Diet and ulcerative colitis relapse

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					Diet and ulcerative colitis
Dr Simon Moodie 2009.

In people without ulcerative colitis, certain foods can be a laxative. These include
excess alcohol, spicy foods (capsaicin induced diarrhoea), too much fructose
(especially in those that malabsorb fructose) such as a very high fruit diet (especially
grapes, pears, apricots, fruit juices, dried fruit), artificially sweetened food (sorbitol,
mannitol – especially too much sugar free chewing gum). Whether or not you have
ulcerative colitis, such foods may induce a looser stool. This is not the same as
causing a flare up of your colitis (that is, causing inflammation of your colon –
typically persistent looser frequent stools with blood and mucous).
        Below I discuss what evidence there is that certain foods may be bad for
ulcerative colitis. That is, whether any dietary change can reduce colitis flare ups or
help treat a flare up. It should be stressed that there have been a huge amount of
studies over many years to try and identify a diet change that definitely improves
ulcerative colitis and as yet, unfortunately, none has been proven beyond doubt to
work. However, as discussed below, some broad recommendations can be made based
on what evidence there is. On a separate information sheet I discuss the role of
specific food/herbal remedies as treatments including probiotics, probiotics (see
“probiotics, herbal remedies and acupuncture for ulcerative colitis” at

Dietary fats and ulcerative colitis
A large multicentre study was recently published (collaboration between UK,
Germany, Sweden, Denmark, Italy) (the EPIC study, GUT Dec 2009). This looked at
over 200,000 healthy people and followed them up for a few years to see who
developed a new diagnosis of ulcerative colitis, there were 126 of these new cases
(spread out between all the countries). Careful diet histories were taken and the diet of
those who did not develop ulcerative colitis compared to those that did. The results
show the following:
         Food that is bad (clear association with developing ulcerative colitis): high
intake of linoleic acid (also called n-6 PUFA). Foods that are high in this are: red
meat (particularly pork and beef), cooking oils (especially corn oil and sunflower oils)
and polyunsaturated margarines. Alternative foods that have lower amounts of
linoleic acid are fish, white meats, olive oil, butter.
         Food that may be good (may protect against developing ulcerative colitis):
high intake of Docosahexaenoic acid (also called n-3 PUFA). Docosahexaenoic acid
(DHA) is an omega-3 fatty acid (fish oil) found in cold water fatty fish, including
salmon, tuna (bluefin tuna have up to five times more DHA than other types of tuna),
mackerel, sardines, shellfish, and herring.
         To date there are no clinical trials showing that once you have ulcerative
colitis changing the type of fat you eat (to low linoleic acid and higher fish oils) will
improve your colitis. In support of this idea, though, are several small studies looking
at taking fish oil suppliments in ulcerative colitis – these mostly show a slight benefit,
although the effect is not strong enough or the trials reliable/large enough for fish oil
supplementation to have become a “standard” medical treatment. It makes sense
from the above evidence that reducing linoleic acid intake, and increasing fish oil
intake might be of benefit and it is a reasonably easy diet change to make.
Dietary sulphur and ulcerative colitis
There have been some studies suggesting that high dietary sulphur may make
ulcerative colitis worse. Magee et al (2005) correlated diet history with activity of the
patients’ colitis ( appearance at sigmoidoscopy) and found the following foods to be
bad (associated with worse colitis): bitter, white wine, burgers, soft drinks from
concentrates, sausages, lager and red wine – these foods have high levels of added
sulphite, a preservative. Jowett et al (2004) looked at diet and risk of relapse in
ulcerative colitis and found the bad foods (associated with relapse) were meat
(particularly red and processed meat), alcohol and protein. The authors point out that
these foods are high in sulphur and this may be the linking factor. They also scored
foods for sulphur content and found high sulphur was a risk factor (The major sources
of sulphur are the sulphur amino acids (found in high protein foods such as red meat,
cheese, milk, fish, nuts, and eggs) and inorganic sulphate (in Brassica vegetables and
as preservatives in processed foods, particularly commercial breads, beers, sausages,
and dried fruit). However, the worst food by far was red and processed meat and it
remains only a theory that it is the sulphur in the meat that is bad, it may of course be
the linoleic acid as discussed above. No one has yet shown that a lower sulphur diet
can improve ulcerative colitis. The consistently bad foods from these studies were
red meat especially if processed/preserved including burgers and sausages, as
well as too much alcohol (beers, wine).

Dietary fibre and dairy products in ulcerative colitis
There is no convincing evidence of a role for fibre or dairy products in colitis. That is,
there is no evidence that reducing/increasing fibre or reducing dairy products can heal
colitis or prevent relapse. However, we do know that high fibre, particularly cereal
fibre (e.g.wheat bran) might increase gas and bloating in some people and that these
symptoms are a more common in patients with colitis. Likewise, lots of milk can lead
to more gas, bloating and sometimes looser stools in some people. Indeed, in irritable
bowel syndrome symptoms of bloating and looser stools are common and often
people reduce their wheat and milk intake to improve symptoms and sometimes try a
formal low fibre diet (see patient information sheets on
on irritable bowel syndrome, low fibre diet and intestinal gas). To be clear, though,
there is no evidence that reducing fibre or dairy products can alter the clinical course
of your colitis.

Summary and recommendations
I have been trying to stress two separate areas of dietary treatment here. Firstly, what
is the evidence that altering diet can alter the clinical course of colitis (reduce/prevent
flare ups and help come off medication)? The answer is that no trial has yet shown
convincingly that a dietary change will help but the studies above suggest that the
following may be bad: red meat, particularly processed meat; linoleic acid (red meat,
sunflower oils, corn oils, polyunsaturated margarines). The following may be good:
oily fish. Secondly, certain foods do not worsen the colitis but can lead to
uncomfortable symptoms – some foods are slightly laxative, some foods are poorly
digested and worsen bloating. It is reasonable to experiment on reducing these if you
have these uncomfortable symptoms (particularly if colitis not active).

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