Crohn's disease diet: what should you eat?

Research-based diet guidelines for Crohn’s disease

Nutrition guidelines for Crohn's disease from physician-led organizations like the International Organization for the Study of Inflammatory Bowel Diseases (IOIBD) recommend increasing the amount of anti-inflammatory foods in your diet and swapping out inflammatory foods and trigger foods for better-tolerated alternatives.^

Inflammatory foods for Crohn’s disease

Inflammatory foods increase your risk for active disease when consumed frequently over time. These foods include:^{ }‍

• Sugar-sweetened beverages 
• Ultra-processed foods 

Emerging evidence suggests that the following may also be inflammatory:

• Gluten 
• Polysorbate 80
• Carboxymethylcellulose
• Carrageenan
• Artificial sweeteners
• Maltodextrin
• Titanium dioxide
• Sulfites

Anti-inflammatory foods for Crohn’s disease

Anti-inflammatory foods decrease your risk for active disease when consumed frequently over time. These foods include:^{    }

• Fruits
• Vegetables
• Omega-3 fatty acids (found in foods such as fatty fish, flaxseed oil, and chia seeds)
• Resistant starches (found in foods such as cooked and cooled potatoes)
• Beans and legumes

Trigger foods & beverages for Crohn’s disease

Trigger foods are any food that causes a symptomatic response when consumed. Trigger foods are unique to every individual and may or may not increase your risk for inflammation. Common trigger foods for people with Crohn’s disease include:^{  }‍

• Spicy foods
• Carbonated drinks
• Milk
• Dairy products
• Energy drinks
• Deep-fried foods & fatty foods
• Alcohol
• Cabbage
• Red meat (Pork, beef, etc.)
• Processed meat (lunch meat, sausage, etc.)
• Coffee
• Pastries
• Sweets
• Soda
• Corn & popcorn
• High fiber foods
• Nuts
• Leafy vegetables
• Gluten 

Keep in mind that not all of these foods may trigger symptoms for you. If a particular food is well tolerated and does not increase your risk for active disease, there is no need to restrict it from your diet unless instructed to do so by your doctor or IBD dietitian.

What to eat with active disease (inflammation)

During periods of active disease (when you have inflammation in your GI tract), it’s recommended to

• Correct malnutrition and sarcopenia (loss of muscle mass or strength) - Work with an IBD dietitian to adjust your diet or add an oral nutrition supplement to increase your caloric intake throughout the day.
• Increase your protein intake - Your body requires more protein during periods of active disease.^ If you consume meat or fish, make sure to eat protein with all meals and snacks, and you’ll likely consume enough. If you are a vegetarian, you may benefit from working with an IBD dietitian to ensure you’re meeting your protein requirements.
• Stay well hydrated - a good marker of hydration is achieving a pale yellow urine color. You may require an oral rehydration solution, which contains a specific proportion of sugar, water, and electrolytes, to help your body hold onto fluids better. 
• Correct nutrient deficiencies - Important nutrients to check regularly include vitamin D, iron, zinc, folate, and vitamin B12.^ Your dietitian may want to check additional nutrients if your diet is lacking certain food groups or if you have signs and symptoms of nutrient deficiencies. 
• Keep your diet as expansive as possible - While restriction is a normal response to symptoms, it’s important to keep your diet as broad as possible to avoid any nutrient deficiencies.
• Consume more anti-inflammatory foods - Incorporate a wide variety of anti-inflammatory foods into your diet. You may need to puree, blend, or food-process certain fiber-containing foods to improve tolerance.
• Swap out inflammatory foods and trigger foods for alternatives - Avoid restricting your diet by adding well-tolerated substitutions in place of inflammatory and trigger foods. 
• Avoid restrictive diets - Unless prescribed by your IBD gastroenterologist and supported by your IBD dietitian, avoid implementing restrictive diets as they could increase your risk for malnutrition, disordered eating, nutrient deficiencies, low bone mineral density, anxiety, depression, and reduce your quality of life.^{   }
• Improve food tolerance by adjusting the cooking method used - Baking, roasting, boiling, steaming, poaching, or grilling your food may help improve tolerance.
• Eat nutrient-dense meals - Instead of small convenient snacks, choose nutrient-dense meals to eat throughout the day so that you get the nutrition you need.

If recommended by your doctor, a specific diet called the Crohn’s disease exclusion diet with or without partial enteral nutrition may be helpful in getting you into remission if you have mild to moderate Crohn’s disease. Work with an IBD Dietitian to implement this diet so that you’re set up for success and can transition to a non-restrictive diet once in remission.

What to eat in a Crohn’s flare-up

A Crohn’s flare-up is when you experience symptoms of the disease. Symptoms are poorly correlated with disease activity, so you may experience a flare-up with or without inflammation. It’s a good idea to have your doctor check your inflammatory markers regularly to know if you have active inflammation. During a flare-up, it’s recommended to:

• Keep your diet as expansive as possible
• Swap out trigger foods for better-tolerated alternatives or decrease the portion size of the trigger food to help improve tolerance without having to completely eliminate it from your diet
• Continue to eat plenty of anti-inflammatory foods 
• Swap out pro-inflammatory foods for anti-inflammatory alternatives
• Have a starch with all your meals such as bananas, rice, or oats^{ }
• Stay hydrated

Some examples of meals to eat during flares include:

• Plain oatmeal with a banana, nut butter, and plain non-fat greek yogurt
• Tofu scramble with tahini, nutritional yeast, garlic, coriander, and sweet paprika on avocado toast
• Burrito bowl with baked chicken breast, rice, roasted zucchini or yellow squash, and avocado with lime juice
• Salmon with rice and fork-tender green beans

What to eat in remission

There’s insufficient evidence to recommend any specific diet (such as the Mediterranean diet, specific carbohydrate diet, anti-inflammatory diet, or autoimmune protocol) for people with Crohn’s disease to stay in remission.^ When you’re in remission, it may be helpful to eat plenty of:^{   }

• Fruits and vegetables
• Resistant starches
• Beans and legumes (if tolerated)
• A variety of protein options (plant-based, fatty fish, lean protein)
• Omega-3 fatty acids
• Water as a main beverage (unless you require an oral rehydration solution)

During periods of remission, try to keep your diet expansive by introducing a variety of anti-inflammatory foods that you enjoy and can tolerate. 

Diets for Crohn's disease

There are many diets that have been researched in Crohn’s disease that may be helpful in reducing symptoms or inducing remission in certain circumstances. 

Exclusive enteral nutrition for Crohn’s disease (EEN)

Exclusive enteral nutrition is a formula-based diet (no solid foods) and is recommended as the first-line treatment to help children with mild to moderate Crohn's disease get into remission.^ In adults with mild to moderate Crohn’s disease, exclusive enteral nutrition may be recommended preoperatively or to those who have fistulas to improve their nutrition and reduce postoperative complications.^ 

• Benefits - less time is needed to plan or cook meals as only oral nutrition supplements are consumed
• Drawbacks - It’s challenging not to eat any food for multiple weeks, which could lead to an increased fear of foods or increased morality associated with foods.

Crohn's disease exclusion diet with partial enteral nutrition (CDED-PEN): 

Crohn's disease exclusion diet with partial enteral nutrition is a diet in which a portion of your calories come from a specific nutrition formula, and the rest comes from an oral diet derived from a list of mandatory and allowed foods.

Research suggests that the CDED-PEN diet was just as effective at inducing remission as EEN and may be more effective in the maintenance of remission in children with mild-to-moderate Crohn's disease.^{ } This diet may also significantly reduce fecal calprotectin levels in adults with mild-to-moderate Crohn's disease.^

• Benefits - compared to exclusive enteral nutrition, the CDED-PEN diet may be easier to follow as you are allowed to eat some foods. 
• Drawbacks - The CDED diet contains a list of “mandatory”, “allowed”, and “excluded” foods which could lead to an increased morality associated with food. The long-term effects of this diet have not been researched, and given its restrictive nature, it may not be appropriate for everyone. 

Crohn's disease exclusion diet (CDED) without PEN

A recent study showed that the CDED diet without partial enteral nutrition may be just as effective as the CDED-PEN diet at helping adults with mild-to-moderate Crohn's disease induce and maintain remission.^

• Benefits - Like the CDED-PEN diet, the CDED without PEN may be easier to follow than EEN as you are allowed to eat certain solid foods while on this diet.
• Drawbacks - Since there are only a small set of allowed and mandatory foods, the diet may become monotonous. Similar to the CDED-PEN, CDED contains mandatory, allowed, and excluded foods which may lead to an increased morality associated with food. Given the restrictive nature of this diet, it may not be right for everyone.

Mediterranean diet for Crohn’s disease

This diet includes regular consumption of fruits, vegetables, whole grains, fish, legumes, nuts, and olive oil, while eggs, chicken, and dairy are consumed in moderation. Red meat and sweets are consumed infrequently with the Mediterranean diet.^

In a randomized controlled trial, the Specific Carbohydrate Diet (SCD) did not outperform the Mediterranean diet in adults with mild-to-moderate Crohn's disease. Therefore the Mediterranean diet would be preferable over the SCD, given its less restrictive nature.^

• Benefits - The Mediterranean diet is a plant-based diet that contains foods from all food groups, which may make it the easiest Crohn’s disease diet to follow over time. It has also been well-researched and is associated with many long-term health benefits, including a decreased risk of heart disease^, regulation of blood sugar levels^, and a lower risk of many types of cancer, including colorectal cancer.^
• Drawbacks - This diet contains a lot of fiber which may be challenging to tolerate if you’re not used to consuming high-fiber foods regularly. Introducing fiber slowly over time and adapting the texture of your foods may help improve tolerability. 

Specific carbohydrate diet (SCD) for Crohn’s disease

The specific carbohydrate diet, or SCD, includes fruits, vegetables, fish, meat, homemade yogurt, aged cheeses, & excludes grains, processed foods, soy, and certain vegetables such as potatoes and corn. The SCD diet has been suggested in research to reduce symptoms in adults with mild-to-moderate Crohn's disease but was not more effective than the Mediterranean diet.^‍

• Benefits - The specific carbohydrate diet encourages consumption of whole foods and promotes cooking meals at home.
• Drawbacks - This diet includes a list of “legal” and “illegal” foods, which may lead to an increased morality associated with food. Studies have also suggested that SCD may increase your risk for certain nutrient deficiencies such as calcium, thiamine, folate, & vitamins A, B6, C, & D, although working with an IBD dietitian may reduce the likelihood of these deficiencies.^{ }‍

Low-FODMAP diet for Crohn’s disease

The low-FODMAP diet is a short-term diet in which certain foods are initially eliminated from your diet and then reintroduced to test your tolerance. This diet may help reduce certain symptoms in people with inflammatory bowel disease and overlapping irritable bowel syndrome. However, the diet has not been shown to reduce inflammation.^{  }

• Benefits - the low FODMAP diet may be helpful in identifying trigger foods if you’re still experiencing symptoms while in remission. 
• Drawbacks - This diet can be challenging to follow, particularly if you’re already avoiding certain foods due to Crohn’s disease. The elimination phase of this diet is intended to be used for a short period of time, followed by a phase of testing FODMAP food groups, then a re-introduction of well-tolerated FODMAP food groups back into your diet. 

Diets with limited research in Crohn's disease

While there are several diets that have been popularized on the internet and social media for the treatment of Crohn's disease, none of the following diets have sufficient evidence to support the use of these diets for the induction or maintenance of remission.

Anti-inflammatory diet (AID)

There is currently no research that supports the use of the IBD-AID diet for the induction or maintenance of remission in patients with Crohn’s disease. One small study of 11 patients (8 with Crohn’s disease) showed that patients who met with a dietitian and adhered to the IBD-AID protocol reported fewer symptoms after four or more weeks.^

However, due to the small number of patients included in the study and the lack of a comparable control arm, it is impossible to draw any conclusions about the role of the IBD-AID diet in reducing Crohn’s disease symptoms. The authors note that this diet can be difficult and restrictive to follow and that more rigorous research and a standardized study design are needed to draw any conclusions.

Autoimmune protocol diet (AIP)

There is currently no research that supports the use of the AIP diet for the induction or maintenance of remission in patients with Crohn’s disease. One small study of 13 patients (7 with Crohn’s disease) showed that those who met one-on-one with a dietitian and adhered to the AIP diet reported fewer symptoms after 11 weeks.^

Another study of 15 patients (9 with Crohn’s disease) showed that patients on the AIP diet improved their quality of life after three weeks.^ However, due to the small number of patients included in these studies and the lack of a comparable control arm, it’s impossible to draw any conclusions about the role of the AIP diet in reducing Crohn’s disease symptoms.

Semi-Vegetarian Diet (SVD)

There is currently insufficient evidence that supports the use of a semi-vegetarian diet to induce or maintain remission in patients with Crohn’s disease. Two small studies in Japan looked at the role of the Semi-Vegetarian Diet on symptoms experienced by study participants with Crohn’s disease. The first study included 22 Crohn’s disease patients in remission and showed that those following a semi-vegetarian diet were significantly less likely to have a symptomatic flare than those following a Westernized diet.^

A second study of 46 Crohn’s disease patients, including adults and children, who were started on Infliximab (Remicade) and the Semi-Vegetarian Diet found that all patients who completed the protocol achieved symptom remission by week six.^ Unfortunately, due to the small number of patients included in these studies, poor study design, and the lack of a comparable control arm, it’s impossible to draw any conclusions about the role of the Semi-Vegetarian Diet in reducing Crohn’s disease symptoms.

CD-TREAT Diet

There is currently insufficient evidence for the use of the CD-treat diet for the induction or maintenance of remission in patients with Crohn’s disease. In one small study, five children with Crohn’s disease were put on the CD-TREAT diet. After eight weeks, three patients were in symptom remission.^ Due to the small number of patients included and the lack of a comparable control arm, it’s impossible to draw any conclusions about the role of the CD-treat diet in reducing Crohn’s disease symptoms.

Gluten-free diet

Up to 1.4% of the world’s population has celiac disease^, with a greater portion reporting that they regularly avoid foods containing gluten. However, there is no evidence that supports the use of a gluten-free diet for the induction or maintenance of remission in Crohn’s disease. A gluten-free diet may relieve GI-related symptoms in certain individuals; however, there’s not enough evidence to recommend restricting gluten or wheat at this time.^{ }

Low-fiber diet

The use of a low-fiber diet is no longer recommended for people with Crohn’s disease. Guidelines recommend increasing your consumption of dietary fiber relative to the general population.^ A recent study showed that people with Crohn’s disease who avoid high-fiber foods were 40% more likely to flare within six months than those who did not avoid high-fiber foods.^

Diet for children with Crohn’s disease

Weight gain and growth are the primary goals of dietary treatment in children with Crohn’s disease. If your child is experiencing growth delays or malnutrition, this may be a sign of active inflammation. In children with mild-to-moderate Crohn’s disease, exclusive enteral nutrition^ or the CDED with PEN can be used as the first-line treatment to help your child get into remission.^

Given the risks for nutrient deficiencies and disordered eating in individuals with IBD, restrictive diets should be recommended with caution for children with Crohn’s disease. Work with an IBD dietitian nutritionist to decrease your child’s risk for nutrient deficiencies and to keep their diet as expansive as possible.^

Diet for stricturing Crohn’s disease

Nutrition guidelines recommend increased consumption of fiber relative to the general population for those living with Crohn’s disease. However, if you have stricturing Crohn’s disease (when you have a build-up of scar tissue or narrowing of your intestines due to inflammation), you’re at an increased risk of having a bowel obstruction.

It’s critical to consult with your gastroenterologist and IBD dietitian before making any dietary changes if you have stricturing Crohn’s disease to ensure you do so safely. Although there is limited research on this topic, guidelines recommend adjusting food textures and the type of fiber consumed to reduce your risk for obstructions.^{ }

To decrease your risk for an obstruction or blockage, your care team may recommend you avoid large particle-size insoluble fiber and tough textured foods such as:

• Steak
• Shrimp
• Tough meats
• Popcorn
• Raw nuts
• Raw kale

To improve tolerance to food with stricturing Crohn’s disease, consider the following:

• Choose foods higher in soluble fiber - Examples of foods higher in soluble fiber include raspberries, cooked zucchini, bananas, and peeled potatoes.
• Adjust the texture of your food - Consider blending, pureeing, or cooking down food into a softer texture.
• Reduce the particle size of food - Cut your food into smaller pieces and chew thoroughly to aid in digestion.
• Adjust the amount of certain foods - Start with a small portion of foods with fiber and slowly increase your intake over time. If you consume a lot more fiber than you’re used to, you may experience increased symptoms. However, if you increase your fiber consumption gradually over time, it may improve tolerance. 

Malnutrition and sarcopenia with Crohn’s disease

Malnutrition is when a nutrition imbalance is present. Malnutrition is found in up to 85% of patients with Crohn’s disease.^{ } Malnutrition is associated with:^{  }

• worse disease prognosis 
• Growth failure in children
• Increased risk for surgery, postoperative complications, risk for death, and longer hospitalizations
• Higher perceived stress, decreased social support and lower quality of life

To quickly screen for your risk of malnutrition, consider your answers to the following questions:^

1. Have you recently lost weight without trying?
2. Have you been eating poorly due to a reduced appetite? 

If you answered yes to either of these questions, you could be at an increased risk for malnutrition and should seek help from an IBD registered dietitian. 

Sarcopenia is when there is loss of skeletal muscle mass and strength and may be found in up to 42% of individuals with Crohn’s disease.^{ } Sarcopenia appears to be associated with an increased risk for:^{  }

• Bone breakdown
• Stress fractures
• Heart disease
• Surgeries 
• Post operative complications 
• Reduced mobility 
• Higher risk for biologic therapy 
• Disease exacerbation

Supplements for Crohn’s disease

Probiotics for Crohn’s disease

There is currently no evidence that any particular probiotic is helpful for the induction or maintenance of remission or reduces symptoms in people with Crohn’s disease.^

Fish oil/omega-3 fatty acid supplementation for Crohn’s disease 

No research supports the use of fish oil or omega-3 fatty acid supplementation for the induction of remission in Crohn’s disease patients, and supplementation is likely ineffective in the maintenance of remission in Crohn’s disease.^

L-Glutamine supplementation

According to a recent meta-analysis of 7 studies, glutamine supplementation was ineffective for the induction or maintenance of remission in Crohn’s disease patients.^

Nutrition support for Crohn's disease

If you want to sustainably reduce your symptoms and optimize your diet, reach out to learn how we can help. Our IBD registered dietitians can help you safely and sustainably expand your diet to include the foods you love while reducing your symptoms and decreasing your risk for flares and active disease. Request a call to learn if our nutrition counseling program is right for you.