficient mice. Gastroenterology. 1999;116:1107–14.
 O’Mahony L., et al. Probiotic impact on microbial flora, inflammation and tumour development in IL-10 knockout mice. Aliment Pharmacol Ther. 2001;15:1219–25.
 McCarthy J., et al. Doubleblind, placebo-controlled trial of two probiotic strains in IL-10 knockout mice and mechanistic links with cytokine balance. Gut. 2003;52:975–80.
 Schultz M., et al. Lactobacillus plantarum 299v in the treatment and prevention of spontaneous colitis in Interleukin-10-deficient mice. Inflamm Bowel Dis. 2002;8:71–80.
 Dieleman L., et al. Lactobacillus GG prevents recurrence of colitis in HLA-B27 transgenic rats after antibiotic treatment. Gastroenterology. 2001;118:A4312.
 Schultz M., et al. Effects of feeding a probiotic preparation (SIM) containing inulin on the severity of colitis and on the composition of the intestinal. microflora in HLA-B27 transgenic rats. Clin Diagn Lab Immunol. 2004;11:581–7.
 Kato K., et al. Randomized placebo-controlled trial assessing the effect of bifidobacteria-fermented milk on active ulcerative colitis. Aliment. Pharmacol. Ther. 2004; 20:1133–1141.
 Tursi A., et al. Low-dose balsalazide plus a high-potency probiotic preparation is more effective than balsalazide alone or mesalazine in the treatment of acute mild-to-moderate ulcerative colitis. Med. Sci. Monit. 2004; 10:PI126–PI131.
 Furrie E., et al. Synbiotic therapy (Bifidobacterium longum/synergy 1) initiates resolution of inflammation in patients with active ulcerative colitis: a randomised controlled pilot trial. Gut. 2005; 54:242–249.
 Miele E., et al. Effect of a probiotic preparation (vsl#3) on induction and maintenance of remission in children with ulcerative colitis. Am. J. Gastroenterol. 2009; 104:437–443.
 Wild G., et al. Nutritional modulation of the infl ammatory response in inflammatory bowel disease- From the molecular to the integrative to the clinical. World J Gastroenterol. 2007; 13:1-7.
 Rajendran N., et al. Role of diet in the management of inflammatory bowel disease. World J Gastroenterol. 2010; 16: 1442-1448.
 Turner D., et al. Maintenance of remission in inflammatory bowel disease using omega-3 fatty acids (fish oil): A systematic review and meta-analyses. Inflamm Bowel Dis. 2010 Jun 17.
 National Center for Alternative and Complimentary Medicine. Omega-3 Supplements: An Introduction.
 Riediger N., et al. A systemic review of the roles of n-3 fatty acids in health and disease. Journal of the American Dietetic Association. 2009;109(4):668–679.