Authors: Ashwin N Ananthakrishnan, Gilaad G Kaplan, Charles N Bernstein, Kristin E Burke, Paul J Lochhead, Alexa N Sasson, Manasi Agrawal, Jimmy Ho Tuan Tiong, Joshua Steinberg, Wolfgang Kruis, Flavio Steinwurz, Vineet Ahuja, Siew C Ng, David T Rubin, Jean-Frederic Colombel, Richard Gearry, on behalf of the International Organization for Study of Inflammatory Bowel Diseases
Journal: Lancet Gastroenterology & Hepatology
Year: 2022
Volume: 7
Pages: 666–78
DOI: https://doi.org/10.1016/S2468-1253(22)00021-8
Study at a glance
- Study type: Consensus statement
- Number of statements: 19 final consensus statements across 11 content areas
- Participants: International Organization for the Study of Inflammatory Bowel Diseases (IOIBD) members
- Population studied: Patients with Crohn’s disease and ulcerative colitis
- Intervention or approach studied: Lifestyle, behavioural, and environmental modifications
- Comparison group: Not applicable
- Follow-up duration: Not applicable
- Main outcome(s): Expert consensus on recommendations for modifying lifestyle and environmental factors in inflammatory bowel disease (IBD) management
Why was this study done?
Environmental and lifestyle factors play an important role in the progression and management of Crohn’s disease and ulcerative colitis. Patients and doctors frequently seek advice about how lifestyle choices might affect IBD course. However, comprehensive guidance on lifestyle and behavioural modifications was previously limited. Ananthakrishnan and colleagues undertook this project to provide clear, evidence-based recommendations to physicians and patients about modifiable environmental and lifestyle factors.
How was the study performed?
The authors used a structured process involving international IOIBD experts. A steering committee identified potential modifiable factors, and IOIBD members voted on which to include. Subcommittees reviewed available research and proposed consensus statements, which were voted on electronically by all IOIBD members. Statements required at least 70% agreement for inclusion. Members scored statements from 1 (strongly disagree) to 7 (strongly agree). Three rounds of voting and refinement produced 19 consensus statements covering 11 factors.
What did the researchers find?
The authors produced recommendations across 11 areas: smoking, e-cigarettes and vaping, cannabis, stress and mental health, diet, alcohol, nutrition and body weight, physical activity, NSAIDs, contraception, and primary prevention in children of people with IBD.
Smoking
All statements achieved 95% or greater agreement. Smoking increases Crohn’s disease risk and worsens its course. All patients with Crohn’s disease who smoke should be strongly encouraged to quit. Although quitting smoking increases ulcerative colitis risk and might increase surgery risk, smoking cessation is still recommended due to broader health benefits.
E-cigarettes and vaping
Data on e-cigarettes in IBD are scarce (78% agreement). Further research is needed to establish whether e-cigarettes are less harmful than traditional cigarettes for people with IBD.
Cannabis
Cannabis or cannabinoid use is not recommended as IBD treatment (76% agreement).
Stress, mood, and mental health
All three statements achieved 90 to 95% agreement. Doctors should ask about anxiety, depression, and psychological stress at diagnosis and during symptom worsening. Patients with mental health disorders should be referred to mental health professionals or primary care doctors. Further studies are needed to explore how psychiatric medication and behavioural therapy might affect IBD course.
Diet
Both statements achieved 95% or greater agreement. Patients using dietary approaches should try evidence-supported strategies and be monitored for objective inflammation resolution, not just symptom improvement. Patients on elimination diets require monitoring for nutrient deficiencies.
Alcohol
Patients with IBD do not need to avoid alcohol for disease activity (93% agreement), though excessive consumption has other adverse health effects.
Nutrition
All patients should have formal assessment for malnutrition, obesity, and muscle loss by an IBD dietitian or relevant expert as routine care (80% agreement).
Physical activity
Physical activity is not associated with adverse outcomes in IBD (93% agreement). Doctors should assess activity levels, address barriers, and recommend increased activity as tolerated.
NSAIDs
All three statements achieved 85 to 98% agreement. Routine long-term or frequent high-dose NSAID use should be avoided. For short-term pain relief, non-drug treatments, paracetamol, COX-2 inhibitors, or low-dose NSAIDs can be used. Aspirin for heart protection is safe in IBD patients.
Contraception
Contraception decisions should be made with primary care or obstetrics and gynaecology doctors, considering IBD characteristics, other health conditions, and blood clot risk (95% agreement). Progestogen-only or low-dose oestrogen methods might be preferred for high-risk patients.
Primary prevention in offspring
Patients seeking advice on preventing IBD in children should consider breastfeeding when able, careful antibiotic use, and avoiding passive tobacco exposure (88% agreement).
Shared decision making
Clinicians should engage in fair dialogue to encourage shared decision making, reducing medication non-adherence associated with worse outcomes and increased costs (98% agreement).
What did the authors conclude?
Assessment of environmental factors and modification of behavioural and lifestyle factors is important for comprehensive IBD care. Much evidence comes from observational studies rather than interventional trials. Interventional studies are needed to examine effects on inflammation and clinical course more robustly. This consensus document provides guidance on how factors can be beneficially modified to improve outcomes. Following age-appropriate general primary care recommendations, including vaccinations, ensures comprehensive good health.
Key takeaways
- Patients with Crohn’s disease or ulcerative colitis who smoke should be strongly encouraged to quit, as this improves Crohn’s disease outlook and provides general health benefits.
- Doctors should routinely ask about anxiety, depression, and psychological stress at diagnosis and during flares, referring patients to mental health professionals when appropriate.
- Patients using dietary approaches should try evidence-supported diets and be monitored for objective inflammation resolution, not just symptom improvement.
- Regular physical activity is safe for IBD patients and should be encouraged as tolerated.
- Patients should avoid routine or frequent high-dose NSAID use, though low-dose aspirin for heart protection is safe.
This Scientific Publication Summary is an objective summary of the published study for personal and educational use. It does not constitute medical advice, endorsement of the intervention, or a recommendation to alter clinical practice.