by In recent years, researchers and patients have paid considerable attention to diet and the impact of nutrition on the management of inflammatory bowel disease (IBD), Crohn’s disease and ulcerative colitis. While it’s one component — albeit a complex one — of an already complex disease process, it’s a modifiable element and an exciting target, experts say.
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“We can’t change our genetics,” says Sandra Kim, MD, Chief of Pediatric Gastroenterology at Cleveland Clinic Children’s.
“However, diet may influence the risk of developing certain types of inflammatory bowel disease. In addition, since specific diets can be used as part of treatment for some patients living with IBD, there is great interest among patients and providers to better understand what available to them to make data-driven decisions,” she says.
Impaired gut function
How exactly does diet affect the GI tract? Diets like the Mediterranean diet, which are less processed with fewer additives like emulsifiers and rich in fruits and vegetables, whole grains and seafood, can help promote greater diversity within the gastrointestinal tract. In addition, this may affect the balance of pro- and anti-inflammatory microbes.
In contrast, Western diets, high in red meat, processed food, refined sugar, and saturated fats, can lead to dysbiosis, or a lack of diversity, within the gut microbiome. Evidence suggests that this may lead to impaired barrier function and dysregulation of immune-regulating cells, making individuals with IBD more susceptible to inflammation in the intestine.
A closer look at recent data
There have been ongoing investigations over the past several years into the overall impact of diet in pediatric patients with IBD, particularly those with Crohn’s disease. This reflects a growing interest in diet, its link to inflammation, and, subsequently, exacerbation of disease – as well as its role as therapy.
Advantages and challenges of formula-based therapies
Exclusive enteral nutrition (EEN) is the primary nutrition-based intervention for the management of patients with mild to moderate Crohn’s disease. Formula consists of most calories consumed as primary or adjuvant therapy, usually for eight to 12 weeks. This approach has been used in Europe and Canada for many years and has seen increased use in the United States over the past decade.
Dr. Kim explains that EEN can be very effective as an induction therapy, the first step of therapy to reduce inflammation, without the side effects of medications such as steroids.
She says, “It can be effective in patients who cannot tolerate solid foods due to complications of their Crohn’s disease, such as small bowel strictures, as an optimization before upcoming IBD-related surgeries, or for refills effective nutrition in suffering patients. malnutrition due to her IBD.”
However, the use of EEN also presents challenges. Despite being recognized as an effective therapy for some patients with Crohn’s disease, this is often not covered by insurance. In addition, there are problems with palatability. “For some patients, oral administration may be easier, while for others delivery through a nasogastric tube is a better option,” notes Dr. Kim.
Finally, as studies have shown, patients – even those who have previously had success with EEN – prefer a specific defined diet over EEN if possible.
Research efforts are underway to address challenges
A whole food blended smoothie. Promising results from a small pilot trial indicate that a whole food blended smoothie, formulated with micronutrients and macronutrients from a polymer formula, may provide similar clinical benefits to that of commercial EEN formulas. Study participants, pediatric patients with newly diagnosed mild-to-moderate Crohn’s disease, experienced reduced fecal calprotectin (a stool marker for inflammation) and clinical remission.
CD-TREAT. Another trial showed that CD-TREAT, a single food-based diet, could offer an alternative to EEN by replicating the nutritional components of the formula but using normal food. The results suggest that it indeed reflects many aspects of EEN and offers a potentially more accessible and desirable alternative.
Crohn’s disease exclusion diet (CDED). In addition to diets replicating EEN, recent studies have investigated the feasibility of specific defined diets, which consist of certain food items that focus on limiting or eliminating processed foods and additives. CDED combines the two elements, a whole food diet and partial enteral nutrition, to minimize exposure to potentially inflammatory components, as a therapy for some patients with Crohn’s disease. Initial studies showed that CDED was effective in clinical remission and reductions in inflammatory markers.
the latest information on older diets
Recent studies have also compared the Mediterranean diet with the specific carbohydrate diet (SCD). The latter, popular in the 1920s, is a diet consisting of specific foods (grain-free, low-sugar, and low-lactose) with whole, unprocessed ingredients.
Despite demonstrated clinical benefit, recent studies have shown that it may provide limited mucosal healing. In a head-to-head study, SCD only slightly edged out the Mediterranean diet, although SCD has more limited options and may be more challenging to implement and sustain.
The next frontier: Precision nutrition, implementation and monitoring, and biomarkers
Although new data points on defined diets for IBD are exciting, Dr. Kim emphasizes that both diets and people are complex and emphasizes, “we need better evidence of specific components within the diet that perpetuate inflammation compared to those that have a protective role, a concept. called precision nutrition.”
She also points to the need for effective implementation and monitoring when starting nutritional therapy for her IBD. Part of this, she says, requires close collaboration with dietitians who play a vital role in the implementation of therapy, nutritional monitoring and patient education.
Finally, better biomarkers are needed to predict the impact of these components on disease.
“This is particularly important given the significant impact IBD has on our patients’ quality of life. If we are going to ask them to use nutritional therapies, recognizing how difficult it can be, we need to make sure we are making informed decisions. Our patients deserve nothing less.”
