What is Nutritional Therapy and How Does It Work?

If you are considering including nutritional therapy in your medical management plan for IBD, likely you have many questions: What exactly is nutritional therapy? How does it differ from a generally healthy diet? How does it work? How will it affect my life? How do I begin? What are my options? A brief overview of these topics may be helpful before discussing nutritional therapy as an option with your medical team.

What is Nutritional Therapy?

There are two types of nutritional therapy: enteral nutrition and therapeutic diets. Enteral nutrition options involve the use of a liquid diet consumed orally or administered with a nasogastric tube, whereas therapeutic diets are carefully designed whole food diets. Both have a role in managing IBD.

Enteral nutrition includes Exclusive Enteral Nutrition (EEN) and Partial Enteral Nutrition (PEN). Exclusive Enteral Nutrition is a diet consisting solely of liquid nutrition (often an over-the-counter meal replacement formula like Boost®, Ensure®, Pediasure®, Kate Farms®, or Modulen IBD®) and water, with no solid foods. It is used for 6 to 8 weeks to induce remission. Partial Enteral Nutrition is a diet that combines liquid nutrition with solid foods. It is generally begun after achieving remission with EEN and its purpose is to maintain that remission. Historically, PEN has been shown to be ineffective at inducing remission when combined with a standard diet. More recently, PEN has been used to induce remission when combined with a therapeutic diet known as the Crohn’s Disease Exclusion Diet (CDED).

Exclusive Enteral Nutrition has been proven to be very effective for inducing remission in children with Crohn’s disease, with the added benefits of improvements in nutritional parameters, weight gain, bone health, and tissue mucosal healing with minimal or no side effects. Those interested in the research behind EEN can find more information on our EEN Page and will find links to studies and review articles in our EEN Research section. The EEN studies are our first scientific evidence that diet and nutrition affect IBD outcomes.

Therapeutic diets are whole-food based, nutritionally balanced dietary plans that improve symptoms, reduce inflammation, and aid in mucosal healing. Diets that control symptoms but do not reduce inflammation or contribute to healing like low-FODMAP and low-residue diets would not be considered a therapeutic diet. Therapeutic diets focus on nutrient-dense whole foods, eliminate harmful components like processed foods and additives, and limit or eliminate foods that are known to be detrimental in IBD, like gluten, sugar, and dairy.

Therapeutic diets are relatively new to clinical practice, and research supporting them is still in the early stages, although some diets have a long history of use by patients outside of a clinical setting. Fortunately, the body of scientific evidence supporting the potential of therapeutic diets is increasing and awareness among clinicians is growing. Those interested in the scientific evidence supporting each of the therapeutic diets can find links to research, publications, and ongoing trials in our research section. Management plans involving a therapeutic diet as primary or supportive therapy must be a cooperative effort between a patient and his/her medical team and all such plans must include regular monitoring of disease with lab work and scopes.

How Do Therapeutic Diets Differ from a Standard Healthy Diet?

Therapeutic diets are similar to general healthy diets like the Mediterranean Diet, with a focus on whole foods, incorporating fruits and vegetables, and avoiding processed foods with additives and preservatives. However, therapeutic diets are more restrictive because they also eliminate or limit foods thought to be problematic in patients with IBD. To be effective, a therapeutic diet must be followed more strictly than a general healthy diet, and a long-term commitment is required to achieve and sustain results. After a prolonged period of remission with healing, many find they can broaden the diet to incorporate a wider range of healthy foods.

How Does It Work

The exact mechanism behind the various nutritional therapies is not entirely known. Effects on the gut microbiome likely play an important role for all nutritional therapy. The gut microbiome is a community of bacteria, viruses, and fungi living within the lining of the gastrointestinal tract. A balanced community of organisms in the microbiome may be essential to good health. In IBD, the gut microbiome composition is altered, a condition known as “dysbiosis.” Interventions that improve the state of the microbiome have potential for managing IBD. Diet influences the gut microbiome and may be the most effective means to modify it in a favorable way. Therapeutic diets are specifically engineered to improve microbiome diversity and restore balance.

Nutritional therapy addresses the dysbiosis of the microbiome and the potential inflammation that results, whereas medications target the inflammatory effects of an activated immune system. In combination, these two therapies work to resolve inflammation from different vantage points. This dual system approach may have the potential to produce better results than either method alone. Those interested in learning more about the microbiome can read about it on our home page and find links to studies on the microbiome and IBD on our Related Research page.

How Might Adopting a Therapeutic Diet Affect My Life

Adopting a therapeutic diet is more than just following a diet, it is a lifestyle change. It usually requires a serious commitment of time, money, and effort. It can have impacts on finances, social engagements, personal relationships, and available free time. It comes with a whole new perception of the role of food in your life and in your health. While you will make sacrifices, many find the benefits worth it. You will have the opportunity to discover new foods and to master culinary skills. You may even discover health benefits not related to your medical condition. Most important, when nutritional therapy is effective, you will feel better again, and feeling better means getting your life back – being able to do the things you used to do before IBD got in the way. Even if your diet appears to be restricted from the outside, you may be able to tolerate a wider range of foods than you could before starting your diet, when disease was active.

Adopting a therapeutic diet generally means giving up preprocessed foods and snacks. When first starting a therapeutic diet, it is often advisable to make as much at home from scratch as you can, using prepackaged foods with acceptable ingredients very selectively and sparingly, and sticking to the simplest/strictest form of the diet. After healing has occurred, more advanced foods, sometimes including prepackaged foods with acceptable ingredients, may be added as tolerated. Some diets have mandatory stages or phases; others have optional stages. Most avoid restaurants when first starting out, in order to have better control of their food and the ingredients used.

Whole food ingredients tend to be more expensive than processed foods. Organic, GMO-free, pasture-raised, grass-fed food products are often recommended, but not usually required. Most on therapeutic diets try to find the highest quality ingredients that they can afford. However, when money is tight and compromises must be made, it is generally considered more important to simply follow the diet strictly any way you can rather than to invest in organic and other preferred food sources.

Cooking your own food creates a big demand on your time, so you will need to hone your time management skills. Batch cooking is often a time saver. However, whole foods do not stay fresh as long as processed foods with preservatives, so having extra freezer space for storing batch-cooked foods is helpful. Therapeutic diets can be implemented with the appliances you already have in your kitchen and there is no requirement for special purchases. However, when they can be afforded, the addition of kitchen accessories can make the day-to-day tasks easier.

You may have to relearn your shopping routine, skipping aisles of boxed, canned, and frozen goods, and instead frequenting the aisles with fresh produce, nuts and seeds, meats, and/or cheeses. Because fresh foods do not last as long as processed foods, you may find yourself making multiple smaller trips to grocery stores during the week. You may also find you need to frequent multiple stores in order to find the variety of allowed foods you need to maintain a healthy diet.

Social engagements often require preplanning. You may have to spend time preparing your own food to bring along, or calling ahead to restaurants to plan for a safe meal. You may experience resistance from friends and family members who may not understand the importance of diet to your health and who want to continue to engage socially by consuming the same foods they are used to.

When starting a therapeutic diet, it is not uncommon to experience cravings for unhealthy foods like white bread and processed sugar. Eventually those cravings will go away and your body will adjust to your new way of eating.

You may have to discuss with family how the household will implement a therapeutic diet. Will everyone be eating the same? Will you be eating one way and others eat another? Will foods that are not allowed be permitted in the house? In the kitchen pantry? When everyone eats the same, it provides a supportive, inclusive atmosphere, and creating a single meal rather than several saves time and energy. However, it can also be a greater financial burden as the ingredients are often more expensive. Many families discover additional unexpected health benefits for the whole family when choosing to collectively transition to a therapeutic diet, making it worth the added expense. When a child is on a therapeutic diet, families sometimes choose to all eat the same way, so the child does not feel he/she is any different. On the other hand, because food prep can be so time consuming, some families find it works better if only the family member on the special diet eats foods that are specially made for that diet. There is no right or wrong way and every family must choose a plan that works for them.