Nutritional and Dietary Protocols for IBD
By Joel Fuhrman, M.D. www.drfuhrman.com
High-Nutrient, Fiber-Rich Diet Is Key To Recovery.
I have treated hundreds of patients with inflammatory bowel disease (IBD) whose conditions included a wide range of severity. Some patients came to me after their doctors had recommended surgical removal of the entire colon because their conditions were too severe for even the most toxic drugs to control. Others have had relatively mild forms of rectal inflammation or proctitis. Most of these patients have made dramatic improvements, with the majority no longer experiencing any symptoms or needing to take any medications.
As I mentioned in the preceding article, IBD patients can recover through aggressive dietary modifications. Reestablishing a cell climate (cellular nutritional competency) that is rich in protective nutrients through a high intake of green juices, green soups, and blended salads is a critical part of the nutritional care of all autoimmune diseases, and IBD is no exception.
When a high degree of inflammation and bleeding is present, most patients do better to avoid raw fruits and vegetables. Blended salads and juices that are gently heated, as well as pureed vegetable soups, are the preferred foods in this initial intervention phase.
The initial goal is to build up phytonutrients in the tissues without irritating the inflamed lining with too many raw foods. Building up antioxidants and green-derived phytochemicals to improve the nutritional deficiencies is important before medications are tapered and before any fasting is considered.
The natural indoles 3,3'-diindolylmethane (DIM), ascorbigen (ASG), indole-3-carbinol (I3C), and indo-lo[3,2-b]carbazole (ICZ), as well as the natural isothiocyanates sulforaphane (SUL), benzyl isothiocyanate (BITC), and phenethyl isothiocyanate (PEITC), all possess cancer chemopreventive properties.1 These substances, derived from green leafy (mostly cruciferous) vegetables, are important to protect against DNA damage and also important to halt the chronic inflammation.
Studies also show that the fibers from green vegetables supply the substrate that promotes the most favorable type of bacteria in the gut and the healthiest intestinal environment. 2 It is known that the chronic inflammation of Crohn’s disease and ulcerative colitis involves an overly aggressive immune response to an unfavorable balance of microflora. That is why the nutritional care of these patients should include supplementation with beneficial bacteria, along with supplying the green substrate to grow the favorable bacterial types.
The initial protocol involves a diet of mostly cooked vegetables:
- High micronutrient intake with green juicing and (cooked) blended salads
- High-dose fish oils (10 grams of oil with at least 5 grams of EPA + DHA)
- Multivitamin for extra B12, zinc, and iodine and additional vitamin D supplementation to assure 25, hydroxyl blood levels above 30
- A mixture of favorable probiotic strains, including lactobacillus plantarum and lactobacillus acidophilus
- Avoidance of refined foods, sugars, and oils
- No dairy or grains, and very little fruit
- Meditation and stress reduction counseling
Phase 1 Diet
(Active disease with blood, typically more than 6 bowel movements daily)
In the midst of a flare-up of IBD, the diet should be mostly cooked vegetables, and even the green vegetable juices should be gently heated. The diet is made up of steamed zucchini, artichokes, asparagus, avocado, butternut squash, steamed carrots and peas, chestnuts and walnuts, papaya, and green vegetable juices, including mild cruciferous leafy greens such as bok choy, kale, and collards. The juices are gently heated almost to boiling. Except for papaya, fresh fruit should not be used in the diet at this stage.
Phase 2 Diet
(Mildly active disease, no blood, fewer than 6 bowel movements daily)
At this stage, fresh squeezed vegetable juice, usually carrot with kale and parsley, is introduced, starting with only 4 ounces or less at first and then advancing to 4 ounces twice daily. Blended salads, also called green smoothies, should be introduced. A small amount of raw lettuce and spinach is introduced by thoroughly blending the greens with avocado and banana.
The diet is still largely cooked vegetables, but tofu, some high omega-3 eggs daily, or a small serving (3 oz.) of fish can be added. Fruit can be added back to the diet, but only one non-citrus fruit with each meal.
Phase 3 Diet
(Normal stool, 3 or fewer bowel movements per day)
This is the long-term, healthful diet to be established once the problem is adequately controlled with a combination of nutritional therapy and medications, if needed. People at this stage usually are well enough to eat most fruits and raw salad vegetables, along with their fresh, raw vegetable juices and cooked vegetable dishes.
Many of my IBD patients in remission continue to juice and consume blended salads every day. They also continue their supplements and intersperse a few days of fasting each month to assure their condition stays in good control.
Individuals who have had inflammatory bowel disease, even after a recovery is achieved via nutritional excellence, still require periodic monitoring of their bowel via colonoscopy because their risk of developing colon cancer later in life is significantly elevated due to all of the years of chronic inflammation. Screening of the colon is important because dysplastic (abnormal cells) areas can be detected and treated even before cancer occurs.
Fasting For IBD
Once the levels of nutrients in the tissues are adequate, which usually takes about 2 months, short periods of fasting can be helpful. First, attempt a one-day fast of water and green juices and then, as tolerated, a one-day water-only fast. Once the one-day fast has been achieved, attempt a two-day fast the following week, gradually extending the periods of fasting to 3–5 consecutive days each month. Fasting not only rests the bowel wall, promoting healing, but also has immune-modulating effects leading to long-term benefits for patients with IBD.
My observation is that IBD patients benefit most from fasting over and over again, sandwiched between weeks of healthful eating and weightlifting (to maintain muscle tissue). Patients with ongoing mild inflammation see lowering of the blood inflammatory markers and reduction in symptoms after utilizing recurrent fasting. Devising a fasting schedule of 3–4 days per month enables patients to gain the weight back before fasting again, maintaining their body weight in a consistently safe range, while still gleaning the well-established benefits of fasting.
Omega-3 Fatty Acids And Fish Oil
Sources of omega-3 fatty acids include fish, fish oil, walnuts, leafy green vegetables, flax, chia, and hemp seeds. Various studies have shown that administration of omega- 3 fatty acids has a positive effect on IBD. However, a recent Cochrane review of all published articles did not demonstrate a positive effect.3
This might be because the studies reviewed used lower dosages of about 3 grams per day, whereas the studies that utilized higher dosages were more clearly positive.4 A larger dose is required for fish oil to have an immunosuppressive effect. I start my colitis patients on 10 grams (two teaspoons) of highly purified fish oil daily when the person has active symptoms, and I find it helpful. This is tapered to one teaspoon per day once the symptoms are better controlled.
When fish oil is highly purified, fresh, and kept refrigerated, it should not have that highly unpleasant taste or cause burping and indigestion. The quality and freshness of the fish oil is very important here. Patients also are encouraged to eat one ounce of walnuts daily, after soaking them in water overnight to make them softer and easier to digest. Other seeds and nuts also can be soaked and/or blended and reintroduced into the diet as the condition improves.
Aloe Vera, Boswellia, Bromelain, And Germinated Barley
Aloe vera, boswellia serrata, bromelain and germinated barley have been used by some patients with IBD with benefit. A few studies have been performed evaluating the effectiveness of these substances, showing mildly positive effects. A randomized, double-blind, placebo-controlled trial of aloe vera in patients with mild to moderate ulcerative colitis demonstrated slight improvement in clinical symptoms and histologic scores in patients taking aloe vera vs. placebo.5 The exact mechanism of action of aloe vera is unclear, but may include antioxidant and immunosuppressive effects. Proposed mechanisms of the effect of boswellia serrata include inhibition of 5-lipoxygenase that could promote inflammation. Natural remedies can be used in conjunction with the nutritional therapy, but when the objective is to recover, not just treat, it is removal of offensive food and establishing nutrition-regulated immune competency—not supplying more remedies—that is the major thrust of this approach.
1. Bonnesen C, Eggleston IM, Hayes JD. Dietary indoles and isothiocyanates that are generated from cruciferous vegetables can both stimulate apoptosis and confer protection against DNA damage in human colon cell lines. Cancer Res 2001; 61(16):6120-30.
2. Ewaschuk JB, Dieleman LA. Probiotics and prebiotics in chronic inflammatory bowel diseases. World J Gastroenterol 2006;12(37):5941-50.
3. De Ley M, de Vos R, Hommes DW, Stokkers P. Fish oil for induction of remission in ulcerative colitis. Cochrane Database Syst Rev 2007;(4): CD005986
4. Hawthorne AB, Daneshmend TK, Hawkey CJ, et al. Treatment of ulcerative colitis with fish oil supplementation: a prospective 12 month randomised controlled trial. Gut 1992;33:922-8. Aslan A, Triadafilopoulos G. Fish oil fatty acid supplementation in active ulcerative colitis: a double- blind, placebo-controlled, crossover study. Am J Gastroenterol 1992;87:432-7.
5. Langmead L, Feakins RM, Goldthorpe S, et al. Randomized, double-blind, placebo-controlled trial of oral aloe vera gel for active ulcerative colitis. Aliment Pharmacol Ther 2004;19(7):739-47.