This question was debated recently in GI and Hepatology News: Can IBD be treated with diet alone?

Ashwin N. Ananthakrishnan, MD, MPH argues that IBD can be treated with diet alone:

  • "Randomized controlled trials published more than a decade ago demonstrated that exclusive enteral nutrition, wherein all table foods are eliminated from a diet and the patient relies on an elemental diet alone for nutrition, was effective in not just inducing clinical remission but also improving inflammatory biomarkers."
  • "More recent rigorous studies have demonstrated that the effects of exclusive enteral nutrition can be mimicked either by a selected, less-restrictive diet (such as CD-TREAT4), which is more sustainable, or by combining partial enteral nutrition with an elimination diet that is quite diverse (such as CDED5)."

Laura Raffals, MD, MS argues against treating IBD with dietary therapy.

  • "Exclusive enteral nutrition (EEN) has been studied the most rigorously of all diets in IBD and has demonstrated the greatest benefit, compared with other diet studies in IBD. EEN requires the intake of elemental, semi-elemental, or polymeric formulas to meet all nutritional requirements without additional intake of food for 6-8 weeks. Studies have been performed mostly in pediatric populations and have shown effectiveness in induction of remission with reduction in inflammatory markers, including C-reactive protein, erythrocyte sedimentation rate, and fecal calprotectin, and even mucosal healing. EEN has not worked out as well for adult populations, because of the poor tolerability of exclusive intake of enteral formulas."
  • "Beyond EEN, there are many diets that have been considered … only the SCD and Crohn's disease exclusion diets have shown improvement in clinical remission and reduction in inflammatory markers."
  • "Most dietary studies are underpowered, lack a control arm, and do not include endoscopic endpoints. The current body of evidence remains insufficient to support the use of diet alone for the treatment of IBD."

My take: Except for exclusive enteral nutrition (EEN) which is quite challenging, dietary therapies have not been proven as effective long-term stand-alone treatments. In patients who choose dietary therapy, careful monitoring is particularly important.

Related blog posts:

  • Dietary Therapy for Inflammatory Bowel Disease This is good lecture review on dietary therapy
  • Good Food and Bad Food for Crohn's Disease -No Agreement | gutsandgrowth
  • Pushing the Boundaries on Dietary Therapy for Crohn's Disease: CD-TREAT
  • Postion Paper: Nutrition in Pediatric IBD
  • CDED Diet for IBD/IBD Updates
  • Specific Carbohydrate Diet | gutsandgrowth
  • Disappointing Results from SCD Diet (small study)
  • Crohn's Disease with Isolated Colonic Involvement Less Responsive to EEN
  • Practical Advice on Enteral Nutrition | gutsandgrowth
  • Head-to-Head: Enteral Nutrition vs. anti-TNF
  • Gut Microbiome, Crohn's Disease and Effect of Diet …
  • The Search for a Dietary Culprit in IBD | gutsandgrowth
  • Top Lecture: Enteral Nutrition for Crohn's Disease …
  • There is No Healthy Microbiome
  • Why Does Enteral Nutrition Work for Crohn's Disease? Is it due to the Microbiome?

My notes from Georgia Chapter of CCFA's conference. There could be errors of omission, transcription and/or errors in context based on my understanding.

Sandy Kim, MD –Children's Hospital of Pittsburgh

Diet in Inflammatory Bowel Disease: Food for Thought

This was a terrific lecture –though much of the topic has been reviewed recently in this blog: Dietary Therapy for Inflammatory Bowel Disease.

Key points:

  • Changes in diet can change microbiome quickly, within 24 hrs
  • Some diets (eg. more fruit/vegetables/fish) may help lower risk of developing IBD
  • Dietary therapy, especially exclusive enteral nutrition (EEN), is effective therapy for Crohn's disease
  • Why does EEN work?  It is not clear.  There are some changes in microbiome but decrease or little change overall in microbial diversity
  • Reviewed newer dietary approaches: SCD (www.nimbal.org), CD-TREAT, Crohn's Disease Exclusion Diet

Related blog posts:

  • Good Food and Bad Food for Crohn's Disease -No Agreement | gutsandgrowth
  • Pushing the Boundaries on Dietary Therapy for Crohn's Disease: CD-TREAT
  • IBD Briefs August 2019: CD Exclusion Diet
  • Position Paper: Nutrition in Pediatric IBD
  • Specific Carbohydrate Diet | gutsandgrowth
  • Disappointing Results from SCD Diet (small study)
  • Crohn's Disease with Isolated Colonic Involvement Less Responsive to EEN
  • Practical Advice on Enteral Nutrition | gutsandgrowth
  • Head-to-Head: Enteral Nutrition vs. anti-TNF

Frank Farraye, MD –Mayo Clinic

Health Maintenance in the Adult Patient with IBD

  • Good Practice: Update Vaccinations in IBD population
  • Recent concerns include measles outbreak, and frequent occurrence of Herpes zoster
  • No evidence that vaccination exacerbates IBD
  • New Hepatitis B Recombination Vaccine (Heplisa-B) -2 doses given over one month (for patients older than 18 years. Seroprotective anti-HBs after two doses: 95.4%
  • Shingrix -new recombinant Zoster vaccine.  Overall efficacy 97.2%.  Frequent adverse reactions
  • Women with IBD should undergo annual cervical cancer screening
  • IBD patients should be seen by dermatology
  • Consider depression screening in IBD patients
  • Counsel patients to quit smoking
  • Consider bone density screening in at risk patients

One audience member (Jeff Lewis, MD) pointed out that more attention needs to be paid to depression and anxiety which are much more common and more frequently health-threatening than issues like vaccination.

Related blog posts:

  • Vaccination and Inflammatory Bowel Disease for Adults with IBD
  • Immunization Recommendations from CDC 2013 | gutsandgrowth
  • Because It Doesn't Just Happen to Other People
  • Protecting the Most Vulnerable
  • Why Rich Kids Get Measles More Often in the U.S.
  • The Paradox of Vaccine Resistance

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Recently, Lindsey Albenberg, DO (from CHOP) provided an excellent update on dietary therapy for Crohn's disease.  She was an invited speaker from CHOA as part of a nutritional support professional development series.  Thanks to Kipp Ellsworth for coordinating this.

Full Slide Set: Nutritional therapies for IBD

Key points from lecture:

  • At CHOP, exclusive enteral nutrition (EEN) is the main dietary approach for Crohn's disease (CD) advocated due to better proof of its effectiveness
  • In children, EEN is as effective as steroids for clinical improvement and better in terms of mucosal healing
  • EEN therapy can be given regardless of CD location
  • For EEN, there is no difference in response between elemental and nonelemental formulas
  • For EEN to be effective, at least 80-90% of all calories need to be administered during induction
  • At CHOP, EEN is often administered at time of diagnosis and oral approach is tried first
  • Newer dietary approaches are being studied and may be effective.  Diets like the specific carbohydrate diet (SCD) can be considered, particularly in patients with milder disease.

The following slide presents SCD diet studies –mostly small studies except for 2016 survey study.

Related blog posts:

  • Good Food and Bad Food for Crohn's Disease -No Agreement | gutsandgrowth
  • Pushing the Boundaries on Dietary Therapy for Crohn's Disease: CD-TREAT
  • Postion Paper: Nutrition in Pediatric IBD
  • Specific Carbohydrate Diet | gutsandgrowth
  • Disappointing Results from SCD Diet (small study)
  • Crohn's Disease with Isolated Colonic Involvement Less Responsive to EEN
  • Practical Advice on Enteral Nutrition | gutsandgrowth
  • Head-to-Head: Enteral Nutrition vs. anti-TNF
  • Gut Microbiome, Crohn's Disease and Effect of Diet …
  • The Search for a Dietary Culprit in IBD | gutsandgrowth
  • Top Lecture: Enteral Nutrition for Crohn's Disease …
  • There is No Healthy Microbiome
  • Why Does Enteral Nutrition Work for Crohn's Disease? Is it due to the Microbiome?

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

A recent study (available online in advance of publication) (V Svolos et al. Gastroenterology https://doi.org/10.1053/j.gastro.2018.12.002) examines the feasibility and science of modifying a diet to mimic exclusive enteral nutrition.

Full text accepted manuscript (from ScienceDirect/Gastroenterology website): Treatment of Active Crohn's Disease With an Ordinary Food-based Diet That Replicates Exclusive Enteral Nutrition (PDF 135 pages)

Background: The authors note that exclusive enteral nutrition (EEN) is the only established dietary treatment for Crohn's disease.

This complicated study had three main parts:

  1. Examining the effects of their CD-TREAT diet compared to EEN in 25 healthy adults in a randomized control trial
  2. Animal experiments (rat model) to explore the anti-inflammatory effect of CD-TREAT
  3. Pilot open-label study of 5 children with CD-TREAT diet (8-weeks)

In the first part of this study, the authors modeled a diet based on the components of the formula modulen. This diet continued to exclude gluten, lactose, and alcohol and tried matching other components (macronutrients, vitamins, minerals, fiber).  In place of maltodextrin (the commonest carbohydrate in EEN feeds), the authors substituted foods high in starch and low in fiber.  Also, the authors decreased carbohydrates in CD-TREAT (particularly complex carbohydrates) in favor of protein.  This diet was given to 25 healthy adults.

Key findings:

  • CD-TREAT induced similar effects to EEN on fecal microbiome, composition,metabolome, mean total sulfide, pH, and short-chain fatty acids (SCFA)

In thesecond part of this study, in the rat model, CD-TREAT and EEN produced similar changes in bacterial load, short-chain fatty acids, microbiome, and in ileitis severity.

In the third part of the study with 5 children, after 8 weeks —Key findings:

  • 4 (80%) had a clinical response
  • 3 (60%) entered a clinical remission with concurrent reductions in calprotectin (mean decrease of 918 +/- 555 mg/kg)

The CD-TREAT diet appears to affect the taxon abundance of many species of the microbiome in a manner similar to EEN therapy.  The authors noted that CD-TREAT also changed the abundance of genera belonging to Actinobacteria, Bacteroides, and Firmicutes.

Unlike EEN, the CD-TREAT diet is subject to more variable individual intakes; it is not identical in all individuals.

My take: The mechanism of action of EEN therapy remains poorly understood.  The CD-TREAT diet, which is far more diverse than EEN, appears to replicate many of the effects of EEN: "the microbial composition, fecal pH, SCFA, total sulfide, fecal bacterial load and fecal metabolome significantly changed in the same direction for both diets." A larger clinical study is needed to confirm the effectiveness of the CD=TREAT diet.

Related blog posts:

  • Crohn's Disease with Isolated Colonic Involvement Less Responsive to EEN
  • Practical Advice on Enteral Nutrition | gutsandgrowth
  • Head-to-Head: Enteral Nutrition vs. anti-TNF
  • Gut Microbiome, Crohn's Disease and Effect of Diet …
  • The Search for a Dietary Culprit in IBD | gutsandgrowth
  • Top Lecture: Enteral Nutrition for Crohn's Disease …
  • There is No Healthy Microbiome
  • Why Does Enteral Nutrition Work for Crohn's Disease? Is it due to the Microbiome?

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

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