Hot Topics In Nutrition & IBD January 6, 2018 · Treatment: Exclusive Enteral Nutrition (EEN) Exclusive enteral therapy-tube feeding or drinking formula only (no food) for 8-12 weeks

Hot Topics In Nutrition & IBDJanuary 6, 2018

Kate Vance, RD

Wael N. Sayej, MD

Nutrients of Focus

Calories

Calcium

Vitamin D

Iron

Nutritional Treatment in IBD

Improve nutritional status

As primary therapy for active disease

For maintenance of remission

Goals of Treatment

Most diets focus on manipulating sugars and carbohydrates

Impact the microbiome in the gut by promoting desirable bacteria

Eliminate symptoms

Normalize biomarkers (CRP, Sed rate, fecal calprotectin, nutritional labs)

Achieve mucosal healing

Dietary Therapy Options

Treatment

Exclusive enteral nutrition

Partial Enteral Nutrition

Other

Parenteral nutrition (TPN)

Adjunct Therapy

Specific Carbohydrate Diet

Mediterranean/anti-inflammatory - (U Mass)

Semi –vegetarian

Gluten Free

IBS/FODMAP

Popular-Maker’s, Paleo, Gaps

Treatment: Exclusive Enteral Nutrition (EEN)

Exclusive enteral therapy-tube feeding or drinking formula only (no food) for 8-12 weeks is as effective as steroids in inducing remission in 75-85% of children/teens with newly diagnosed Crohn’s disease

First line therapy in other countries

Some centers allow a small percentage of calories from foods

Not as effective in people with Ulcerative colitis

Critch et al. Use of Enteral nutrition for the control of intestinal inflammation in pediatric Crohn’s disease. JPGN 2102;54:298-305

Partial EN (PEN)Crohn’s Disease Exclusion Diet (CDED) Pediatric studies- 50% of calories from formula and 50%

from defined food choices for initial tx of Crohn’s disease

Results: 47 subjects treated for 6 weeks. 70% of pt. achieved clinical remission

Pediatric and adult study of Crohn’s patient failing biological therapy

Treatment- PEN +CDED for 12 weeks

Pediatric pts w/ severe flares received 14 days of EEN then PEN + CDED

Results:

Specific Carbohydrate diet (SCD)-NIMBAL

Retrospective review of 7 patients to review mucosal healing effect of SCD in Crohn’s based on endo scopicfinding before and after diet

on SCD/mSCD for average of 26 months

No active symptoms before repeat endoscopy, majority had consistently norml crp, alb, Hct, mildly elevated fecal cal protectin

Results- 1 pt had complete ileocolic healing but persistent upper GI tract ulcerations.

Complete macroscopic mucosal healing was not seen in any patient.

Wahbeh,G, Ward,B et al, Lack of Mucosal Healing From Modified Specific Carbohydrate Diet in Pediatric Patients With Crohn’s Disease. JPGN 2017;65:289-92

SCD vs Mediterranean Style Diet (MSD)

CCFA Study run from 3/2016- 2020

Recruiting 194 people w/active Crohn’s disease

Assigned to SCD or MSD 1:1 for 6 weeks

3 meals and 2 snack delivered to patient for 6 weeks

Review of CDAI, fecal calprotectin

Diet followed additional 12 weeks - patient purchasing foods

Review CDAI, fecal calprotectin

Supportive: Gluten Free

Cross sectional study GFD questionnaire 1647 pt. w/ IBD participating in CCFA partners longitudinal internet-based cohort

314 (19.1%) reported having tried GFD, 135 (8.2%) report current use

65.6% of all patients who attempted GFD report improved GI symptoms

38.3% reported fewer or less severe IBD flares

Excellent adherence was associated w/improvement of fatigue

Herfarth H, Martin C et al Prevalence of a Gluten-free Diet and Improvement of Clinical Symptoms in Patients with Inflammatory Bowel Diseases. Inflamm Bowel Dis 2014;20:1194-1197

Supportive: IBS/FODMAPs

52 consecutive patients w/ Crohn’s and 20 w/ UC given dietary advise on FODMAPs

Retrospective phone questionnaire

Asked to recall: dietary advise, dietary adherence, change GI symptoms

70% reported being adherent to diet

1 in 2 responded to diet changes (defined as improvement of 5 of 10 in overall symptoms (abdominal pain, bloating, wind, diarrhea)

No improvement w/ constipation

Gearry R, Irving P et al Reduction of dietary poorly absorbed short chain carbohydrates (FODMAPs) improves abdominal pain in patients with inflammatory bowel disease- a pilot. J of Crohns and Colitis;3:8-14

Unproven: Maker’s, Paleo, Gaps

Most eliminate or limit carbohydrates

There are no studies proving effectiveness in treating IBD

Recommended supplements no proven value in IBD

Concerns of major nutrients eliminated

Supplements and Nutraceuticals

Calories

Calcium

Vitamin D

Iron

Probiotics

Glutamine

MVI

Calories

No matter what diet your child is on, it should have adequate calories to promote age expected growth

Calories need to come from a variety of sources

In some cases oral supplements (Boost, Ensure, Pediasure, Pediasmart, homemade shakes)

Supplements

USP verification

https://www.consumerlab.com

Calcium

Essential for formation & health of bones and teeth

Calcium is essential for muscle contraction including maintaining normal heart rhythm

Childhood impacts adult bone health for a lifetime

No more than ½ of daily calcium come from supplements

Food sources: dairy, bok choy, collards, calcium fortified products

Age Male Female Tolerable

Upper limit

1-3 years 700 mg 700 mg 2500 mg

4-8 years 1000 mg 1000 mg 2500 mg

9-18 years 1300 mg 1300 mg 3000 mg

19-50 years 1000 mg 1000 mg 2500 mg

Calcium Recommended intake

Vitamin D

Vitamin D is involved in anti-inflammatory pathways in the body in addition to it’s key role in bone health

In mice, vitamin D has been shown to promote epithelial resistance to injury and suppress inflammatory response to antigens in the gut

Food sources: dairy products (additive),eggs, fatty fish, shittake mushrooms, fortified cereal, sunlight

Should be monitored 2 x year- supplements are often needed.

Iron

Anemia is the most common systemic complication of IBD

Iron deficiency -leading cause of anemia

Iron deficiency anemia is associated with decreased physical activity, fatigue and decreased quality of life, ? Decrease appetite

Food sources: Red meats, Molasses, Seafood Fortified cereals, Baked beans

Supplements- oral or IV repletion

Probiotics

Faecalibacterium prausnitzii protective against IBD

Currently not available as a supplement

Provides energy to the colonocytes

Control inflammation through inflammatory

cytokine inhibition

Mucosal protective properties

High intake of foods with fermentable fibers in diet will increase bacteria population

Probiotics: VSL#3

There is no apparent benefit for probiotics in maintenance of remission in Crohn’s disease based on clinical and/or endoscopic relapse rates.

One study w/ VSL#3 showed no difference in endoscopic relapse @ 90 days versus placebo.

At 365 days lower mucosal levels of cytokines & recurrence

Suggests some efficacy

Probiotics: UC-VSL#3

Two recent studies using VSL#3 as adjunct therapy

(+ aminosalicylates or thiopurines)

Study1-VSL#3 increase remission rate at 12 weeks (UCDAI)

Study2-No difference in remission rate versus placebo (based on PGA & endoscopic findings)-showed improved clinical effects w/ reduction in rectal bleeding & stool frequency score

Probiotics: Pouchitis-VSL#3

VSL#3 highly effective in the primary prevention of pouchitis following an IPAA

Also superior in maintaining remission after tx of pouchitis w/ antibiotics

L-glutamine

Taking glutamine orally doesn't seem to improve symptoms of Crohn's disease (1,2). Neither supplemental glutamine 7 grams three times daily nor a glutamine-enriched diet seems to have any benefit in patients with Crohn's disease (1,2,3).

1.Den Hond E, Hiele M, Peeters M, et al. Effect of long-term oral glutamine supplements on small intestinal permeability in patients with Crohn's disease. J Parenter Enteral Nutr 1999;23:7-11.

2.Akobeng AK, Miller V, Stanton J, et al. Double-blind, randomized, controlled trial of glutamine-enriched polymeric diet in the treatment of active Crohn's disease. J Pediatr Gastroenterol Nutr 2000;30:78-84.

3.Zoli G, Care M, Falco F, et al. Effect of oral glutamine on intestinal permeability and nutritional status in Crohn's disease [abstract]. Gastroenterology 1995;108:A766.

Multivitamin

A multivitamin with minerals is suggested

Chewables are ok no matter how old you are!

Gummies usually don’t contain iron

Taking vitamins at night may be more comfortable

Future Trends

Likely not a single diet

Designer diets based on genetics, microbiome, specific individually identified crucial nutrients

Supplements of specific nutrients may be necessary

Take away tips

IBD is not a static disease- different diets may be appropriate at different times

Therapy is often individualized

Liberalize diet restrictions as soon as feeling well

Strive to consume minimally processed food choices

Eat a variety of foods from all of the food groups

Limit caffeine

Avoid high intake of animal fats

Buy organic at least for the “Dirty Dozen”

https://www.ewg.org/foodnews/dirty_dozen_list.php