Meditation and Mindfulness for Ulcerative Colitis and Crohn’s Disease

Summary: Meditation and mindfulness are becoming increasingly popular in the health sphere, and rightly so – ample evidence indicates that these practices are extremely beneficial for health. However, as far as their practical efficacy in managing IBD, the jury is still out. Clinical trials in IBD have fairly consistently shown improvements in overall quality of life, but thus far haven’t demonstrated improvements in flare rate or severity. That said, trials in a variety of patient populations have shown that mindfulness appears to down-regulate NF-κB activity, reflecting an overall less inflammatory gene expression profile. Other evidence supports the idea that mindfulness markedly changes how the central nervous system physiologically responds to stressors, including down-regulation of sympathetic nervous system and HPA-axis activity. Taken together, it appears likely that mindfulness could confer more measurable benefits with regards to inflammation and disease progression in IBD over the long term.

This article is part of the IBD Index. Last updated on March 14, 2022.

Mind-body medicine is currently an area of particular research focus for me, so you can expect this post to be expanded and updated in the near future! Follow me on Instagram for personal content related to mind-body medicine, as well as snippets of interesting research that might not make it into a blog post.

Mindfulness is one of those golden health practices that I call “no brainers” – in other words, you have nothing to lose and everything to gain. At the outset, I can say that I’d recommend some type of mindfulness practice to every person with IBD, almost without exception (and anyone who knows me knows that I’m not usually in the business of recommending things).

So if you want to learn more, read on. Otherwise, save your time and go meditate!

Table of Contents
What exactly is “meditation”?
Is there clinical evidence that meditation or mindfulness is effective in IBD?
Can meditation reduce inflammation?
How does meditation “work”?
Resources to get started with meditation and mindfulness
Review of the literature

What Exactly is “Meditation”?

Terminology can be a challenge when discussing mindfulness-based practices and their clinical health benefits. Most people are familiar with the concept of “meditation,” although that word often has strong spiritual connotations that can be a turn-off for some people. The more basic concept of “mindfulness” is probably somewhat less well-known, although that’s certainly changing as more people become aware of the benefits.

Mindfulness can be defined as a non-judgmental awareness of one’s own thoughts, emotions, body sensations, and their interactions in the present moment. Awareness and acceptance are generally recognized to be the two key players here.

Meditation could be considered by some to be the “purest” form of mindfulness, since it typically involves sitting still and doing nothing aside from practicing that awareness and acceptance, but other popular practices such as yoga, tai chi, and qigong also cultivate mindfulness. And beyond that, it’s important to realize that absolutely anything can be done mindfully; indeed, the goal of any good mindfulness practice should be to bring more awareness and acceptance into all your daily activities.

Mindfulness-based stress reduction (MBSR) is the most widely-used curriculum for teaching mindfulness in the clinical setting. It has been shown to reduce anxiety and depression among several different patient populations, and has improved inflammatory cytokine profiles in studies of cancer and HIV patients. The 8-week curriculum was developed by Jon Kabat-Zinn and consists of eight weekly 2.5-hour group classes, one day-long workshop, and 45 minutes per day of at-home practice guided by CD. (Source) The classes involve both formal “exercises” or “meditations” (including sitting meditation, body scans, and yoga postures) and informal practices (such as awareness of personal reactions to everyday events).

Other programs that have been used in IBD studies are often derivative of MBSR and include mindfulness-based cognitive therapy, multi-convergent therapy, and acceptance and commitment therapy. Also note that “meditation” does not always mean “mindfulness meditation.” Loving-kindness meditation is another popular approach that is still very beneficial, but doesn’t have a strong emphasis on mindfulness.

Is There Clinical Evidence That Meditation or Mindfulness is Effective in IBD?

To date, we really only have about six trials testing the efficacy of mindfulness interventions in IBD (and several of them are either very small, somewhat poorly designed, or both): Neilson et al 2016, Gerbarg et al 2015, Schoultz et al 2015, Jedel et al 2014, Berrill et al 2014, and Elsenbruch et al 2005. We also have a couple review articles covering mindfulness interventions (usually including things like yoga as well) in IBD.

You can check out the lit list at the end of this article to see all the relevant papers, but the two that deserve special mention are Gerbarg et al 2015 and Jedel et al 2014.

The Gerbarg study, The Effect of Breathing, Movement, and Meditation on Psychological and Physical Symptoms and Inflammatory Biomarkers in Inflammatory Bowel Disease: A Randomized Controlled Trial, was quite small, with only 29 participants total, but it was very well controlled and the experimental group experienced significant improvements in both psychological and physical symptoms, quality of life, and c-reactive protein.

The Jedel study, A randomized controlled trial of mindfulness-based stress reduction to prevent flare-up in patients with inactive ulcerative colitis, was also very well controlled and was larger, with 55 patients total, and is the only study so far with disease flare-ups as an endpoint. At a high level, the results were disappointing – no significant difference in flare rate or severity. But looking more closely, they reported some very interesting findings: 1) for the subset of participants with the highest baseline stress and cortisol levels, the MBSR group did have a lower flare rate; 2) the MBSR group had higher levels of cortisol and IL-10 (an anti-inflammatory cytokine) during flare-ups, potentially indicating a more robust anti-inflammatory response; and 3) the MBSR group did not experience a decline in quality of life scores during flares, while the control group did.

Overall, the evidence we have so far in IBD doesn’t show consistent benefits of mindfulness to markers of inflammation or disease progression, but it does consistently show benefits to overall quality of life. And the several recently-conduced feasibility trials bode well for future research – hopefully we’ll see some larger RCTs coming down the pipeline soon.

Can Meditation Reduce Inflammation?

In light of the relative paucity of IBD-specific meditation studies, I wanted to broaden my scope for a minute and include a quick discussion of the potential effects of meditation and mindfulness on inflammation in general.

One review from 2016 (Mind-body therapies and control of inflammatory biology: A descriptive review) summarized all of the RCTs to date that evaluated inflammatory biomarkers (including but not limited to IBD studies) following mind-body interventions (including tai chi, qigong, yoga, or meditation). Most of the studies evaluated circulating inflammatory markers or cellular production of inflammatory markers, like IL-6 or CRP, and most did not report a significant response (with the other three disciplines reporting more significant responses than meditation).

However, a small subset of studies instead evaluated gene expression in inflammatory pathways, and all seven of those studies (including three using meditation) reported significant changes in gene expression; particularly a down-regulation of NF-κB activity, reflecting an overall less inflammatory gene expression profile. At least one of those studies also observed increased glucocorticoid receptor activity, which is highly relevant to chronic inflammatory disease states such as IBD; cortisol is one of the body’s most potent anti-inflammatory molecules, but it can only do its job if the cell receptors are sensitive to it.

As another review article put it, the overall observed change in gene expression in response to these mindfulness practices can be understood as “the reversal of the molecular signature of the effects of chronic stress”.

The authors speculate that gene expression may be a more sensitive marker for changes in inflammatory status, and that perhaps longer trials would more reliably show decreases in circulating inflammatory markers. They point out that in the exercise literature, year-long interventions have been required to reduce circulating levels of CRP, so it’s not totally unreasonable to expect that mindfulness practices may take a while to show results, too.

How Exactly Does Meditation “Work”?

It’s not hard to understand how mindfulness could lead to an improvement in overall mental state and quality of life. What may seem less obvious is how it could influence very objective physiological measures like inflammatory markers or gene expression.

What you have to remember is that the brain is a physical organ, and like our other organs, it adapts its structure and function over time to better accommodate the demands we place on it. In the case of meditation, the brain changes that researchers have observed include increased activity and connectivity in the prefrontal cortex (the top-down regulatory pathway) and decreased reactivity and connectivity in regions like the amygdala involved in the fight-or-flight stress response (the bottom-up reactivity pathway). (Source)

These neural changes in turn decrease physiological stress reactivity in the sympathetic nervous system and HPA-axis. They also impact how we respond to and cope with stress on a conscious behavioral level, which should not be discounted; better self-regulation leads to better choices, which usually have a positive feedback effect (a virtuous cycle, if you will, instead of the dreaded vicious cycle).

These pathways are depicted in the figure below.

While those pathways begin with top-down changes, other researchers have proposed that meditation may work via bottom-up mechanisms as well. As discussed in my post about vagus nerve stimulation, mindfulness practices have been shown to stimulate the vagus nerve and improve vagal tone over time, which has anti-inflammatory effects through numerous. One paper posits that these practices stimulate the vagus nerve primarily because they usually involve deep, slow, controlled breathing.

Resources to Get Started with Meditation

My personal favorite meditation app that I’ve tried is FitMind. They have a one-week free trial; after that it costs $70/year. I’ve tried several meditation apps and approaches over the past decade, and I like this one for a few reasons:

1. It begins with a structured program where you don’t have to make any decisions. On Day 1, you complete the Day 1 meditation and listen to the Day 1 training. Rinse and repeat for the rest of the first month.
2. The sessions are a manageable length. Each practice is only about ten minutes, and each training is usually less than five.
3. The approach is very matter-of-fact and goal-oriented, without being either too rigid or too ethereal. He encourages you to be gentle with yourself, while also holding yourself to a certain standard and having the expectation of effort and improvement.
4. Conceptualizing meditation as “brain training” has been helpful for me, since the idea of “training” comes with the understanding that it will be hard at first, but your body will adapt and it will become easier over time. (As he puts it, each time you notice your attention wandering and bring it back to the present moment is like doing a mental bicep curl. Cheesy, perhaps, but I like it!)

As far as other apps go, there are a number of options:

• Sam Harris’ app Waking Up. This one also starts with a 30-day set program, which is very helpful, but overall it wasn’t for me. The techniques he focused on were a bit too advanced and bordering on the spiritual/ethereal for my taste, but I’d encourage you to try the free trial to see if it jives with you. I will say though, I’ve found the non-meditation content of the app (essentially a bunch of podcast interviews) valuable, and I really like the “moment” feature that gives you a little 2-minute “food for thought” type thing each day, but with all the excellent free podcasts available, I don’t think these features alone make the price of the app ($100/year) worth it.
• The most popular apps seem to be Calm and Headspace, both of which I’ve tried in the past but haven’t stuck with. Take that for what you will.

As far as more structured support, you have a couple options:

• MBSR training. I won’t lie, trying to google MBSR classes (online or in-person) did not turn up the “official-looking” website that I was hoping for. That said, it did turn up some in-person classes (for example, here’s one at Duke University in NC), as well as some online courses (like this one that purports to be “official” and “authentic” but seems a bit sketchy to me). In any case, if you’re interested, google classes in your area, and see what you come up with.
• Meetup groups. Check Meetup.com for local meditation groups in your area. They probably exist, and it can be helpful to meditate in a group for accountability purposes and improved focus.

Review of the Literature

Wren et al. Mindfulness-Based Virtual Reality Intervention for Children and Young Adults with Inflammatory Bowel Disease: A Pilot Feasibility and Acceptability Study. 2021. Children.

• Very brief study where participants underwent just one 6-minute mindfulness experience, but the concept is neat – essentially, the intervention was a short guided mindfulness meditation assisted by relaxing virtual reality scenes (of a meadow and the northern lights). The patients seemed to quite like it, so hopefully treatments like this will slowly make their way into clinical practice.

Kohut et al. Feasibility and Acceptability of a Mindfulness-Based Group Intervention for Adolescents with Inflammatory Bowel Disease. 2020. J Clin Psychol Med Settings.

• Study was designed to assess feasibility rather than efficacy, but qualitative analysis indicated beneficial emotional effects

Ewais et al. A systematic review and meta-analysis of mindfulness based interventions and yoga in inflammatory bowel disease. 2019. J Psychosom Res.

• Eight studies included in the meta-analysis.
• Conclusions: Mindfulness interventions are effective in reducing stress and depression and improving quality of life and anxiety, but do not lead to significant improvements in the physical symptoms of IBD.

Hood, Megan M and Jedel, Sharon. Mindfulness-Based Interventions in Inflammatory Bowel Disease. 2017. Gastroenterol Clin North Am.

• This article reviews eight studies, assessing seven psychosocial interventions, which include mindfulness and/or meditation components. Strongest effects of the interventions were found in quality of life and anxiety/depression, with inconsistent or minimal changes in other psychosocial areas, such as perceived stress and in disease-related outcomes and other physiologic functioning.

Neilson et al. A Controlled Study of a Group Mindfulness Intervention for Individuals Living With Inflammatory Bowel Disease. 2016. Inflamm Bowel Dis.

• Trial was not randomized – researchers allowed patients to self-select either the intervention group (MBSR) or the control group (treatment-as-usual)
• Of the 33 patients who elected to participate in the experimental group, 27 completed the treatment program and reported improved mental health and quality of life

Gerbarg et al. The Effect of Breathing, Movement, and Meditation on Psychological and Physical Symptoms and Inflammatory Biomarkers in Inflammatory Bowel Disease: A Randomized Controlled Trial. 2015. Inflamm Bowel Dis.

• 29 patients were randomized to a Breath-Body-Mind Workshop (BBMW) or an educational seminar
• The BBMW group experienced significant improvements in both psychological and physical symptoms, quality of life, and c-reactive protein; the control group did not experience any significant changes (so placebo effect was minimal in this study)
• BBMW consisted of a 2-day workshop where patients were taught 4 breathing techniques, various qigong movements, and open focus meditation. Weekly 90-min follow-up sessions were offered for 6 weeks, then monthly until week 26.
• The control group had the same number and length of sessions, but the material took the format of educational seminars on various topics such as the importance of medication compliance, stress, and nutrition on IBD, and other educational topics.

Schoultz et al. Mindfulness-based cognitive therapy for inflammatory bowel disease patients: findings from an exploratory pilot randomised controlled trial. 2015. Trials.

• The MBCT intervention consisted of 16 hours of structured group training over 8 weeks, plus guided home practice and follow-up sessions, and patients reported improvement in depression, anxiety, and overall quality of life
• This study wasn’t particularly well controlled in my opinion – the “control” group apparently just received a leaflet entitled “Staying well with IBD.” That said, the main purpose of the trial wasn’t to test efficacy, but to determine the feasibility of conducting a large-scale RCT on MBCT in IBD
• Related citation: Participants’ perspectives on mindfulness-based cognitive therapy for inflammatory bowel disease: a qualitative study nested within a pilot randomised controlled trial

Jedel et al. A randomized controlled trial of mindfulness-based stress reduction to prevent flare-up in patients with inactive ulcerative colitis. 2014. Digestion.

• 55 patients with UC were randomized to either the experimental MBSR group or the time/attention control group; dropout rate was fairly low (only one in each group)
• Control group intervention was a carefully-designed time/attention control comprising the same number of in-person group sessions and homework sessions. The course content was mind-body medicine related, but was primarily educational and did not teach practical skills for coping with stress.
• There was no difference between the groups in rate or severity of flare-ups, time-to-flare, or inflammatory markers. However, among the subset of patients with the highest perceived stress and highest cortisol levels at baseline, the MBSR group had a statistically significantly lower flare rate.
• The MBSR group had significantly higher levels of cortisol and the anti-inflammatory cytokine IL-10 during flare-ups, potentially indicating a more robust anti-inflammatory response by the body; however, this did not appear to confer any clinical benefit in flare severity.
• The MBSR group also reported a more stable quality of life: whereas patients in the control group experienced a significant decrease in quality of life during a flare, the MBSR group did not.

Berrill et al. Mindfulness-based therapy for inflammatory bowel disease patients with functional abdominal symptoms or high perceived stress levels. 2014. J Crohn’s Colitis.

• Enrolled 66 IBD patients who were in clinical remission but had continuing functional GI symptoms or high levels of perceived stress, and allocated them to either a 16-week MCT course or waiting list control group
• MCT course consisted of 6 face-to-face sessions over the span of 16 weeks; a description of the sessions is given in Table 1 of the paper
• Results did not reach pre-determined levels of statistical or clinical significance, but there were trends towards decreased severity of functional GI symptoms and improved quality of life in the experimental group

Elsenbruch et al. Effects of mind-body therapy on quality of life and neuroendocrine and cellular immune functions in patients with ulcerative colitis. 2005. Psychother Psychosom.

• In 30 UC patients in remission or with low disease activity (15 underwent the MBSR program, 15 were controls)
• Intervention group reported reduced symptoms and overall improvement in quality of life, but no differences in inflammatory biomarkers were observed between the groups.

Two “acceptance and commitment therapy” trials, which were lumped in with other mindfulness training in some review articles:

• The effectiveness of acceptance and commitment therapy on stress coping strategies in women with ulcerative colitis
• Acceptance and Commitment Therapy Reduces Psychological Stress in Patients With Inflammatory Bowel Diseases
• A randomised controlled trial of acceptance and commitment therapy for the treatment of stress in inflammatory bowel disease