Crohn’s disease (CD) and ulcerative colitis (UC) are chronic inflammatory bowel diseases (IBD) typically featuring chronic diarrhoea (with or without bleeding), abdominal pain, and weight loss. These affect an estimated 3.1 million adults in the USA and another 1.3 million in Europe[1],[2]. Globally, the incidence of IBD is increasing, particularly in newly industrialised countries[3].
These diseases are characterised by chronic inflammation of the gastrointestinal tract. However, other symptoms of inflammatory bowel diseases also exist. Although in most cases the gastrointestinal tract is the tissue mainly affected, both UC and CD are systemic disorders that often involve other organs and tissues. These non-intestinal effects are termed extraintestinal symptoms[4]. Extraintestinal disease can involve almost every organ system with the organs most commonly involved being the skin, eyes, joints, and biliary tract, among others with up to 30% of people with IBD experiencing one or more[5].
Its global prevalence has been on the rise, prompting researchers and healthcare professionals to explore multifaceted approaches for prevention and management. Among the factors implicated, lifestyle emerges as a significant determinant in IBD prevention and management.
It is well recognised that a safe and low-cost approach to prevent and reverse chronic diseases is via modification of lifestyle risk factors. Various observational studies have identified several lifestyle factors to be associated with IBD, but there remains uncertainty of the confidence of outcome of the various approaches in complex cases[6]. However, some core strategies are gaining interest from major gastrointestinal journals and their target audience – gastro-enterologists.
Diet and Nutrition
One of the pivotal lifestyle factors linked to IBD prevention and management is diet and nutrition. In many cases dietary modification is already perceived by patients to affect their symptoms and disease course[7]. Yet the only currently medically accepted nutritional therapy involves exclusive enteral nutrition, which is nearly impossible to continue for a long time due to taste fatigue and social incompatibility[8]. Therefore, more palatable, yet effective and personalised dietary strategies are needed.
In one very innovative open-label RCT called the Faecal Microbial Transplant (FMT)- anti- inflammatory diet (AID) the researchers followed 66 patients with mild-to-moderate UC on stable medications, who received seven multi- donor FMT infusions in addition to an AID and the outcomes were compared with standard medical therapy (increase or addition of 5- ASA (5-aminosalicylic acid) or corticosteroids)[9].
The diet was followed for 1 year and as you would expect mainly excluded gluten- based grains, dairy products and margarine (curd was allowed), processed and red meat, food additives and refined sugars, and increased intake of fresh fruits and vegetables, fermented foods, aryl hydrocarbon receptor ligand- ich vegetables (cruciferous vegetables) and polyphenols. In terms of outcomes, it had a clear benefit with the FMT-AID showing superior management to standard medical therapy in inducing and maintaining endoscopic remission until 48 weeks (period covered in the trial).
As food additives, and in particular emulsifiers, have been implicated to affect the gut microbiota, inflammatory responses and the gut barrier in animal studies and cell lines, the first human trials in healthy volunteers and patients with IBD were published in 2021[10]. An RCT where patients with UC followed a carrageenan- free diet and were supplemented with either carrageenan or placebo showed that carrageenan intake contributed to earlier relapse, suggesting restriction of this emulsifier might be a viable strategy in UC[11].
A small randomised-controlled feeding trial in healthy volunteers has also shown that carboxymethylcellulose (essentially a thickening agent used in all kinds of food products) adversely impacts on the gut microbiota and metabolome, thereby possibly contributing to the increasing prevalence of IBD worldwide[12].
Three trials assessed the utility of a low fermentable oligo-saccharides, disaccharides, monosaccharides and polyols (FODMAP) diet for four to 6 weeks in quiescent or mildly active IBD and consistently reported improved symptoms and/or improved quality of life (QoL) compared with the control diet[13]. Regarding biomarkers, one study showed improved faecal calprotectin levels when on the low FODMAP diet, whereas the others did not find any improvements in any biomarkers at all and even significantly lower abundances of Bifidobacterium adolescentis, Bifidobacterium longum and Faecalibacterium prausnitzii than patients on the control diet, suggesting worsening dysbiosis. The latter concurs with other dietary trials and suggests this type of diet is not promoting long- lasting disease remission or healing and should therefore only be implemented for short periods of time[14].
A review paper released in the Journal Nutrients in 2021 provides a comprehensive discussion around the challenges of identifying and removing trigger food groups, but also recognises the valuable role that nutrient management can have in the prevention and resolution of IBD symptomology and pathogenesis. Based on this evidence the Groningen anti-inflammatory diet (GrAID) was designed[15].
Smoking and Alcohol Consumption
Cigarette smoking has consistently been associated with an increased risk of Crohn’s disease while paradoxically showing a decreased risk in ulcerative colitis[16]. Conversely, alcohol consumption, particularly heavy drinking, has been linked to a higher incidence of IBD and may exacerbate its symptoms (Rodríguez et al., 2019). Quitting smoking and moderate alcohol consumption can thus be important preventive measures.
Sleep Deprivation, Stress
Inadequacy of sleep and psychological distress are additional intrinsic factors known to be associated with inflammation and the inflammation system. Sleep disturbances are said to be common in IBD patients[17]. Alteration of sleep pattern or circadian rhythms and insufficient sleep (<6 h/day) has a direct impact on disease course and severity[18]. A positive correlation between psychological distress and IBD flare-ups also indicates the need for timely psychological therapy in IBD patients[19]. Stress management techniques such as mindfulness, meditation, and yoga have been shown to alleviate symptoms and improve the overall quality of life in IBD patients[20].
Physical Activity
Regular physical activity contributes to IBD prevention through various mechanisms. Exercise enhances immune function, reduces inflammation, and supports gut health by influencing the gut microbiota composition. In people with inactive or mildly active IBD that are sedentary, moderate walking or yoga can improve quality of life and stress levels, and typically does not worsen symptoms of IBD. Experts recommend 30 minutes of moderate exercise at 60% of maximal heart rate, three to five days per week[21].
The European Crohn’s and Colitis Organisation (ECCO) published a Topical Review on Complementary Medicine and Psychotherapy in Inflammatory Bowel Disease in 2019 and provided clinical guidance based on the current available evidence[22]. They outlined that curcumin, in combination with 5-ASA, may be effective in inducing remission in mild-to-moderate UC as well as potentially being effective as a complementary maintenance therapy in UC. They concluded that omega-3 fatty acids may be beneficial in maintaining remission in Crohn’s disease; however, study quality and heterogeneity of trials limit these findings. A further paper in 2022 sees the role of nutrition, probiotics, and omega-3 fatty acids as having benefit[23].
Curcumin
Recent research has seen more focus on the effects of natural anti-inflammatories, such as curcumin, on intestinal inflammatory diseases, largely due to its safety profile and affordability. Curcumin is characterised by beneficial effects on the microbiome, antimicrobial properties, inhibition of TLR4/NF-κB/AP-1 signal transduction, changes in cytokine profiles, and alterations to immune cell maturation and differentiation. The culmination of the vast number of effects of curcumin on the intestinal epithelium and immune system is to strengthen the intestinal barrier through a reduction in bacterial translocation and inflammation, making a useful addition to clinical management of IBD and other gastrointestinal inflammatory conditions[24].
Conclusion
In conclusion, a growing body of evidence underscores the close relationship between lifestyle choices and the prevention of Inflammatory Bowel Disease. Diet and nutrition, smoking, alcohol consumption, physical activity, stress management, and sleep play integral roles in modulating inflammation, immune response, and gut health.
Implementing a holistic approach that integrates these lifestyle factors can significantly contribute to reducing the risk of IBD and enhancing overall well-being. Healthcare professionals and individuals alike should recognise the vital role of lifestyle in IBD prevention and consider it a cornerstone of comprehensive disease management.
References
[1] Dahlhamer JM, Zammitti EP, Ward BW, et al. Prevalence of inflammatory bowel disease among adults aged ≥18 years — United States, 2015. MMWR Morb Mortal Wkly Rep 2016;65:1166–9
[2] Zhao M, Gönczi L, Lakatos PL, et al. The burden of inflammatory bowel disease in
Europe in 2020. J Crohns Colitis 2021;15:1573–87
[3] Ng SC, Shi HY, Hamidi N, et al. Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies. Lancet 2017;390:2769–78
[4] Guo X, Cai L, Cao Y, Liu Z, Zhang J, Liu D, Jiang Z, Chen Y, Fu M, Xia Z, Yi G. New pattern of individualized management of chronic diseases: focusing on inflammatory bowel diseases and looking to the future. Front Med (Lausanne). 2023 May
[5] Van Bodegraven AA, Peña AS. Treatment of Extraintestinal Manifestations in Inflammatory Bowel Disease. Curr Treat Options Gastroenterol. 2003 Jun;6(3):201-212
[6] Piovani D, Danese S, Peyrin-Biroulet L, et al. Environmental risk factors for inflammatory bowel diseases: an umbrella review of meta-analyses. Gastroenterology 2019;157:647–59
[7] Triggs CM, Munday K, Hu R, Fraser AG, Gearry RB, Barclay ML, Ferguson LR. Dietary factors in chronic inflammation: food tolerances and intolerances of a New Zealand Caucasian Crohn’s disease population. Mutat Res. 2010 Aug 7;690(1-2):123-38.
[8] Wellens J, Vermeire S, Sabino J. Let food be thy Medicine- Its role in Crohn’s disease. Nutrients 2021;13.
[9] Kedia S, Virmani S, K Vuyyuru S, et al Faecal microbiota transplantation with anti-inflammatory diet (FMT-AID) followed by anti-inflammatory diet alone is effective in inducing and maintaining remission over 1 year in mild to moderate ulcerative colitis: a randomised controlled trial
Gut 2022;71:2401-2413.
[10] Bancil AS, Sandall AM, Rossi M, Chassaing B, Lindsay JO, Whelan K. Food Additive Emulsifiers and Their Impact on Gut Microbiome, Permeability, and Inflammation: Mechanistic Insights in Inflammatory Bowel Disease. J Crohns Colitis. 2021 Jun 22;15(6):1068-1079.
[11] Bhattacharyya S, Shumard T, Xie H, Dodda A, Varady KA, Feferman L, Halline AG, Goldstein JL, Hanauer SB, Tobacman JK. A randomized trial of the effects of the no-carrageenan diet on ulcerative colitis disease activity. Nutr Healthy Aging. 2017 Mar 31;4(2):181-192.
[12] Chassaing B, Compher C, Bonhomme B, Liu Q, Tian Y, Walters W, Nessel L, Delaroque C, Hao F, Gershuni V, Chau L, Ni J, Bewtra M, Albenberg L, Bretin A, McKeever L, Ley RE, Patterson AD, Wu GD, Gewirtz AT, Lewis JD. Randomized Controlled-Feeding Study of Dietary Emulsifier Carboxymethylcellulose Reveals Detrimental Impacts on the Gut Microbiota and Metabolome. Gastroenterology. 2022 Mar;162(3):743-756.
[13] Cox SR, Lindsay JO, Fromentin S, Stagg AJ, McCarthy NE, Galleron N, Ibraim SB, Roume H, Levenez F, Pons N, Maziers N, Lomer MC, Ehrlich SD, Irving PM, Whelan K. Effects of Low FODMAP Diet on Symptoms, Fecal Microbiome, and Markers of Inflammation in Patients With Quiescent Inflammatory Bowel Disease in a Randomized Trial. Gastroenterology. 2020 Jan;158(1):176-188.e7.
[14] Halmos EP, Christophersen CT, Bird AR, Shepherd SJ, Muir JG, Gibson PR. Consistent Prebiotic Effect on Gut Microbiota With Altered FODMAP Intake in Patients with Crohn’s Disease: A Randomised, Controlled Cross-Over Trial of Well-Defined Diets. Clin Transl Gastroenterol. 2016 Apr 14;7(4):e164.
[15] Campmans-Kuijpers MJE, Dijkstra G. Food and Food Groups in Inflammatory Bowel Disease (IBD): The Design of the Groningen Anti-Inflammatory Diet (GrAID). Nutrients. 2021 Mar 25;13(4):1067
[16] Lakatos PL, Szamosi T, Lakatos L. Smoking in inflammatory bowel diseases: good, bad or ugly? World J Gastroenterol. 2007 Dec 14;13(46):6134-9
[17] Barnes A, Mountifield R, Baker J, Spizzo P, Bampton P, Andrews JM, Fraser RJ, Mukherjee S. A systematic review and meta-analysis of the prevalence of poor sleep in inflammatory bowel disease. Sleep Adv. 2022 Aug 26;3(1):zpac025
[18] Swanson GR, Burgess HJ, Keshavarzian A. Sleep disturbances and inflammatory bowel disease: a potential trigger for disease flare? Expert Rev Clin Immunol. 2011 Jan;7(1):29-36.
[19] Bartocci B, Dal Buono A, Gabbiadini R, Busacca A, Quadarella A, Repici A, Mencaglia E, Gasparini L, Armuzzi A. Mental Illnesses in Inflammatory Bowel Diseases: mens sana in corpore sano. Medicina (Kaunas). 2023 Mar 30;59(4):682.
[20] Black J, Sweeney L, Yuan Y, Singh H, Norton C, Czuber-Dochan W. Systematic review: the role of psychological stress in inflammatory bowel disease. Aliment Pharmacol Ther. 2022 Oct;56(8):1235-1249.
[21] Lamers CR, de Roos NM, Koppelman LJM, Hopman MTE, Witteman BJM. Patient experiences with the role of physical activity in inflammatory bowel disease: results from a survey and interviews. BMC Gastroenterol. 2021 Apr 14;21(1):172.
[22] Torres J, Ellul P, Langhorst J, Mikocka-Walus A, Barreiro-de Acosta M, Basnayake C, Ding NJS, Gilardi D, Katsanos K, Moser G, Opheim R, Palmela C, Pellino G, Van der Marel S, Vavricka SR. European Crohn’s and Colitis Organisation Topical Review on Complementary Medicine and Psychotherapy in Inflammatory Bowel Disease. J Crohns Colitis. 2019 May 27;13(6):673-685e
[23] Morshedzadeh N, Rahimlou M, Shahrokh S, Mirmiran P, Zali MR. Nutritional management of inflammatory bowel disease; an overview of the evidences. Diabetes Metab Syndr. 2022 Mar;16(3):102440.
[24] Burge K, Gunasekaran A, Eckert J, Chaaban H. Curcumin and Intestinal Inflammatory Diseases: Molecular Mechanisms of Protection. Int J Mol Sci. 2019 Apr 18;20(8):1912.
