UC: Dietary and Lifestyle Interventions

"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this 12-part journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.

One question patients newly diagnosed with ulcerative colitis (UC) are bound to ask when discussing treatments is, "Should I change my diet? What else can I do to feel better?" While drug therapy will always be the mainstay of UC treatment, there are other things patients can do to help themselves -- at least to keep from aggravating their condition unwittingly.

These can be categorized as follows:

• Food choices

• Nutritional supplements

• Physical activity

• Probiotics

• Mind-body interventions

Diet

Digestion is disrupted to varying degrees in UC and its cousin Crohn's disease. One key aspect of this is that the lesions that develop in the lower bowel expose underlying tissues where immune cells reside. Normally they are insulated from intestinal contents, but with the endothelium stripped away, now these cells may come into contact with passing antigenic molecules. This may manifest as something like a food allergy and can lead to new or renewed inflammation and symptoms such as diarrhea and bleeding.

As well, patients may have actual comorbid food allergies or gluten or lactose intolerance, which perhaps were not diagnosed against the background of UC. Checking for their presence can be considered if initial drug treatment does not lead to remission. Some common triggers include dairy products (even if lactose-free), artificial sweeteners such as sorbitol and mannitol, and so-called FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols).

The Crohn's & Colitis Foundation has developed extensive guidance around foods to eat or avoid which you may wish to share with your UC patients. Some of the recommendations include:

• If food allergy or intolerance is suspected, try removing the potential trigger food from the patient's diet. Lactose-containing dairy products are a common trigger, and milk proteins can also be antigenic when bowel lesions are present

• Minimize intake of insoluble fiber (such as fruit skins and nuts); soluble fiber, however, may help by slowing digesting transit times

• Eat smaller but more frequent meals

• Reduce consumption of fatty foods

Another type of food that may aggravate UC symptoms is carbonated beverages, according to the consumer health site Everyday Health (a corporate cousin to MedPage Today). In some cases it's the carbonation itself that causes problems by introducing gas into the digestive tract. But ingredients including caffeine and sweeteners can negatively affect digestion in UC.

Supplements

UC's intestinal pathology may also result in dysregulation of nutritional absorption, such that patients may experience deficiencies despite eating what should be a normal diet.

In particular, supplements of calcium, zinc, iron, vitamins D and B₁₂, and folic acid may be needed. Insufficiency or deficiency in these are already common in much of the population, and UC or the medications used to treat it can make them worse by interfering with their absorption and metabolism.

Physical Activity

Understandably, patients experiencing significant UC symptoms may not feel like exercising, but they should be encouraged to try nonetheless. A review article in Clinical and Experimental Gastroenterology in 2017 cited multiple studies indicating that physical activity does not worsen symptoms in inflammatory bowel disease (IBD) and may help alleviate them.

"Exercise has theoretical benefits on the immune response, and the limited available data suggest that exercise may improve disease activity, quality of life, bone mineral density, and fatigue levels in patients" with UC and other IBDs, the review authors wrote.

Patients with active symptoms may be reluctant to exercise outside the home because of concerns about bathroom access, so clinicians should plan on discussing what patients can do at home and/or other ways to reduce perceived barriers to physical activity.

Note, too, that exercises targeting pelvic floor muscles can help with incontinence issues.

Probiotics

Many patients will ask whether probiotics and related products can help them -- or they may just start taking them on their own. At this point, there is little high-quality science to guide their use.

The American College of Gastroenterology's (ACG) 2019 guideline on UC management stated that these treatments "require further study with adequate power and clarification of endpoints." Similarly, the American Gastroenterological Association's most recent guidance indicated that "their benefit for either inducing or maintaining remission is unclear," although they do seem to be safe. Both groups currently make no recommendation for or against use of probiotics in UC.

The concept does make some sense. The Crohn's & Colitis Foundation notes that commensal intestinal bacteria can themselves form a protective layer inside the large bowel that may reduce untoward interactions with antigens and pathogens. As well, a number of studies have documented disruptions to the intestinal microbiome in IBD, and probiotics are intended to restore a healthy bacterial community.

But as the gastroenterology societies pointed out, the evidence that probiotics help in UC has come only from small studies with many limitations and potential biases. Moreover, there are as many different types of probiotic products as there are producers, making it next to impossible to generalize about these treatments.

Mind-Body Interventions

A later installment in this series will address UC's emotional and psychological impacts in detail. For now, it will suffice to say that these are considerable, but can be ameliorated. Clinicians may recommend cognitive behavioral therapy to help patients cope with disease flares, and studies have supported benefits from such practices as mindfulness training and yoga to help patients relax mentally as well as physically.

What About Smoking?

The effects of cigarette smoking are among the most fraught topics in UC. Studies indicating that smoking has some sort of preventive effect in UC, with quitting linked to increased risk of disease worsening and/or new flares, are now well known in the UC community. Thus, patients who smoke may ask whether they should keep on with it, and some nonsmokers may even wonder if they should start.

In both cases the answer is no. It's true that the ACG recommends that clinicians ask patients showing newly worsened disease if they recently stopped smoking. But smoking's "effect size" for prevention appears to be small and some studies have disputed whether it's real at all.

Great Britain's National Institute for Health and Care Research is among the skeptics, declaring in 2019 that "people who stop smoking after being diagnosed with ulcerative colitis are unlikely to have more flare-ups or other signs of worsening disease, compared with those who continue to smoke." And no U.S.-based professional society or government agency recommends that UC patients who smoke continue to do so.

Next up: When initial treatments lose steam or fail

Read previous installments in this Medical Journeys series:

Part 1: UC: Understanding the Epidemiology and Pathophysiology

Part 2: UC: Symptoms, Exams, Diagnosis

Part 3: UC: How and Why Does It Arise?

Part 4: Case Study: Why Is This Teen's Ulcerative Colitis So Severe, So Resistant?

Part 5: UC: Initial Treatments and Response Monitoring