The use of complementary alternative medicine (CAM) is common among patients living with inflammatory bowel disease (IBD). For the purpose of this article, CAM is defined as therapies that go beyond traditional pharmacological approaches. Patients turn to CAM for many reasons, but most commonly the patient is either unhappy with their current treatment or is looking for a more holistic approach to their care. Many patients do not report the use of CAM to their healthcare providers, and that is concerning. Depending on the type of CAM being used, this approach can have serious impacts on health, especially if patients reduce their dosage of prescribed medication.
Complementary therapies such as diet, physical activity and exercise (PA/E) and psychotherapy are not always considered mainstream therapies; however, they are relevant to the patient living with IBD. Our team completed a scoping review of these therapies to provide the most current evidence for their adjunctive use in maintaining remission in IBD. The ultimate goal was to provide both patients and healthcare professionals with a summary of the scientific evidence, so they could make informed decisions about CAM.
Improved disease activity and prolonged time to relapse are both benefits of diet manipulation in IBD; however, these results must be interpreted with caution as high quality, well-designed randomized control trials are lacking. Restrictive diets are not recommended as they can predispose patients to nutritional deficiencies. In fact, no single diet can currently be recommended for all patients with IBD; instead, personalized dietary recommendations need to be created for each patient.
For the patient in remission, a diet rich in fruit, vegetables and fiber, and reduced in red/processed meat and n-6 polyunsaturated fats (e.g. corn, soybean, safflower, sunflower oils), could be considered, as emerging evidence suggests these dietary changes may prolong remission. Although healthcare professionals often recommend avoiding fiber, evidence for this recommendation is lacking. In fact, evidence suggests that a high fiber diet, rich in soluble fiber sources, imparts a benefit that is likely due to the beneficial influence of fiber on the gut microbiome. For IBD patients with functional gut symptoms (e.g. gas, pain, bloating and diarrhea) specifically during remission, a low FODMAP diet may aid in reducing these symptoms, but a paucity of research exists regarding nutrition guidelines for patients with active IBD.
Lack of physical activity and exercise (PA/E) have been linked to osteoporosis, reduced cardiovascular capacity and impaired muscle function in patients with IBD. Patients report that regular PA/E can be challenging as they can experience pain, muscle weakness, an increased need for defecation, and fatigue. Despite these barriers, regular physical activity has been shown to improve IBD-related activity and fatigue. There are no specific exercise guidelines that exist for this population. However, current evidence suggests that low-to-moderate intensity physical activity, including cardiovascular and resistance exercise, can improve quality of life and inflammation.
Patients with IBD frequently report negative psychosocial outcomes, such as reduced quality of life, anxiety, depression and a reduced ability to cope. Cognitive behavioral therapy (CBT) and mindfulness-based therapies (MBT) have been shown to improve coping, reduce stress and improve quality of life, however their efficacy for reducing anxiety and depression is not profound and inconsistent between reports. Hypnosis has shown promise in reducing disease activity and pain in IBD, whereas the evidence for the impact of CBT and MBT on reducing clinical disease activity is limited. Stress management, defined as education on stress and/or coping or utilizing relaxation techniques, has been shown to aid patients with IBD who have anxiety or depression, as well as assisting with pain management.
Therapies such as diet, PA/E and psychotherapy should be used as an adjunctive treatment in the management of IBD and many patients would benefit from a more holistic approach to managing their disease. Future trials need to be well-designed and sufficiently powered, while requiring both objective measures (e.g., biomarkers, disease activity) and subjective measures (e.g. quality of life) in order to advance the overall care of patients living with IBD.
Duff W, Haskey N, Potter G, et al. Non-pharmacological therapies for inflammatory bowel disease: Recommendations for self-care and physician guidance. World J Gastroenterol. 2018 Jul 28;24(28):3055-3070. doi: 10.3748/wjg.v24.i28.3055.