by There is some support for the incorporation of diet into Crohn’s disease (CD) treatment regimens, with a shift toward a whole-food nutritional approach for symptom relief and healing.
Although not definitively established, inflammation is a potential mechanism by which diet can modulate the onset of CD.
“There is some evidence that certain dietary components may increase the risk of developing CD, but it is less clear whether diet has any effect on flareups of existing disease,” said Linda A. Feagins , MD, from the Dell School of Medicine at the University of Texas at Austin. “The diet studies are mainly retrospective, so we have to take the data with a grain of salt.”
Although no specific food or environmental factor is known to directly cause or promote inflammatory bowel disease, a review of three large prospective health professional cohorts found that people with diets high in inflammatory potential to develop CD.
Specifically, compared to participants in the lowest quartile of mean cumulative empirical dietary inflammatory pattern (EDIP) score, those in the highest quartile had a 51% higher risk of CD (HR 1.51, 95% CI 1.10-2.07,). p=0.01 for trend). Compared to participants with low continuous EDIP scores, those who switched from a potentially low to a high inflammatory diet had a greater risk of CD (HR 2.05, 95% CI 1.10-3.79, and HR 1.77 continuously eat a pro-inflammatory diet. , 95% CI 1.10–2.84).
Components in typical Western diets in particular have been proposed as triggers of CD, and dietary antigens induce changes in the gut microbiome leading to flora dysbiosis, altered host homeostasis, and a dysregulated T-cell immune response.
These potentially harmful aspects of the Western diet include higher intakes of red and processed meats, ultra-processed convenience foods, sugar, and refined grains. Other factors include increased consumption of unhealthy fats, such as saturated and trans fats and omega-6 polyunsaturated fatty acids, as well as exposure to commercial food additives and emulsifiers such as carrageenan and additive-related inorganic microparticles.
“The data on food additives comes primarily from animal studies, although there is some small human data to suggest they may play a role,” Feagins said.
In contrast, a reduced risk is associated with higher intakes of fiber in the Mediterranean diet and the omega-3 polyunsaturated fats found in fish, nuts, seeds and avocados. Individuals can easily make beneficial changes by eating a high-fiber Mediterranean diet, said Ashwin Ananthakrishnan, MD, MBBS, MPH, of Massachusetts General Hospital and Harvard Medical School in Boston. MedPage Today.
Although most physicians agree that good nutrition is essential in CD, the best way to do this is less clear. In terms of maintenance, high-quality data on diet are limited, and studies to identify dietary triggers of relapse have yielded mixed results. Many gastroenterologists still do not use nutritional therapies, and the most common diets lack randomized controlled trials.
Moreover, integrating diet into management is clinically challenging, Ananthakrishnan said. “Dietary strategies require a lot of patient commitment and motivation for continued adherence, and partial adherence is less effective than full adherence.”
In addition, relying on fresh, high-quality home-cooked food is expensive and time-consuming. “This may not be possible for everyone,” he said. “Children, adolescents and young adults going to college have limited control over their food quality and preparation methods. This makes dieting challenging without adequate buy-in from the whole family.”
Other Regiments
Among overall dietary patterns aside, dietary interventions with benefit tested in randomized trials include exclusive enteral nutrition or the CD exclusion diet, Ananthakrishnan said.
An Israeli-Canadian trial in 74 children, for example, found that a CD exclusion diet with 50% of calories from enteral nutrition resulted in sustained remission in a significantly higher proportion of patients than exclusive enteral nutrition. It also produced remission-related changes in the fecal microbiome. At week 12, after dropping to 25% enteral nutrition with either the CD exclusion diet or a free diet, corticosteroid-free remission rates were 75.6% and 45.1%, respectively (OR 3.77).
“Several other exclusion diets, including the specific carbohydrate diet, have also shown benefit in reducing CD symptoms,” Ananthakrishnan said. “But it seems beneficial to ensure adequate soluble fiber from fruits and vegetables, minimize processed foods and red meat intake, and reduce sugar-sweetened beverages. In general, it is important to combine dietary therapy with pharmacological therapy to to ensure the greatest benefit for the CD patient.”
But is that approach routinely recommended by gastroenterologists? “There are no published data on physician practices, but I think that more doctors, especially at academic centers, are at least beginning to see that diet plays a role,” said Feagins. “But there is still a set of physicians and an older dogma that says that diet has no role.”
The challenge with recommending any diet is that the disease and people’s eating preferences are diverse, she said. “And doctors rarely have the knowledge to recommend which diet to their patients.”
Ananthakrishnan agreed: “Historically gastroenterologists, and even nutritionists, received insufficient training in the role of diet in CD. But this is changing with growing data and training programs to address this.”
In the current clinical setting, if a patient has active disease and is starting a new therapy, Feagins often encourages synergistic treatment with a Mediterranean-type diet. “And if CD is under control and the patient is on the best medications with no active disease but starts experiencing the symptoms of irritable bowel syndrome [IBS] on top of CD, I will look at the IBS spectrum and maybe advise trying low FODMAP [fermentable oligo-, di-, and monosaccharides and polyols] diet,” she said.
As for potentially anti-inflammatory supplements like fish oil and turmeric, “I don’t recommend these routinely but I don’t have a problem if a patient wants to take them,” Feagins said. “And there is some evidence that turmeric helps [ulcerative colitis].”
Given the danger of macro and micronutrient deficiencies in specialized diets, gastroenterologists should consider enlisting registered dietitians to optimize nutrition in inpatient and outpatient settings. All CD patients should be screened for malnutrition, Feagins said. “This is what we do at least once a year if not more often in my clinic. There is a very simple filter with two questions to do this. This helps me decide who will needed to see the dietitian sooner rather than later.”
Disclosure
Feagins reported research support from Arena Pharmaceuticals, CorEvitas, Janssen Pharmaceuticals, and Takeda Pharmaceuticals.
Ananthakrishnan had no competing interests to disclose.
