Lifestyle, Behavioral, and Environmental Recommendations for Managing Inflammatory Bowel Disease

stomach pain
Experts from the International Organization for the Study of Inflammatory Bowel Diseases released recommendations for managing IBD.

A group of experts from the International Organization for the Study of Inflammatory Bowel Diseases (IOIBD) released a set of consensus statements for the management of inflammatory bowel disease (IBD). The full report, published in the Lancet Gastroenterology & Hepatology, comprised 19 consensus statements on lifestyle, behavioral, and environmental modification for patients with IBD.

Consensus statements were authored by IOIBD subcommittees and selected through a 3-round voting process. Subcommittees were designated to each address a separate set of lifestyle, behavioral, or environmental factors in IBD. Statements that met a 70% agreement threshold were retained.

The final 19 statements below — grouped by category — have been summarized from the original text and include additional information from the report:

Smoking

Statement #1: While smoking cigarettes increases the risk of developing Crohn disease (CD), quitting smoking also increases the risk for ulcerative colitis (UC). To reduce the risk for IBD, clinicians should make every effort to discourage young patients from ever starting to smoke. The effect of passive smoking is less clear and requires future research. However, minimizing passive tobacco exposure when possible is recommended.

Statement #2: Smoking exacerbates the symptoms of CD. Current smokers with CD should be strongly encouraged to quit tobacco.

Statement #3: Smoking cessation has long-term health benefits and should still be encouraged in patients with UC, despite the higher risk for colectomy after quitting smoking. It is unclear why smoking appears to be a protective factor for UC, and the relationship warrants further study.

E-Cigarettes (Vaping)

Statement #4: Further research is necessary to determine whether e-cigarettes are a safer alternative to traditional smoking. Presently, clinicians should not recommend e-cigarettes in patients with IBD attempting to limit tobacco intake.

Cannabis Use

Statement #5: Cannabis and cannabinoids are not recommended treatments for IBD. There is a lack of clinical and endoscopic evidence supporting any positive effect of cannabis.

Stress, Mood, and Mental Health

Statement #6: Providers should engage with patients’ mental health. Specifically, clinicians should screen for anxiety, depression, and psychosocial symptoms at baseline. Clinicians should continue to capture mental health symptoms throughout follow-up.

Statement #7: Patients with IBD and mental health disorders should be referred to mental health professionals to receive appropriate treatment.

Statement #8: Further research is necessary to understand the effects of mental health treatment on the disease course of IBD. For example, the interaction between certain antidepressants and IBD treatments is unclear. However, treating the symptoms of mood disorders is important to the overall prognosis of patients with IBD.

Diet

Statement #9: Patients who start elimination diets for IBD should use evidence-supported strategies. There are multiple diet options in IBD, including gluten-free, lactose-free, and low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diets. The evolving evidence base requires clinicians to remain up-to-date on literature. In addition to clinical improvement, patients on elimination diets should be monitored for objective resolution of inflammation.

Statement #10: Patients with IBD on elimination diets should be monitored carefully for nutrient deficiencies. Elimination diets can result in certain deficiencies, including iron, vitamin B12, vitamin D, and zinc or other micronutrients. Periodic monitoring is necessary to identify and resolve these deficiencies.

Alcohol

Statement #11: Patients with IBD do not need to abstain from alcohol to improve their disease symptoms. However, excess alcohol consumption has negative overall health effects and should be discouraged by clinicians.

Nutrition

Statement #12: A formal assessment for malnutrition, obesity, and sarcopenia should be performed regularly in patients with IBD. These are common comorbidities in IBD and are associated with worse disease outcomes.

Physical Activity

Statement #13: Studies show no evidence of adverse outcomes from physical activity in patients with IBD. Clinicians should ask patients about activity levels, address barriers appropriately, and recommend physical activity.

NSAIDs

Statement #14: Long-term or frequent use of high-dose, nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in patients with IBD. High-dose NSAIDs have been associated with increased flare risk in IBD.

Statement #15: To address pain in IBD, nonpharmacological therapy, paracetamol, cyclooxygenase-2 (COX-2) inhibitors, and low-dose NSAIDs are recommended over high-dose NSAIDs. These options have fewer gastrointestinal side effects and are less likely to induce flares.

Statement #16: Cardioprotective aspirin use is safe in patients with IBD. Low-dose aspirin is used in the secondary prevention of coronary artery disease and stroke. Research suggests this low-dose option is safe in patients with IBD.

Contraception

Statement #17: Decisions about contraceptive methods for patients with IBD should be made in conjunction with a primary care or obstetrician-gynecologist physician. Patients’ IBD severity, concomitant symptoms, and risk for thromboembolism should be carefully considered when selecting contraceptive methods. Progesterone-only or low-dose estrogen methods may be preferable in patients at high risk for venous thromboembolism.

Shared Decision Making

Statement #18: Clinicians should engage in shared decision making with patients. Patients should be involved in treatment dialogue whenever possible. Shared processes are associated with improved adherence and better health outcomes.

Primary Prevention in Patients’ Children

Statement #19: Patients who ask about preventing IBD in their children should be instructed to breastfeed when possible, avoid excessive use of antibiotics, and minimize passive tobacco exposure.

Taken together, these statements identify critical components to IBD patient care.

“[Our] consensus document aims to provide guidance to both the treating clinician and patients on how [behavioral] and lifestyle factors can be beneficially modified to improve the outcomes of patients with IBD,” investigators wrote. “Although patient input was not part of these guidelines, we acknowledge the importance of greater involvement of patients and other stakeholders in formulating guidelines for IBD.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 

Reference

Ananthakrishnan AN, Kaplan GG, Bernstein CN, et al. Lifestyle, behaviour, and environmental modification for the management of patients with inflammatory bowel diseases: an International Organization for Study of Inflammatory Bowel Diseases consensus. Lancet Gastroenterol Hepatol. 2022;7(7):666-678. doi:10.1016/S2468-1253(22)00021-8