Non-pharmacological therapies for inflammatory bowel disease: Recommendations for self-care and physician guidance

Table 1 Summary of best available evidence for diet management of inflammatory bowel disease (remission)

Diet	Recommendation	Ref.
Fiber	There is a lack of evidence that fiber intake should be restricted in patients with IBD. Soluble fiber sources are encouraged[32]. A high fiber diet is likely safe in patients with IBD and may impart a weak benefit[33] Cruciferous vegetables, fruit peels, nuts, seeds should be avoided in patients with known fibrostenotic stricture with obstructive symptoms[29,33]	Hwang et al[29], 2014 Wedlake et al[32], 2014 Kaplan et al[33], 2016
Dairy products	Strict avoidance of dairy products is not justified unless it clearly worsens diarrhea[52]. For patients who are lactose intolerant, it may still be possible to consume small amounts of dairy products with lower amounts of lactose such as fermented dairy products (yogurt and kefir), cottage cheese, butter and aged cheeses[29]	Richman/Rhodes[52], 2013
Low-FODMAP	A low-FODMAP diet may be worth trying in patients with IBD who have FGS such as bloating, abdominal pain or watery diarrhea that have persisted despite appropriate treatments[25,52]	Maagaard et al[25], 2016
Plant-based	Plant-based diets such as a lacto-ovo vegetarian diet or Mediterranean diet pattern may reduce gut inflammation in IBD[19,20]	Chiba et al[19], 2010 Marlow et al[20], 2013
Fat/animal protein	Avoidance of trans fatty acids from processed foods, margarine and fast foods may be warranted[34,52] A diet low in animal fat, particularly from processed meat and red meat (< 2/wk) is encouraged[34,122]	Jowett et al[34], 2004 Owczarek et al[122], 2016
Specific carbohydrate/IBD-AID/gluten-free	The effect of the SCD, IBD-AID and the gluten-free diet on clinical course in IBD remains to be elucidated in future trials

IBD: Inflammatory bowel disease; FODMAP: Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols; SCD: Specific carbohydrate diet; AID: Anti-inflammatory diet.

Table 2 Summary of best available evidence for physical activity and exercise in inflammatory bowel disease

Type	Recommendation	Ref.
Physical activity	Lower levels of physical activity are associated with fatigue[60,61], systemic inflammation[60], and reduced cardiovascular fitness[61], whereas higher levels of physical activity may improve quality of life[67] and decrease risk of active disease[62]. Unstructured “lifestyle” and work-related physical activity may be preferential over exercise[58,60,67], although both are encouraged	van Langenberg et al[60], 2015 Vogelaar et al[61], 2015 Jones et al[62], 2015 Crumbock et al[67], 2009 Mack et al[58], 2011
Exercise	Structured exercise may improve overall fatigue[70], general well-being[68], and disease activity[70]. Thus, exercise, including cardiovascular and resistance training, should supplement “lifestyle” physical activity	Van Langenberg et al[70], 2014 Chan et al[68], 2013
Cardiovascular training	Low-moderate intensity cardiovascular training may improve cardiovascular fitness[64], disease activity[65], perceived stress[64,65], and quality of life[64,65], including social and general well-being[63,64]. Cardiovascular training should be incorporated into exercise regimen a minimum of 30 mins, 3 d per week	Klare et al[63], 2015 Loudon et al[64], 1999 Ng et al[65], 2007
Resistance training	Low-moderate intensity progressive resistance training may improve bone health[66], strength[73], and quality of life[73]. More evidence is needed for a specific prescription	Robinson et al[66], 1998 de Souza et al[73], 2014

Table 3 Summary of best available evidence for psychological interventions in inflammatory bowel disease

Intervention	Recommendation	Ref.
Cognitive behavioural therapy	May be useful for developing adaptive coping skills[85,88,90], reducing IBD-related stress[85], and improving quality of life[86-88,90] Therapeutic gains are observed in individuals with varying degrees of distress.[85,86,90,91] Outcomes on anxiety and depression are inconsistent[85,86,88-90]	Mussell et al[85], 2003 Díaz-Sibaja et al[86], 2009 Keefer et al[87], 2012a McCombie et al[88], 2016 Mikocka-Walus et al[89], 2016 Mikocka-Walus et al[90], 2015 Keefer et al[91], 2012
Mindfulness-based therapies	Could foster adaptive coping[96] and maintain quality of life during flare ups, particularly among individuals with moderate-severe distress or abdominal symptoms[96,97]. The evidence for managing anxiety and depression[98], as well as disease activity[97,99], is limited.	Berrill et al[96], 2014 Jedel et al[97], 2014 Schoultz et al[98], 2015 Gerbarg et al[99], 2015
Hypnosis	Demonstrates the most promise for managing disease activity[104,106,107]	Keefer et al[104], 2013 Miller/Whorwell[106], 2008 Mawdsley et al[107], 2008
Stress management	These interventions appear to target anxiety[110-112], reduce IBD-related stress[109,110], and improve quality of life[108,110]. There is some support for managing pain[110,114,115]	Boye et al[108], 2011 Milne et al[109], 1986 Mizrahi et al[110], 2012 Larsson et al[111], 2003 Smith et al[112], 2012 Shaw/Ehrlich[114], 1987 Garcia-Vega/Fernandez-Rodriguez[115], 2004
Psychodynamic psychotherapy, supportive expressive group therapy, solution-focused therapy, multi-component behavioural treatment	Insufficient evidence to make recommendations at this time

IBD: Inflammatory bowel disease.