Rethinking Restrictive Diets in IBD: Toward an Inclusion-Focused Nutritional Paradigm

Patient-initiated elimination diets are widely adopted by those with inflammatory bowel disease (IBD), yet the evidence supporting their long-term use remains limited and their risks are increasingly recognized. Some common elimination diets utilized by patients include the specific carbohydrate diet (SCD), low-FODMAP diet, and gluten-free and dairy-free diets. This narrative review critically examines the role of self-initiated restrictive dietary strategies in IBD management, evaluating the evidence for and against common elimination-based approaches, and contrasts these with emerging data supporting more inclusive dietary patterns.

Sustained elimination diets carry meaningful risks: malnutrition, micronutrient deficiency, sarcopenia, gut microbial dysbiosis, food anxiety, and avoidant/restrictive food intake disorder (ARFID). Current evidence demonstrates that the Mediterranean diet performs comparably to more restrictive approaches in inducing symptomatic remission, and generally is not associated with adverse nutritional and psychosocial consequences. Contemporary recommendations from several gastrointestinal societies discourage long-term elimination diets and favor inclusive, nutritionally adequate patterns, particularly the Mediterranean diet, as a preferred dietary framework for most patients with IBD, though supporting evidence remains largely observational and randomized controlled trial data are limited. We propose a paradigm shift from dietary exclusion toward inclusion, diversity, and nutritional adequacy, with registered dietitians as essential partners in IBD care. When elimination is clinically indicated, it should be time-limited, goal-directed, and followed by structured food reintroduction. Moving beyond restriction represents not a retreat from dietary focus, but its maturation, aligning nutritional guidance with the principles of patient-centered, evidence-based disease management.