Hot Topics In Nutrition & IBD January 6, 2018 · Treatment: Exclusive Enteral Nutrition (EEN)...
Transcript of Hot Topics In Nutrition & IBD January 6, 2018 · Treatment: Exclusive Enteral Nutrition (EEN)...
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