IBD and Exercise: A review of the evidence:

There are many well-known benefits to exercise...but what are the specific benefits of physical activity in individuals with inflammatory bowel disease (IBD)? Is exercise even safe for people with IBD? What are the common barriers to exercise and how does one overcome them? Are there specific guidelines for people with IBD regarding physical activity? With so many unknown questions surrounding exercise, and a lack of information available on the internet, I wanted to answer these questions and provide a comprehensive review of the current scientific research on physical activity in people with crohn’s and ulcerative colitis. 

Exercise Guidelines:

According to the Physical Activity Guidelines for America, the recommendations for each age-group are shown below in Chart A (1).

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These guidelines are based on the general population and not based on individuals with inflammatory bowel disease. To my knowledge, there are currently no validated physical activity guidelines for individuals with IBD. 

How to Calculate Exercise Intensity

To determine the level of physical activity intensity, you first need to calculate your estimated maximum heart rate. To do so, subtract your age by 220. Moderate-intensity physical activity is associated with a heart rate between 64-76% of your maximum heart rate and vigorous physical activity is associated with a heart rate between 76-93% of your maximum heart rate (2).

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For example, if you’re 35 years old, your estimated maximal heart rate is approximately 185 beats per minute (220-35= 185). To obtain moderate-intensity, you’ll need to keep your heart rate between 118-140 beats per minute and to obtain vigorous-intensity, you’ll need to keep your heart rate between 140-172 beats per minute.

Exercise and the Development of IBD:

Exercise has been suggested to play a role in the development of Inflammatory bowel disease. In two large research studies, a total of 647 cases of IBD were documented in the 194,700 US women that were involved in the studies. Researchers broke the women up into five categories based on their level of physical activity. The risk of crohn’s disease significantly decreased with increasing levels of physical activity. Ulcerative colitis did not appear to be associated with exercise in these research studies (3). A different research study that reviewed seven different studies on this topic also concluded that physical activity is protective against the development of crohn’s disease, but not ulcerative colitis (4). 

Exercise Performance in IBD;

Patients with crohn’s and colitis may perform worse on exercise performance testing compared to their healthy peers. In a study containing 41 crohn’s disease patients in remission, compared to the healthy control, the crohn’s disease patients scored lower on the strength tests (5). In a different study comparing 23 female ulcerative colitis patients with varying disease activity to healthy controls, the ulcerative colitis patients scored lower on the strength and speed tests than the healthy controls (6).

Benefits of Exercise in IBD:

Bone health is an important benefit of exercise in patients with IBD. Patients with crohn’s and colitis are at an increased risk for bone breakdown and low muscle mass due to medications (corticosteroids), malabsorption, and the inflammatory disease process itself. Research suggests that exercise can improve bone mineral density, muscle mass, and functional capacity in patients with IBD. In study with 110 IBD patients in remission, moderate-intensity combined aerobic and resistance training was not only safe, but the IBD patients experienced improved body composition changes and improved overall fitness including reduced body fat, increased muscle mass, and improved physical activity performance (7, 8). A different study that reviewed 13 different research studies on the effects of exercise in IBD patients suggested that patients who were physically active had an increase in bone mineral density. Other benefits included improved fitness, overall quality of life and a decrease of IBD related stress and anxiety (9). 

Physical activity also plays a role in reducing the risk for certain types of gastrointestinal cancers. Two research studies that reviewed many studies on exercise and colon as well as colorectal cancer risk suggested that as levels of physical activity increase, the risk of colon and colorectal cancers decrease (10, 11). Since physical activity is a modifiable risk factor, individuals at an increased risk for these cancers, including patients with ulcerative colitis, crohn’s colitis, and particularly those with primary sclerosing cholangitis-IBD, could benefit from increasing their level of physical activity. 

Effect of Exercise on Inflammation in patients with IBD: Is Exercise safe for IBD?

Exercise may play a protective role in preventing disease flare ups. In a large study containing 1,308 crohn’s disease and 518 colitis patients in remission, crohn’s disease patients with higher exercise levels were significantly less likely to flare at 6 months. However, there was no significant relationship found between physical activity levels and ulcerative colitis/indeterminate colitis patients (12).

Physical activity has also been suggested to be beneficial in reducing symptoms and inflammatory markers in pediatric IBD patients as well. In a review of 21 studies on the physical activity of pediatric IBD patients, physical activity was suggested to improve symptoms and physical well-being. Children who engaged in regular physical activity saw improvements in inflammatory markers and decreased the chances of future flares. It was recommended that pediatric patients perform 30-60 minutes of mild-to-moderately intense aerobic exercise at least six times a week. Moderate and vigorous-intensity physical activity was noted to be tolerated by most IBD pediatric patients (13).

Effect of Exercise on IBD Symptoms:

Physical activity may play a role in improving symptoms in patients with IBD. Research suggests that low to moderate intensity physical activity decreases the risk of constipation (7). A small study with 22 IBD patients suffering from either bowel incontinence (bowel accidents) or constipation completed an average of two pelvic floor strengthening sessions reported a 77% improvement in fecal incontinence and 83% improvement in constipation (14). Even though larger research studies need to be conducted before drawing conclusions from this, it’s a therapy to consider due to the potential benefits. A study surveying 918 IBD patients found that patients attributed significant symptom improvement to exercise. In this study, 72% of participants reported that exercise made them feel better overall. Some other reported benefits included, improved confidence, more energy, feeling healthier, reducing IBD-related symptoms, weight management, improved sleep quality, feeling more ‘normal’, and having something to focus on other than IBD (15). 

Low to moderately intense physical activity appears to reduce symptoms in patients with IBD. In a study with 110 IBD patients in remission, no patients experienced an increase of symptoms after combined moderately-intense aerobic and resistance training (8). In a study that reviewed 13 different research articles, a variety of low to moderate intensity exercises (walking programs, yoga, cycling, resistance training) were implemented. Three of these studies showed positive effects on symptom surveys and the remainder had a neutral effect. It’s important to note though, that all of these research studies were conducted in IBD patients in remission or in a mild to moderate flare (9). 

There has only been one research study to my knowledge on high intensity exercise in IBD patients. In the study, 53 crohn’s disease patients in remission or mildly active disease were randomized to either perform moderate-intensity continuous training or high intensity interval training three times a week for 12 weeks. Two exercise participants (one from each exercise group) experienced a disease flare (fecal calprotectin increased) during the study however one of those patients was in a flare prior to the start of the study (16). More research needs to be conducted on high intensity physical activity in IBD patients before conclusions can be drawn around whether it’s safe.

Common Barriers to Exercise: 

There are many barriers and concerns that arise when patients with IBD discuss starting to exercise. Some questions that may pop up include: “What if I have to go to the bathroom-will there be one close by?”, “Will exercise trigger my symptoms?”, “How can I exercise when I’m exhausted?”, “If I’m in a flare, should I even exercise-is it safe?”. 

A few research studies have reviewed barriers to exercise in IBD patients. In one study with 918 IBD patients, reported barriers to exercise included fatigue, increased bowel urgency, increased abdominal pain, increased joint pain, exacerbation of IBD symptoms, slower exercise recovery times, fear of lack of access to a bathroom, health concerns, pain, and financial constraints (15). In another research study containing 227 IBD patients, 44% of the patients reported fatigue, joint pain, embarrassment, and weakness as barriers to exercise (17).

Some healthy athletes that perform vigorous-intensity exercise have been suggested in research studies to experience reduced blood flow to the gastrointestinal system which can lead to bloody diarrhea, vomiting, abdominal pain, and nausea (18). Therefore, it’s not surprising that high intensity workouts such as running/jogging is a form of exercise that’s more commonly avoided by IBD patients (19). 

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Dealing with Exercise Barriers:

Due to uncertainty of symptoms, it can be extremely challenging to exercise when you have crohn’s or colitis. Some common barriers to exercise include fatigue, abdominal pain, joint pain, bowel urgency, and unintentional weight loss (19, 20). Always talk to your doctor about any new or exacerbated symptom you’re experiencing to rule out a flare. 

Fatigue: Many diet, lifestyle, and psychological factors can contribute to fatigue and approximately 70% of patients with IBD struggle with fatigue (19). Below are some tips to help maximize your energy:

• Improve your sleep quality: Getting a good night of sleep, avoiding daytime naps, and sticking to consistent sleep/wake times can help reduce fatigue (21). 
• Consume adequate fluids: Drinking plenty of water helps you to stay hydrated which affects mental status and perceived feelings of fatigue (22, 23). If you had a recent bowel surgery or if you’re experiencing frequent trips to the bathroom, consuming water with electrolytes may be more effective in keeping you hydrated.
• Managing your stress: planning for future stressful events and performing stress management activities frequently such as meditation may also help to reduce fatigue.
• Eating regularly: Skipping meals can lead to a drop in blood sugar and energy. So eat every few hours to help keep your energy levels up. 
• Eat your vitamins: Eating a wide variety of tolerated colorful fruits and vegetables will help ensure that you’re getting more antioxidants. Fruits and vegetables also contain fiber which can be broken down in the large intestine and used by colon cells for energy. So, get in a wide variety of tolerated fruits and vegetables as well as fresh herbs to provide your body with the energy it needs.
• Check for anemia: Anemia, iron deficiency, and/or vitamin B12 or folate deficiencies can all contribute to fatigue. Ask your doctor whether you’re deficient in any of these nutrients and whether you’ll need supplementation to correct the deficiency.
• Get moving: Exercise has been suggested to improve fatigue in IBD patients. Try starting out with short low intensity walks or a restorative yoga and slowly work up from there. 

Bowel urgency:  The fear of needing to run to the bathroom and not being close to one is a common barrier to exercise in people with IBD. In one study, 61% of the patients with IBD struggled with restroom urgency throughout the day (19). Bowel urgency can be triggered by many factors including inflammation, food triggers, and/or stress or anxiety. To combat bowel urgency, consider the following recommendations:

• Address inflammation: talk to your doctor to find out whether you’re in an active flare, then make sure something is being done about it! Make sure that after you’re put on a new treatment plan your inflammation is checked again to ensure you’re in remission. Also, talk to your IBD dietitian about how to eat an anti-inflammatory diet/lifestyle for your IBD. 
• Find your trigger foods: Work with a dietitian that specializes in IBD so that you can get an individualized plan to help find your trigger foods so that you can avoid them and decrease bowel urgency. 
• Address stress and anxiety: You could be in remission, know, and be avoiding every single one of your trigger foods, but if you’re anxious about not knowing where the closest bathroom is, that alone could trigger an urgent trip to the bathroom because of the connection between the brain and the gut. That’s why when your goal is to decrease your symptoms you’ll also need to address finding a stress management technique that helps you gain stress resilience. Meditation and yoga are two great stress management activities that you could try to incorporate into your daily routine. If you’re suffering from anxiety, you may want to schedule an appointment with a mental health professional, ideally, one that specializes in helping people with chronic illnesses.

Joint pain:  For some IBD patients, joint pain is a barrier to physical activity. If you’re experiencing joint pain, consider the following tips so that you can exercise.

• Address the inflammation: Talk to your doctor about whether there are medications that could help reduce your joint pain. You may also want to schedule an appointment with a rheumatologist to ensure you don’t have another autoimmune disease that’s triggering the joint pain.
• Eat an anti-inflammatory diet: Research suggests that consumption of omega 3 fatty acids from fatty fish sources (i.e. salmon, tuna, and mackerel) may help to reduce inflammation related joint pain (25). Also, try to eat a wide variety of tolerated colorful fruits and vegetables as well as fresh herbs to increase your overall antioxidant intake. Red/processed meats, processed foods, and added sugars have been suggested to increase bad gut bacteria and lead to damage of the intestinal barrier, so try to limit these foods as much as possible. 

• Physical activity: Research suggests that regular walking over the course of a year could improve joint pain (26). Swimming or aqua aerobics might be better alternatives as they can take weight off the joints.
• Addressing stress and anxiety and prioritizing adequate sleep may also play a role in reducing joint pain. 

Abdominal pain:  Abdominal pain is another common barrier to exercise. Below are a few tips on how to combat your abdominal pain.

• Address the inflammation: Abdominal pain could be triggered by bowel inflammation. Talk to your doctor about whether you’re in a flare to rule out inflammation as the trigger for your pain. If you’re in an IBD flare, you may need a change in your treatment plan to address the inflammation.
• Find your trigger foods: If your doctor tells you that you’re in remission, then the abdominal pain is likely caused by food intolerances. Work with a specialized IBD dietitian (like me!) to help you find your trigger foods. 
• Address your stress: In a study containing over 200 people, researchers measured stress levels of the participants as well as their symptomatic reactions. The participants with higher stress levels also had more symptoms (27). Try adding a stress management activity into your daily routine to potentially help reduce abdominal pain. Therapy has also been suggested in research to be an effective tool in reducing abdominal pain (28).

Unintentional Weight Loss:  Weight loss is another common barrier to exercise. Please consider the following regarding unintentional weight loss and exercise. 

• Address the inflammation: Rapid unintentional weight loss is a sign that inflammation is present. Talk to your doctor as soon as you realize you’re losing weight unintentionally. Also consider working with a specialized IBD dietitian to help you create an individualized plan to combat your weight loss and ensure you’re getting the vitamins/minerals you need.
• Optimize your diet: Consume frequent, calorically-dense meals and snacks throughout the day. Also, consider drinking some calories through smoothies, homemade juices, and complete nutrition formulas such as Kate Farms, Owyn, Ensure, etc. Here’s some more tips to prevent weight loss that you might find helpful.
• Low-intensity physical activity: depending on how you’re feeling, it may be helpful to go for short low-intensity walks, stretch, or do a restorative yoga workout as these forms of physical activities likely won’t burn as many calories and may help to improve your appetite.

Closing Thoughts:

Exercise appears safe and may confer a beneficial effect on symptoms and systemic inflammation. To my knowledge there are currently no research studies on exercise in individuals with IBD in a moderate to severe flare. This is likely because if you’re already running to the bathroom 15 times a day, it’ll be tough to exercise and may be too much for you!

In high school during my first UC flare, I had to be dragged out of the pool after my swim races due to asthma attacks caused by my severe iron deficiency. A few years later, I became a collegiate National All American (placed in the top 8 at the national championship) swimmer. I know personally how challenging it can be when you really want to exercise, but feel held back by your disease. Give yourself some grace for what you’re going through right now. It’s OKAY if you can’t workout if you’re currently struggling to do anything other than what’s necessary because of your debilitating exhaustion. Workout when you can, on the days you can, and know that some activity is better than none. 

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What are your barriers to exercise? Let me know in the comments below!  

Scientific References:

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2. U.S. Department of Health and Human Services Center for Disease Control. (2020, April 10). Target Heart Rate and Estimated Maximum Heart Rate. Retrieved from https://www.cdc.gov/physicalactivity/basics/measuring/heartrate.htm
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