Recommended Diet for Crohn's Disease
All patients with Crohn's disease should follow a Mediterranean diet rich in fresh fruits and vegetables, monounsaturated fats, complex carbohydrates, and lean proteins while minimizing ultraprocessed foods, added sugar, and salt—unless they have symptomatic intestinal strictures that require texture modifications. 1
Core Dietary Framework
The Mediterranean diet pattern serves as the foundation for nutritional management in Crohn's disease, supported by the most recent 2024 AGA guidelines 1. This recommendation applies universally to patients in both remission and active disease states, with specific modifications based on complications 1.
What to Emphasize:
- Fresh fruits and vegetables in variety 1
- Monounsaturated fats (olive oil, avocados, nuts) 1
- Complex carbohydrates (whole grains when tolerated) 1
- Lean proteins (fish, poultry, legumes) 1
- Soluble fiber sources 1
What to Minimize or Avoid:
- Sugar-sweetened beverages (strongly linked to worse disease course) 1, 2
- Ultraprocessed foods high in additives 1, 2
- Added sugar and excess salt 1
- Red and processed meats (evidence stronger for ulcerative colitis, but prudent to limit) 1, 2
Critical Modification: Patients with Intestinal Strictures
Patients with symptomatic strictures cannot tolerate raw, fibrous plant-based foods due to mechanical obstruction risk 1, 3. This is a common pitfall—the healthy Mediterranean diet must be adapted for texture, not abandoned 1.
Texture Modifications for Strictures:
- Cook, steam, mash, or blend all fruits and vegetables to soft consistency 1, 3
- Emphasize careful, thorough chewing of all fibrous foods 1, 3
- Peel fruits before consumption 1
- Choose cooked/steamed vegetables over raw 1
- Consider avoiding high-risk foods entirely if strictures are symptomatic (mushrooms, lettuce, unpeeled apples) 1, 3
The goal is to maintain nutritional diversity while preventing obstruction 1.
Diet as Active Therapy (Not Just Symptom Management)
Beyond general dietary patterns, specific nutritional interventions can induce remission in Crohn's disease:
Exclusive Enteral Nutrition (EEN):
EEN using liquid nutrition formulations is an effective steroid-sparing therapy for inducing clinical and endoscopic remission in Crohn's disease 1, 2. Evidence is stronger in children than adults, but both populations benefit 1, 2.
Indications for EEN:
- Active Crohn's disease requiring remission induction 1
- Malnourished patients heading for elective surgery (optimizes nutritional status and reduces postoperative complications) 1
- Steroid-sparing bridge therapy 1, 2
Crohn's Disease Exclusion Diet (CDED):
CDED with partial enteral nutrition may induce clinical and endoscopic remission in mild to moderate Crohn's disease of relatively short duration 1, 2. This represents a middle ground between full diet and exclusive liquid nutrition 1.
Common Pitfalls to Avoid
Overly Restrictive Elimination Diets:
Do not adopt non-evidence-based self-directed elimination diets 2, 3. Crohn's patients are already at high risk for malnutrition, and excessive restriction worsens nutritional deficiencies 2, 3. The 2024 AGA guidelines emphasize that patients historically avoided healthy foods even in remission due to poor guidance 1.
Gluten Avoidance Without Indication:
There is no consistent evidence supporting gluten avoidance in Crohn's disease without celiac disease diagnosis or suspected gluten sensitivity 1, 2. This is a common patient-initiated restriction that lacks scientific support 1.
Lactose Restriction:
Only restrict lactose if lactose intolerance is documented 1. Acquired lactase deficiency is particularly prevalent in proximal Crohn's disease, but blanket dairy elimination is not warranted 1.
Role of Registered Dietitians
All patients with Crohn's disease warrant involvement of a registered dietitian as part of the interdisciplinary team 1, 3. This is particularly critical for:
- Patients with complicated disease or strictures requiring individualized texture modifications 3
- Nutritional assessment and malnutrition screening (unintended weight loss, edema, muscle/fat mass loss) 1
- Implementation of exclusive enteral nutrition protocols 1
Parenteral Nutrition: Limited Indications
Parenteral nutrition plays a role only in specific scenarios 1:
- Intra-abdominal abscess/phlegmon limiting enteral intake preoperatively 1
- High-output fistulas 1
- Short bowel syndrome 1
- Prolonged ileus 1
- Severe malnutrition when enteral nutrition has failed 1
Transition from parenteral to oral intake whenever possible to decrease long-term complications 1.
No Benefit from Omega-3 Supplementation
Omega-3 fatty acid supplementation should not be advised for maintenance of remission in Crohn's disease 1. Despite laboratory interest, clinical trials have not demonstrated benefit 1.
Monitoring Requirements
Regular screening for malnutrition is mandatory by assessing unintended weight loss, edema, and muscle/fat mass loss 1. Serum proteins (albumin, prealbumin) are no longer recommended for malnutrition diagnosis due to lack of specificity and high sensitivity to inflammation 1.