What is the recommended dietary approach for managing Crohn's disease?

Dietary Management of Crohn's Disease

The Mediterranean diet rich in fresh fruits, vegetables, monounsaturated fats, complex carbohydrates, and lean proteins, while low in ultraprocessed foods, added sugar, and salt is the recommended primary dietary approach for managing Crohn's disease, with specific therapeutic diets like the Crohn's Disease Exclusion Diet (CDED) recommended for active disease flares. 1

First-Line Dietary Approaches

Mediterranean Diet for Maintenance

• Emphasize variety of fresh fruits and vegetables, monounsaturated fats (olive oil), complex carbohydrates, and lean proteins
• Limit ultraprocessed foods, added sugar, salt, and sugar-sweetened beverages
• Avoid red and processed meats which may worsen inflammation
• This approach supports overall health and may help maintain remission 1

Texture Modifications for Strictures

For patients with intestinal strictures:

• Modify fibrous foods to softer consistency through:
  • Thorough cooking and steaming of vegetables
  • Mashing or blending vegetables
  • Peeling fruits
  • Chewing food thoroughly
• Avoid roughage like unpeeled apples, raw lettuce, and raw broccoli 1

Therapeutic Diets for Active Disease

Exclusive Enteral Nutrition (EEN)

• First-line therapy for inducing remission, especially in pediatric patients
• Consists of 100% liquid nutrition formulations for 6-8 weeks
• Achieves 60-80% clinical remission rates, similar to corticosteroids
• More effective in children than adults (due to adherence challenges)
• Can be used as steroid-sparing bridge therapy 1

Crohn's Disease Exclusion Diet (CDED)

• Whole foods diet combined with partial enteral nutrition (PEN)
• Implemented in 3 phases (each 6 weeks long):
  • Phase 1: Fish, chicken breast, eggs, rice, cooked potatoes, select vegetables, fruits, olive oil
  • Phase 2: Adds tuna, whole-grain bread, oats, more vegetables
  • Phase 3: Maintenance phase with additional foods including seafood, eggs, cocoa, coffee, grains
• Shown to be effective for mild-to-moderate Crohn's disease with short duration flares
• Better tolerated than EEN with 97.5% vs 73.6% adherence rates 1, 2, 3
• Recent studies show 68% clinical remission at 6 weeks with CDED plus PEN 2

Other Dietary Approaches

Specific Carbohydrate Diet

• Grain-free diet, low in sugar and lactose
• Restricts hard-to-digest carbohydrates
• Similar efficacy to Mediterranean diet in clinical trials
• Challenging to follow long-term 1

Low-FODMAP Diet

• Limits fermentable oligosaccharides, disaccharides, monosaccharides, and polyols
• May be beneficial for patients with concomitant IBS-like symptoms
• Uses elimination and rechallenge approach (up to 8 weeks) 1

Food Reintroduction After EEN

• After completing EEN, foods should be gradually reintroduced
• Low fat, low fiber exclusion (LOFFLEX) diet can be used for 2-4 weeks followed by gradual food reintroduction 1

Clinical Decision Algorithm

1. For patients in remission without strictures:

   • Recommend Mediterranean diet
   • No need to limit fiber intake

2. For patients with active mild-to-moderate disease:

   • First choice: CDED plus partial enteral nutrition (better tolerated)
   • Alternative: EEN for 6-8 weeks (if adherence possible)

3. For patients with strictures:

   • Mediterranean diet with texture modifications
   • Emphasize careful chewing and processing of fibrous foods

4. For patients with IBS-like symptoms:

   • Consider low-FODMAP diet trial

Important Considerations

• Dietary management should be part of a comprehensive treatment plan that may include medications
• All newly diagnosed patients should have access to a registered dietitian 1
• Individual food intolerances are common and should be identified
• The CDED approach has shown promising results in both children and adults, with recent studies showing sustained remission at 24 weeks in 80% of patients who achieved remission at 6 weeks 2, 4

Common Pitfalls to Avoid

• Unnecessarily restricting healthy foods during remission
• Attempting EEN without proper support and monitoring
• Failing to modify food textures appropriately for patients with strictures
• Overlooking the importance of gradual food reintroduction after EEN
• Not considering individual food intolerances that may trigger symptoms