Chronic inflammatory bowel diseases pose major challenges for both patients and treating physicians—making modern, holistic approaches all the more important. In addition to effective medications and innovative diagnostic methods, nutrition, lifestyle, and structured models of care are also essential for successful therapy.
Together, these elements enable an individualized treatment approach that alleviates symptoms and sustainably improves quality of life. The editorial team of the Leading Medicine Guide spoke with Professor Robert Ehehalt, MD, to learn more.
Chronic inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis arise from a complex interplay of genetic factors, a misdirected immune response, and influences from the environment and lifestyle. People with a corresponding predisposition react with an exaggerated immune response to components of the intestinal flora or to stimuli that are completely harmless for healthy individuals.
This excessive immune reaction leads to persistent inflammation of the intestinal mucosa, which spreads differently depending on the type of disease: Crohn’s disease can affect the entire digestive tract and inflame all layers of the bowel wall, whereas ulcerative colitis is limited to the colon and primarily affects the superficial mucosal layers. The microbiome also plays a role, as changes in the composition of intestinal bacteria can further stimulate the immune system and promote disease flares.
“The development of chronic inflammatory bowel diseases has not yet been fully clarified. However, it is assumed that a defect in the intestinal barrier plays a central role. In this case, the intestinal wall is no longer as stable, allowing substances from food or the environment—and also the natural intestinal bacteria—to penetrate the intestinal wall more easily. This leads to an excessive inflammatory response.
Two factors appear to be responsible: first, genetic influences—by now, more than 300 so-called susceptibility genes are known which, in certain combinations, promote increased vulnerability. Second, an environmental trigger is required to ultimately cause the disease to manifest. Such triggers may include changes in the microbiome, but also lifestyle factors such as stress, lack of sleep, insufficient sunlight and thus low vitamin D levels, infections, or medications such as antibiotics. In principle, the disease can first appear at any age, even though there are typical peaks.
The most common period for initial manifestation is between the ages of 18 and 35—precisely a phase of life when many people start a family, pursue higher education, begin their careers, or build a home. As a result, the disease particularly affects an active, productive segment of the population. It can also occur in older individuals, but this is significantly less common,” explains Prof. Ehehalt, continuing:
“Because it is a bowel disease, it primarily manifests through abdominal symptoms: pain, cramping, diarrhea, occasionally constipation, blood in the stool, bloating, or fever. The symptoms depend strongly on where the disease is located. Ulcerative colitis affects only the colon and typically leads to diarrhea, abdominal cramps, and blood in the stool.
Crohn’s disease, by contrast, can affect the entire gastrointestinal tract. If it is located, for example, in the mid-small intestine, abdominal pain and bloating tend to predominate, while blood in the stool is less common. In most cases, it all begins with recurring or persistent abdominal complaints that do not resolve—and eventually this leads to medical evaluation and diagnosis.”
Crohn's_Disease_vs_Colitis_ulcerosa.svg by Samir, vectorized by Fvasconcellos, CC BY-SA 3.0
In Germany, approximately 0.5 to 0.9 percent of the population is currently affected by chronic inflammatory bowel diseases—and the trend is rising. By 2030, prevalence is expected to reach around one percent, or roughly 800,000 people. Modern lifestyles likely play a role: highly processed foods and emulsifiers can promote disease flares. A fresh, diverse, Mediterranean-style diet is recommended—“like at an Italian restaurant,” but freshly prepared rather than from the freezer.
An effective nutritional therapy for chronic inflammatory bowel diseases depends on flexibility rather than rigidity, adapting to the current condition of the intestine. People with Crohn’s disease or ulcerative colitis have very different triggers, tolerances, and disease courses, making an individualized approach essential. Fundamentally, nutrition pursues different goals during active flares than during remission, and this distinction forms the core of a personalized strategy.
During acute flares, reducing strain on the bowel is the primary objective. The inflamed intestine reacts more sensitively to fiber, fat, large portions, or heavily spiced foods. Many patients benefit during this phase from easily digestible foods, smaller meals, and an overall reduction in irritants.
Depending on severity, temporary enteral nutrition may even be appropriate—that is, a form of nutritional support that spares the bowel while ensuring adequate nutrient intake. It is important that this phase is not misunderstood as a permanent form of nutrition, but rather as a therapeutic measure that gives the intestine time to recover.
“Nutrition can mitigate quite a bit in chronic inflammatory bowel diseases, especially with regard to flares. Crohn’s disease follows a relapsing course, and during phases of intense inflammation the body tolerates different foods than during quieter phases. In addition, people with Crohn’s disease have the same food intolerances as everyone else—such as lactose or fructose intolerance—which often makes the situation more difficult to interpret and leads to great individual variability.
From a medical perspective, nutrition can partially prevent flares or lessen their severity. There are even specific nutritional therapies, such as modular diets like Modulen IBD (a fully balanced medical nutritional product; IBD = inflammatory bowel disease), which are primarily used in children. In these cases, normal food intake is completely replaced, which can actually cause the inflammation to subside. However, the problem remains: once normal eating resumes, the inflammation usually returns. Therefore, medications are needed in the long term—nutrition alone is probably only rarely sufficient to control the disease,” Prof. Ehehalt emphasizes.
Another building block of individualization is the targeted supply of critical nutrients. Inflammation, diarrhea, or malabsorption can lead to deficiencies in iron, vitamin B12, vitamin D, zinc, or folic acid. These deficits cannot always be corrected through general dietary recommendations alone and instead require regular monitoring and personalized supplementation.
Nutritional therapy is only effective if it remains practical for everyday life. This means that personal preferences, cultural eating habits, occupational demands, and psychological factors must be taken into account. Stress, lack of sleep, and irregular meals can promote flares, which is why a good nutritional therapy always considers these aspects as well.
Modern therapies have fundamentally changed the treatment of chronic inflammatory bowel diseases in recent years. Instead of relying exclusively on broadly acting immunosuppressants, targeted medications are now available that block specific immune signaling pathways and thereby control inflammation more precisely. Which therapy is suitable depends largely on the type of disease, severity of the course, previous medication trials, and individual risk factors.
“Various pharmacological approaches are available for the treatment of chronic inflammatory bowel diseases. Fundamentally, a distinction is made between conventional therapies and so-called advanced therapies. Conventional therapies include salicylates such as mesalamine—often referred to as ‘aspirin for the gut’—classic or locally acting corticosteroids, and immunosuppressants such as azathioprine, which have been used for decades and influence the immune system in a way that brings inflammation under control.
Advanced therapies include biologics—protein molecules that specifically target certain inflammatory mediators or structures, such as anti-TNF antibodies or agents directed against interleukin-23. These are usually administered by subcutaneous injection. Also among advanced therapies are modern oral medications, such as JAK inhibitors or sphingosine-1-phosphate modulators, which reduce inflammatory activity within the immune system.
An excellent, easy-to-understand overview of all available medications is provided by the Competence Network for Bowel Diseases, which offers regularly updated information. At initial diagnosis, therapy always begins with conventional medications, since biologics and modern small-molecule therapies are only approved once one (not all) of these baseline therapies has failed. If these are not sufficiently effective, treatment can be switched to advanced agents.
The choice of medication in an individual case depends on many factors: pre-existing conditions such as cardiac arrhythmias or prior infections, an existing or planned pregnancy, as well as practical considerations such as whether someone prefers tablets or wishes to avoid injections. Ultimately, the decision is always made together with the patient—medically sound, but individually tailored,” Prof. Ehehalt explains.
Biologics revolutionized IBD therapy
TNF-α blockers (medications that specifically neutralize the inflammatory messenger tumor necrosis factor alpha, TNF-α) are among the classic representatives and are used when conventional therapies such as corticosteroids or immunosuppressants are insufficient. They are effective in Crohn’s disease and ulcerative colitis and can significantly reduce flares. Newer biologics target other inflammatory pathways, such as interleukin-12/23 or interleukin-23. They often enable stable remission even in long-standing, difficult-to-control disease courses. Another important group are integrin blockers: they act specifically in the gut by preventing certain immune cells from migrating into the mucosa—an option for people at increased risk of systemic side effects or with relevant comorbidities.
At the start of therapy, it is important to define clear time frames within which a medication should demonstrate its effect. This is always discussed individually with the patient.
Prof. Ehehalt comments: “With corticosteroids, for example, a clear improvement is expected after one to two weeks. If this does not occur, it is unlikely that corticosteroids will reliably bring the inflammation under control. Then the question arises as to why the medication is not working, whether further diagnostics are needed, or whether therapy should be changed.
This principle applies to all medications: some act faster, others more slowly, but there must always be a defined period after which response is assessed. If no effect occurs, one moves on to the next medication. If there is a response, treatment is initially continued. Corticosteroids are always tapered because, due to their many side effects, they are not suitable for long-term therapy, whereas many other medications can be used long term.
Since Crohn’s disease follows a relapsing course, there are also phases in which the disease becomes quiescent and medications can be temporarily reduced or discontinued—so lifelong therapy is not always strictly necessary.”
Structured care concepts, such as those found in specialized IBD centers or interdisciplinary networks, have gained enormous importance in recent years because they achieve something that is often difficult to implement in conventional care: they pool expertise, coordinate complex treatment pathways, and support patients over the long term through a disease that can change constantly.
“Finding the right physician is not easy when dealing with a chronic disease. First and foremost, the chemistry has to be right: you need someone with whom you can build a good doctor-patient relationship, because care often spans many years. At the same time, the physician should be professionally competent and experienced in treating chronic inflammatory bowel diseases. University outpatient clinics are very often specialized in this area.
In private practice, it is worthwhile to specifically look for practices that treat a high volume of IBD cases and enjoy managing this complex therapy. A good point of reference is the certification for IBD practices issued by the Professional Association of Office-Based Gastroenterologists (BNG). These list practices that consider themselves IBD experts. Another option is ambulatory specialized medical care (ASV) for IBD patients. Here, hospital-based and office-based physicians work together interdisciplinarily and have created a network that is important for care—such as rheumatologists, dermatologists, infusion facilities, endoscopy, and ultrasound. Through the Association of Statutory Health Insurance Physicians, one can see where such ASV sites are located; patients are generally well cared for there.
With regard to endoscopy, quality in Germany is generally very high. More important than the question of ‘good or bad’ is that the procedure is performed where treatment is also provided. Those who have seen the bowel themselves can better interpret findings and guide therapy more safely. Modern equipment is standard today, and much also depends on preparation—how well the bowel is cleansed. For people with IBD, it makes sense to undergo endoscopy with someone who regularly treats these diseases and is familiar with their specific characteristics.
Because up to one percent of the population may suffer from chronic inflammatory bowel disease in the future, many specialized gastroenterologists are needed to provide good care for these patients. It is therefore worthwhile to consciously seek out these specialists—they are the central points of contact for long-term, stable, and competent care,” Prof. Ehehalt recommends.
Effective relapse prevention in chronic inflammatory bowel diseases works best when nutrition, lifestyle, and pharmacological therapy do not exist side by side, but instead support one another. IBDs are dynamic diseases whose activity fluctuates considerably.
Therefore, an interplay is required between stabilizing medical treatment, a diet that does not place additional strain on the bowel, and lifestyle habits that calm rather than fuel inflammatory processes. The microbiome serves as a kind of biological link between all these areas.
“The microbiome has become something of a trend topic in recent years—not only because it is scientifically fascinating, but also because it offers much to discuss. When looking at the body’s cell mass, one realizes that only a small portion is actually human; the vast majority consists of bacteria.
These bacteria are metabolically active, and their metabolic products measurably influence our bodies. Studies show that some detectable metabolites in the blood are not of human origin but come from the environment—largely shaped by the microbiome. We therefore live in a mutualism: we influence our bacteria, and our bacteria influence us.
Accordingly, it seems obvious that the microbiome also plays a role in disease development—from neurological disorders to intestinal diseases. The reason the topic has gained so much importance over the past 10–15 years is primarily that we can now measure much more precisely what is happening in the gut. In the past, one relied on cultured bacteria or protein analyses.
Today, ‘big data,’ AI, and modern high-throughput methods allow for more precise quantification of the microbiome—and thus completely new insights. It is therefore no surprise that many people try to influence their diseases via the microbiome,” Prof. Ehehalt explains, adding critically:
“Of course, marketing also plays a role. Terms like ‘microbiome’ sound healthy and modern, and the food industry readily picks this up. A broad, diverse microbiome is considered desirable, and diet has a significant influence on it. Studies show that the composition of the gut flora can change within just a few days when, for example, one switches from a Western, meat-heavy diet to a vegetarian diet.
There are pathogenic bacteria such as Salmonella that we do not want in the body. In addition, there is the normal microbiome, in which some bacteria irritate the gut more than others—which can trigger symptoms in people with a compromised barrier, such as those with IBD. Bacterial metabolic products can also influence the body, possibly even mood and emotions. The latter has not yet been conclusively proven, but it is being intensively discussed.”
Continuous care by specialized teams offers people with chronic inflammatory bowel diseases a tangible advantage, as it accompanies a condition that rarely remains stable and repeatedly presents new challenges.
In specialized IBD centers or closely networked teams, gastroenterology, surgery, radiology, nutritional therapy, nursing, and psychosocial support ideally work not alongside one another, but together. This close coordination ensures that changes in the disease course are recognized early, therapeutic decisions are made more quickly, and complications are not only treated once they are already far advanced.
“If a patient is well controlled on biologics or other modern medications, they can generally achieve a completely normal quality of life. When the disease is under control, daily life is no different from that of other people. Thanks to today’s medical options, life expectancy for IBD patients is considered normal.
Most are able to work, build a career, start a family, build a home—all the things one hopes for in a fulfilling life. Our practice is both certified as an IBD specialty practice by the BNG and active in ASV IBD care—both structures that enable particularly good, networked care. Above all, these structures show that people work here who are consciously and passionately dedicated to the treatment of chronic inflammatory bowel diseases.
For patients, they provide good orientation, as do platforms such as the Leading Medicine Guide, through which one can specifically find physicians who specialize in IBD,” Prof. Ehehalt concludes our conversation.
Thank you very much, Professor Ehehalt, for this excellent insight into the management of chronic inflammatory bowel diseases!
- Specialist in gastroenterology, owner of the Gastroenterology Practice Heidelberg
- Board-certified specialist in internal medicine & gastroenterology; additional qualifications: diabetology, emergency medicine, infectiology
- Areas of focus: IBD, endoscopy/colonoscopy, colorectal cancer screening, gastrointestinal and liver diseases, nutritional medicine, capsule endoscopy
- Director of a clinical research center with access to innovative therapies
- Use of modern technology such as GI Genius™ (AI-assisted endoscopy)
- Adjunct professor at Heidelberg University; active in teaching and lecturing
- Fellow of the American Gastroenterological Association – internationally networked
- Certified IBD specialty practice
