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Time to evaluate diet quality and give dietary advice is limited in clinical inflammatory bowel disease (IBD) practice. The Eetscore is a web-based tool that assesses diet quality according to the Dutch dietary guidelines and provides personalised dietary advice. We aimed to assess diet quality of IBD patients using the Eetscore and to study changes in diet quality, health-related quality of life (HRQoL) and clinical disease activity over time. A prospective cohort study was performed in 195 adult IBD patients. Participants were invited to fill out questionnaires (Eetscore-FFQ, short Inflammatory Bowel Disease Questionnaire and Patient Harvey Bradshaw Index/Patient Simple Clinical Colitis Activity Index) at baseline and after 1 and 4 months. The Eetscore calculates diet quality based on sixteen food components (ten points per component, total score 0–160; the higher the better) and provides dietary advice per component based on the assessment. At baseline, mean diet quality was 98 (sd 19). Diet quality was positively associated with age, female sex and level of education. Component scores were highest for red meat, wholegrain products and sweetened beverages, and lowest for legumes, nuts and processed meat. Over time, diet quality increased to 107 (sd 21) at 4 months (P < 0·001). Each ten-point improvement in diet quality was associated with an increase in HRQoL (β = 0·4 (95 % CI (0·02, 0·7), P = 0·04). Clinical disease activity did not change. In conclusion, diet quality of IBD patients significantly improved following personalised dietary advice of the Eetscore. Improvement of diet quality was associated with a slight improvement in HRQoL. The Eetscore is a practical and useful tool to monitor and support a healthy diet in IBD patients.

Inflammatory bowel disease (IBD) is a chronic inflammatory disorder of the gastrointestinal tract of which Crohn’s disease (CD) and ulcerative colitis (UC) are the main subtypes. Both are characterized by a variable and unpredictable disease course with periods of active disease alternating with periods of remission. The pathogenesis of IBD seems to be a complex interaction between the gut microbiota, immune system, genetics and environmental factors like diet and physical activity. Besides the likely contribution to the development of IBD, diet and physical activity also significantly impact the disease course and clinical outcomes in patients with established IBD. However, evidence-based guidelines in clinical IBD practice are lacking, which hampers the guidance of IBD patients who are interested in diet and physical activity as part of their treatment. All currently available evidence regarding beneficial effects of nutrients and physical activity in IBD is in line with the Dutch guidelines for a healthy diet and physical activity. However, these guidelines as a whole have not been investigated in IBD yet. Therefore, the aim of this thesis was to investigate the health effects of the Dutch dietary and physical activity guidelines as part of treatment in IBD patients.First, we used an online survey to investigate associations between the habitual diet of IBD patients and disease activity. The Dietary Inflammatory Index (DII) was used to determine the inflammatory potential of the diet. A higher DII indicates a more pro-inflammatory diet that is not in line with the Dutch dietary guidelines, while a lower DII indicates the opposite: a more anti-inflammatory diet that is in line with the guidelines. We found that the inflammatory potential of the diet was associated with clinical disease activity in Crohn’s disease patients, meaning that patients who consumed a diet more in line with the Dutch dietary guidelines had a lower disease activity and vice versa. No significant association was found in ulcerative colitis patients.We also used an online survey to investigate associations between level of physical activity of IBD patients and disease activity. We found that the level of physical activity, based on the number of minutes per week and the intensity of activities, was inversely associated with clinical disease activity in Crohn’s disease patients, while no significant association was found in ulcerative colitis patients. Interviews performed to further elucidate the association between physical activity and clinical disease activity revealed that IBD patients generally experience beneficial effects of physical activity, such as improved general fitness, quality of life, and self-image. However, barriers caused by active disease like pain, fatigue and urgency may put them off to be physically active.Hereafter, an observational study during the Nijmegen Four Days Marches was performed. In that study, we assessed whether moderate-intensity physical activity is safe for IBD patients since this type of physical activity is an important part of the Dutch physical activity guidelines. We found that cytokine responses during this repeated prolonged moderate-intensity walking exercise were not different in IBD patients compared to controls without IBD. Furthermore, faecal calprotectin was not affected by the walking exercise when comparing concentrations of IBD patients who participated in the marches to concentrations of IBD patients who did not. In contrast to these objective findings, there was a slight increase in subjective clinical disease activity in CD patients who participated in the marches, but not in UC patients. Since faecal calprotectin better correlates with endoscopic disease activity than clinical disease activity questionnaires, we overall concluded that it seems safe for IBD patients to perform repeated prolonged moderate-intensity exercise without substantial exacerbation of inflammation.We then performed a combined lifestyle intervention study based on the Dutch dietary and physical activity guidelines. During this 6-month study, personal dietary and physical activity advice was provided by a dietician and physiotherapist. This resulted in a substantial improvement of diet quality, while the level of physical activity remained the same. Over time, impact of disease on daily life reduced and fatigue decreased, while clinical disease activity, health-related quality of life and faecal calprotectin did not change. Improvement in diet quality was associated with a lower impact of disease on daily life and less fatigue. No associations were found between physical activity and disease-related outcomes.Lastly, we investigated the use of a web-based tool, the Eetscore, to assess diet quality and provide personalized dietary advice to IBD patients based on the Dutch dietary guidelines. In this prospective cohort study, diet quality of IBD patients improved following dietary advice of the Eetscore and this improvement was associated with a slight improvement in health-related quality of life. The Eetscore seems to be a practical and useful tool to monitor and support a healthy diet in IBD patients.From this thesis, we conclude that the inflammatory potential of the diet and level of physical activity are associated with disease activity in CD patients, while no associations were found in UC patients. Besides, moderate intensity physical activity does not appear to have harmful effects on IBD and can be safely performed. The Dutch dietary guidelines are consistent with a more anti-inflammatory potential of the diet. When applying the Dutch dietary and physical activity guidelines, impact of disease on daily life and fatigue decreased; likely as a result of a substantial improvement in diet quality. Also, when informing patients about the Dutch dietary guidelines via web-based dietary assessment and advice, diet quality improved.

Background Despite the potential benefits of diet and physical activity, evidence for beneficial effects of a combined lifestyle intervention is lacking in patients with inflammatory bowel disease (IBD). Therefore, we assessed its effects on impact of disease on daily life, clinical disease activity, fatigue, and health-related quality of life (HRQoL) in patients with IBD. Methods A 6-month single-arm intervention study was performed in adult IBD patients in remission or with mildly active disease. Participants received personal dietary and physical activity advice from a dietician and a physiotherapist in 6 consults. At baseline and over time, questionnaires on diet quality, physical activity, and disease-related outcomes were completed and fecal calprotectin was determined. Data were analyzed by linear mixed models. Results During the intervention, diet quality significantly increased (P < .001), but the level of physical activity remained the same. Over time, impact of the disease on daily life reduced (P = .009) and fatigue decreased (P = .001), while clinical disease activity, HRQoL, and fecal calprotectin did not change. Improvement in diet quality was significantly associated with a lower impact of disease on daily life (β = 0.09; 95% confidence interval [CI], 0.03 to 0.15; P = .003) and less fatigue (β = -0.13; 95% CI, -0.20 to -0.07; P < .001) but not with clinical disease activity, HRQoL, and fecal calprotectin. No associations were found with physical activity. Conclusions This combined lifestyle intervention significantly improved diet quality, and this improvement was associated with a reduction in the impact of disease on daily life and fatigue in patients with IBD in remission or with mildly active disease.

Background Physical activity may affect disease activity in patients with inflammatory bowel disease. We used a survey to investigate this association and performed interviews to get a better understanding of patient experiences, and therefore the nature of this association. Methods Patients with Crohn’s disease (CD, n = 176) and ulcerative colitis (UC, n = 162) completed the short Crohn’s Disease Activity (sCDAI) or Patient Simple Clinical Colitis Activity Index (P-SCCAI) and the Short Questionnaire to Assess Health-enhancing physical activity (SQUASH). Associations were investigated by multiple linear regression. Semi-structured interviews (7 CD, 7 UC) were conducted to assess patient experiences with the role of physical activity in their disease. Results The majority of survey participants were in remission (70%) and adhered to the Dutch physical activity guidelines (61%). In Crohn’s disease, the total physical activity score was inversely associated with disease activity, even after adjustment for confounders (β = − 0.375; p = 0.013). No association between physical activity and disease activity was found in ulcerative colitis. Of the interviewees, 86% experienced beneficial effects of physical activity, such as improved general fitness, quality of life and self-image. However, during periods of active disease they struggled to find the motivation and perseverance to be physically active due to physical barriers. Conclusions Crohn’s disease participants with a higher physical activity level had a lower disease activity. This inverse association was not found in ulcerative colitis. Interviews revealed that IBD patients generally experience beneficial effects from physical activity, although the barriers caused by active disease may put them off to be physically active.

OBJECTIVES: Data on diet and physical activity in ulcerative colitis patients are scarce and frequently mixed with data of patients with Crohn's disease. Therefore, the objective of this study is to investigate habitual diet and physical activity of ulcerative colitis patients and to determine whether there is an association with disease activity. METHODS: In this cross-sectional study, data of 172 subjects were collected via an online questionnaire that consisted of several validated questionnaires: the Patient Simple Clinical Colitis Activity Index (P-SCCAI) to assess disease activity, a Food Frequency Questionnaire (FFQ) to assess habitual nutrient intake and the Short QUestionnaire to ASsess Health-enhancing physical activity (SQUASH) to assess habitual physical activity. Nutrient intake was used to calculate the Adjusted Dietary Inflammatory Index (ADII). Physical activity data were used to calculate intensity levels (light, moderate or vigorous intensity) and duration of activity (min/week). These were used combined with age to calculate activity scores. Correlations between the ADII and physical activity with disease activity were investigated. RESULTS: The ADII ranged from −5.45 to 3.79 with a mean (±SD) of 0.00 (±1.55). The mean ADII was anti-inflammatory (−0.08) in subjects in remission, while it was pro-inflammatory in subjects with mild and moderately active ulcerative colitis (0.06 and 0.42, respectively), although the correlation between ADII and disease activity was not significant. With regard to physical activity, most minutes per week were spent on light to moderate activity at work or school (median [IQR] of 1375 [825]). The activity with the highest activity score was heavy activity at work or school (median [IQR] of 2160 [6480]). Subjects mostly performed activities of light intensity (median [IQR] of 840 [1575]). No significant differences in intensity levels, duration and activity score between subjects in remission and mild or moderately active ulcerative colitis were found. Also, no correlations were found between intensity levels, duration and activity score with disease activity. CONCLUSIONS: We found no associations of diet and physical activity with disease activity in patients with ulcerative colitis. FUNDING SOURCES: N.A.