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Consensus Statement: Lifestyle and Behavior Modification for Management of IBD

Key findings

  • A panel of the International Organization for the Study of Inflammatory Bowel Diseases (IBD) has issued guidance to physicians and patients about the role of modifiable environmental factors in managing Crohn's disease and ulcerative colitis (UC)
  • The panel most strongly agreed about the need for smoking cessation, including by patients with UC; careful monitoring of patients on elimination diets; avoiding routine use of NSAIDs; and referring patients to mental health care as needed
  • Other topics addressed are contraception, physical activity, alcohol, nutrition, e-cigarettes, cannabis use, and primary prevention in children of patients with IBD

Environmental factors are important in the pathogenesis of inflammatory bowel disease (IBD) and contribute to its rising incidence worldwide. Based on a comprehensive literature review, a consensus panel of the International Organization for the Study of Inflammatory Bowel Diseases (IOIBD) has issued guidance about the role of lifestyle and behavior modification in managing Crohn's disease (CD) and ulcerative colitis (UC).

Ashwin N. Ananthakrishnan, MBBS, MPH, director of the Crohn's and Colitis Center at Massachusetts General Hospital and associate professor of Medicine at Harvard Medical School, served on the steering committee of the panel and as first author of the consensus document, which was published in The Lancet Gastroenterology and Hepatology.

Consensus Process

The steering committee identified 22 potential risk factors based on a literature search and presented them to the globalization task force of the IOIBD. 11 factors achieved a majority vote.

All scientific members of the IOIBD were eligible to participate in further consensus-building. Each of the 11 factors was assigned to a subcommittee of IOIBD members and junior collaborators, which conducted a more thorough literature search and proposed two to five consensus statements.

In the third round of electronic voting by IOIBD members, statements that met the threshold of 70% agreement were retained.

Consensus About Clinical Modification

The consensus document presents evidence for each of the following recommendations (edited for length in some cases here):

Smoking—Children, adolescents, and young adults should be encouraged never to start smoking to reduce the risk of developing IBD, among other long-term health benefits (100% agreement). All patients with CD who smoke cigarettes (tobacco) should be strongly encouraged to quit smoking (100%).

Continuing to smoke does not improve the natural history of UC. Although quitting smoking might be associated with a higher risk of colectomy, smoking cessation should be encouraged in patients with UC due to long-term ancillary health benefits (95%).

Diet—Patients who initiate elimination diets should preferentially try a dietary strategy best supported by evidence at that time. They should be monitored for symptom improvement and objective resolution of inflammation (95%). Patients on elimination diets should be carefully monitored for evidence of nutrient deficiencies because of their IBD and dietary eliminations (98%).

Nonsteroidal anti-inflammatory drugs—Routine long-term or frequent use of high-dose NSAIDs should be avoided in patients with established IBD (98%). For short-term pain relief, non-pharmacological therapy, acetaminophen, COX-2 inhibitors, or low-dose NSAIDs can be used (93%). Cardioprotective use of aspirin is safe in patients with IBD (85%).

Stress, mood, and mental health—Clinicians should inquire about diagnoses or symptoms of anxiety, depression, and psychosocial stressors at diagnosis and when patients present with new or worsening symptoms (90%). Patients with mental health disorders should be referred to a mental health professional or their primary care physician to help with diagnosis and treatment (95%).

Contraception—A decision about the appropriate contraception methods should be made in conjunction with primary care or obstetrician–gynecologist physicians incorporating characteristics of the patients' IBD, concomitant comorbidity, and risk factors for venous thromboembolism (VTE). Progestogen-only or low-dose estrogen-containing methods might be preferred in patients at high risk for VTE (95%).

Physical activity—There is no evidence that physical activity is associated with worse outcomes. Clinicians should inquire about patients' physical activity levels, identify and address barriers to physical activity, and make recommendations to increase the amount of physical activity as tolerated (93%).

Alcohol—Patients do not need to avoid alcohol consumption to affect their IBD activity (93%).

Primary prevention in offspring—Patients seeking advice on preventing the development of IBD in their children should be counseled to consider breastfeeding when able, use antibiotics judiciously in their children, and avoid passive exposure to tobacco (88%).

Nutrition—A formal assessment for malnutrition, obesity, and sarcopenia by a dedicated IBD dietitian or healthcare provider with relevant expertise should be performed as a routine part of care (80%).

E-cigarettes (vaping)—Further research is needed to establish whether e-cigarettes can be a less harmful alternative to traditional cigarette smoking (78%).

Cannabis use—Cannabis or cannabinoid use is not recommended as a treatment for IBD (76%).

The panel also recommends following age-appropriate recommendations for general primary care, including vaccinations, to ensure comprehensive good health.

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