What is the recommended diet for patients with ulcerative colitis?

Dietary Recommendations for Ulcerative Colitis

For patients with ulcerative colitis, a Mediterranean diet rich in fresh fruits, vegetables, monounsaturated fats, complex carbohydrates, and lean proteins, while low in ultraprocessed foods, added sugar, and salt is recommended as the optimal dietary approach. 1

General Dietary Principles

During Remission:

• No specific restrictive diet is required during remission phases 1
• Mediterranean diet is the most evidence-supported approach, which includes:
  • Variety of fresh fruits and vegetables
  • Monounsaturated fats (olive oil, nuts)
  • Complex carbohydrates
  • Lean proteins
  • Low amounts of ultraprocessed foods
  • Limited added sugar and salt 1
• For ulcerative colitis specifically:
  • Reducing red and processed meat consumption may help reduce flares 1
  • Avoiding sugar-sweetened beverages is recommended as they have been linked to more severe disease course 1

For Patients with Strictures:

• Modify texture of fibrous foods:
  • Cook and steam vegetables thoroughly
  • Mash or blend vegetables
  • Peel fruits
  • Chew food well 1
• Avoid roughage like:
  • Unpeeled apples
  • Raw lettuce
  • Raw broccoli 1

Individual Food Intolerances

Many patients with ulcerative colitis have individual food intolerances that should be identified and addressed 1:

• Common problematic foods include:
  • Lactose and dairy products (especially with proximal Crohn's disease)
  • Spices and herbs
  • Fried foods
  • Gas-generating foods
  • Fiber-rich products when poorly tolerated 1

Fiber Considerations

The approach to fiber should be tailored based on disease state:

• For UC without strictures:

  • Soluble fiber is generally well-tolerated and may be beneficial 1
  • A Mediterranean diet rich in fruit and vegetable fiber is appropriate 1
  • Recent research shows a low-fat, high-fiber diet may reduce markers of inflammation and dysbiosis in UC patients 2

• For patients with strictures:

  • Limit fibrous foods that could cause obstruction
  • Process fibrous foods to softer consistency 1

Supplements and Probiotics

• Omega-3 fatty acid supplementation is not recommended for maintaining remission 1
• Probiotics may be considered for maintenance of remission in UC but evidence is limited 1
• Vitamin B9 (folic acid) supplementation should be considered for patients treated with sulphasalazine and methotrexate 1

Special Dietary Considerations

During Flares:

• More restrictive diet may be needed during active disease
• Focus on well-cooked, soft foods
• Temporarily reduce fiber if causing symptoms
• Ensure adequate hydration

For Patients with Overlapping IBS:

• Low FODMAP diet may help manage symptoms but should be supervised by a trained dietitian 3

Common Pitfalls to Avoid

1. Overly restrictive diets: Many patients unnecessarily restrict healthy foods, which can lead to nutritional deficiencies 1

2. Self-prescribed elimination diets: These often eliminate nutrient-rich foods without clear evidence, potentially worsening nutritional status 4

3. Ignoring individual food intolerances: Identifying and addressing personal food triggers is important for symptom management 1

4. Assuming all fiber is harmful: For UC patients without strictures, fiber (especially from fruits and vegetables) may be beneficial rather than harmful 2, 5

5. Neglecting nutritional counseling: All IBD patients should receive counseling from a dietitian as part of multidisciplinary care 1

The evidence supports that while no single diet is universally effective for all UC patients, a Mediterranean-style diet with attention to individual food intolerances represents the best general approach for maintaining remission and quality of life.