What diet is recommended for a patient with inflammatory bowel disease (IBD) who has responded to prednisone (corticosteroid) therapy started 4 days ago?

Dietary Recommendations for IBD Flare Responding to Prednisone

All patients with IBD, including those recovering from a flare on prednisone, should follow a Mediterranean diet rich in fresh fruits and vegetables, monounsaturated fats, complex carbohydrates, and lean proteins while avoiding ultraprocessed foods, added sugar, and salt. 1

Core Dietary Framework

The American Gastroenterological Association's 2024 guidelines establish the Mediterranean diet as the foundational eating pattern for all IBD patients regardless of disease activity, with specific texture modifications during active inflammation. 1 This approach has demonstrated lower rates of active disease, reduced inflammatory biomarker elevation, and improved quality of life after 6 months of adherence in both Crohn's disease and ulcerative colitis patients. 1

Foods to Emphasize

• Fresh fruits and vegetables (cooked, steamed, mashed, or blended to soft consistency if any residual symptoms or strictures remain) 1, 2
• Monounsaturated fats from olive oil, fish, nuts, and seeds 1, 2
• Lean proteins including fish, poultry, shellfish, beans, legumes, and low-fat dairy if tolerated 1, 2
• Complex carbohydrates from whole grains 1, 2
• Soluble fiber sources, which generate anti-inflammatory short-chain fatty acids like butyrate 3

Foods to Strictly Avoid

• Sugar-sweetened beverages are directly linked to increased IBD risk and more severe disease course in prospective cohort studies 1, 2
• Red and processed meats, particularly for ulcerative colitis patients where reduction may decrease flare risk 1, 2
• Ultraprocessed foods high in added sugar, salt, and artificial additives 1, 2

Texture Modifications During Recovery

Since your patient is only 4 days into prednisone therapy and likely still has residual mucosal inflammation, texture modifications remain critical even as symptoms improve. 1

Specific Texture Guidelines

• Cook, steam, mash, or blend all fruits and vegetables to achieve soft, less fibrous consistency 1, 2
• Avoid raw, unpeeled fruits (especially apples) and raw vegetables (especially lettuce and whole corn) 1, 2
• Emphasize careful chewing of all foods 1
• Choose cooked/steamed vegetables like broccoli over raw roughage 1

This approach allows incorporation of plant-based foods and fiber without triggering obstructive symptoms in patients with potential strictures or ongoing inflammation. 1

Critical Pitfalls to Avoid

Never recommend overly restrictive elimination diets during this recovery phase, as IBD patients are already at high risk for malnutrition (affecting 28% of Crohn's disease patients and 13% of ulcerative colitis patients with low muscle mass). 4, 2 Excessive dietary restriction worsens nutritional deficiencies and sarcopenia. 4

Do not follow carnivore or other extreme restrictive diets (like strict low-FODMAP beyond 8 weeks), as these contradict evidence-based guidelines and eliminate essential nutrients. 4, 2 The low-FODMAP diet should only be considered if concomitant IBS-like symptoms persist after inflammation resolves. 1

Avoid focusing solely on symptom relief at the expense of nutritional adequacy—the goal is to transition toward a health-promoting diet that reduces future flare risk, not just manage current symptoms. 1

Protein and Nutritional Optimization

Given the catabolic effects of both active disease and corticosteroid therapy, increase protein intake to 1.2-1.5 g/kg/day from diverse sources including lean meats, fish, eggs, legumes, and dairy if tolerated. 4 This helps prevent sarcopenia and supports mucosal healing.

Specialist Involvement

All patients with complicated IBD, malnutrition, or requiring complex nutrition therapies warrant co-management with a registered dietitian. 1, 4, 2 The AGA recommends that all newly diagnosed IBD patients have access to a registered dietitian. 1

Alternative Dietary Approaches (If Mediterranean Diet Fails)

If the Mediterranean diet approach does not maintain remission or the patient requires additional dietary intervention:

• Specific Carbohydrate Diet has shown similar efficacy to Mediterranean diet in mild-to-moderate Crohn's disease, though it is more challenging to follow 1
• Crohn's Disease Exclusion Diet (CDED) with partial enteral nutrition may be effective for mild-to-moderate Crohn's disease of short duration 1
• Exclusive enteral nutrition can be considered as steroid-sparing bridge therapy, particularly in pediatric patients 1

No Evidence for Gluten Avoidance

There is no consistent evidence supporting gluten avoidance in IBD patients without celiac disease diagnosis or suspected gluten sensitivity. 1