For patients with ulcerative colitis (UC), developing an effective strategy for the management of the condition can be a never-ending challenge. During UC flare-ups, patients find themselves desperate for interventions that can dampen debilitating symptoms. During periods of remission, many UC patients constantly worry about the possibility of a relapse. However, for UC patients who are pregnant, dealing with active and/or latent UC symptoms becomes an even greater challenge, since treatment options are much more limited.
During pregnancy, surgical interventions are essentially out of the question, even for women who have recently been diagnosed with UC, since studies show that surgery increases the fetal mortality rate. While most pharmaceutical therapies are generally considered safe for pregnant women, there are a few significant exceptions: both methotrexate and thalidomide are contraindicated for pregnant women, having been designated as Pregnancy Category X medications. There are also several classes of drugs that have been placed in Pregnancy Category C, including mesalamine and corticosteroids, which means that animal studies that have suggested possible negative consequences for pregnant mothers. On the whole, given the lack of clear, comprehensive evidence on most drugs, both patients and practitioners remain concerned about using these pharmacotherapeutics during pregnancy.
As a result of these limitations, many patients and practitioners are considering nutrition-based management strategies that can effectively address UC symptoms without putting the health of the mother or the infant at risk. Effective strategies can include a combination of anti-inflammatory food choices (such as carrageenan elimination and gluten elimination), as well as the intake of dietary supplements that suppress inflammation and address concerns about maintaining essential nutrient levels during pregnancy.
The Importance of Controlling Ulcerative Colitis During Pregnancy
For decades, scientists have recognized that managing UC symptoms is especially important for women during pregnancy. In 1980, a study on over 250 British patients indicated that the activity of UC could directly affect birth outcomes. Women with active UC had a slightly lower chance of producing a live, healthy baby than those who were in remission, and the risk was considerably higher for the patients with the most severe symptoms. More recently, these findings were supported by a nationwide study on Danish patients, which was published in 2011. For patients who had been diagnosed with UC within 0 to 6 months of pregnancy—and therefore were likely to be experiencing active symptoms—there was a significantly higher risk of preterm birth.
Similarly, in 2018, a group of researchers at Tokyo Women’s Medical University conducted a retrospective study on the role of UC disease course on pregnancy outcomes in middle-aged women. Once again, abnormal pregnancy—which was defined as abnormal delivery and/or low birthweight—was much more likely in patients with active UC (30.1 percent, as compared with only 17 percent for women in the remission group). The statistical significance of these results verifies the hypothesis that UC disease activity is directly related to pregnancy progression and patient outcomes. Given the concerns about pharmacological treatment for UC during pregnancy, these results clearly indicate the potential value of targeted dietary changes for pregnant UC patients.
Reducing the Intake of Inflammation-Inducing Food Additives: The No-Carrageenan Diet
Some UC patients worry that anti-inflammatory elimination diets will effectively reduce their intake of key nutrients that support the health of their growing baby. This is a particular concern for UC patients since nutrient malabsorption is a common symptom. One solution is to eliminate inflammatory food additives that contribute no significant nutritional value, such as carrageenan. Based on in vitro and animal studies implicating this common food additive in multiple inflammatory processes, a group of researchers based at the University of Illinois set out to explore whether reducing carrageenan intake could reduce aid in the management of UC.
In a randomized, double-blind, placebo-controlled study in 2017, patients were first instructed to adopt a no-carrageenan diet. Then half were given a carrageenan-containing supplement, while the others were given a placebo. In the patients who took the supplement, the researchers observed higher levels of inflammatory biomarkers and a statistically higher risk of remission. Therefore, the scientists were able to conclude that carrageenan restriction could reduce the risk of early relapse—a major goal for UC patients who are in remission at the start of their pregnancy. Moreover, the evidence from this study also indicates that cutting out carrageenan can potentially ameliorate symptoms in UC patients when the disease does flare up during pregnancy.
Considering a Gluten-Free Diet During Pregnancy
Gluten-free diets may also be a safe way for pregnant patients to reduce UC symptoms. A combination of preliminary research and anecdotal evidence suggests that gluten can trigger inflammation, further exacerbating the most common symptoms of UC, and elimination may be an effective management strategy. Indeed, in one study of over 1600 patients who had been diagnosed with an inflammatory bowel disease (such as UC) and celiac disease, 38.3 percent reported that a gluten-free diet led to fewer or less severe UC flare-ups.
However, many gluten-containing foods (like whole wheat bread and whole grain cereal) are fortified with essential B vitamins, including folate, which are particularly important for women during pregnancy. As a result, there is a chance that removing gluten from a patient’s diet will simultaneously eliminate important sources of B vitamins. Consistent with this concern, studies on mostly-female patients on gluten-free diets indicate that the diet may increase the likelihood of folate deficiency. Therefore, pregnant UC patients who choose a gluten-free diet should make sure that they add a highly bioavailable folate supplement to their diet. A gluten-free pregnancy diet should also emphasize the intake of high-folate fruits and vegetables like leafy greens, lentils, avocado, and papaya.
Controlling Ulcerative Colitis and Promoting Iron Absorption with a Quercetin Supplement
Another nutritional supplement that pregnant UC patients may want to consider is quercetin. Quercetin is an all-natural polyphenol that is derived from plant extracts, and its anti-inflammatory and antioxidant properties have made it a prominent candidate for all patients looking for UC management alternatives. This plant-based nutritional supplement is especially appealing for pregnant patients because it poses no major safety concerns. In fact, a 2011 study in the journal Toxicology indicates that quercetin intake may actually have additional benefits for both the mother and the child, beyond just reducing inflammation in UC patients. Specifically, an animal study in mouse models showed that a quercetin supplement can raise iron levels in the mother, which is particularly relevant because iron-deficiency anemia is more common among UC patients than the rest of the population. At the same time, the study indicated that exposure to a quercetin supplement can improve the infant’s future capacity for iron homeostasis (that is, their ability to maintain healthy iron levels). These results suggest that quercetin can simultaneously help UC patients manage symptoms and address nutrient deficiency-related concerns during pregnancy.
Clearly, it is essential for UC patients to effectively manage their symptoms during pregnancy, and dietary changes offer a safe, evidence-based alternative to traditional pharmaceutical therapies and invasive medical procedures. By eliminating certain dietary components (like food additives and gluten) and boosting their intake of others (like B vitamins and quercetin) through supplementation, UC patients can reduce inflammation while still ensuring that they get the nutrients they need to support their own health and that of their baby.
Bhattacharyya S, Shumard T, Xie H, Dodda A, Varady KA et al. 2017. A randomized trial of the effects of the no-carrageenan diet on ulcerative colitis disease activity. Nutrition and Healthy Aging. 4(2):181-92. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5389019/
Habal FM, Ravindran NC. 2008. Management of inflammatory bowel disease in the pregnant patient. World Journal of Gastroenterology. 14(9):1326-32. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2693677/
Hashash JG, Kane S. 2015. Pregnancy and inflammatory bowel disease. Gastroenterology & Hepatology. 11(2). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4836574/
Herfarth HH, Martin CF, Sandler RS, Kappelman MD, Long, MD. 2014. Prevalence of a gluten free diet and improvement of clinical symptoms in patients with inflammatory bowel diseases. Inflammatory Bowel Diseases. 20(7):1194-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4331053/
Ito A, Iizuka B, Omori T, Nakamura S, Tokushige K. 2018. Relationship between the clinical course of ulcerative colitis during pregnancy and the outcomes of pregnancy: A retrospective evaluation. Internal Medicine. 57(2):159-64. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5820031/
Norgard BM. 2011. Birth outcome in women with ulcerative colitis and Crohn’s disease, and pharmaepicemiological aspects of anti-inflammatory drug therapy. Danish Medical Bulletin. 58(12):B4630. https://www.ncbi.nlm.nih.gov/pubmed/22142578
Poturoglu S, Ormeci AC, Duman EE. 2016. Treatment of pregnant women with a diagnosis of inflammatory bowel disease. World Journal of Gastrointestinal Pharmacology and Therapeutics. 7(4):490-502. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5095568/
Stein J, Dignass AU. 2013. Management of iron deficiency anemia in inflammatory bowel disease – A practical approach. Annals of Gastroenterology. 26(2). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959949/
Valente FX, Campos TN, de Sousa Moraes LF, Hermsdorf HHM, Cardoso LM et al. 2015. B vitamins related to homocysteine metabolism in adults celiac disease patients: A cross-sectional study. Nutrition Journal. 14:110. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4617727/
Vanhees K, Godschalk RW, Sanders A, van Waalwijk van Doorn-Khosrovani SB, van Schooten FJ. 2011. Maternal quercetin intake during pregnancy results in an adapted iron homeostasis at adulthood. Toxicology. 290(2-3):350-8. https://www.ncbi.nlm.nih.gov/pubmed/22064046
Willoughby CP, Truelove SC. 1980. Ulcerative colitis and pregnancy. Gut. 21(6):469-74. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1419661/