Food Matters in Inflammatory Bowel Disease (IBD)
For a long time, it was thought that diet does not matter when it comes to managing IBD. Growing evidence suggests that food does indeed matter, as diet is both a risk factor (Lo CH et al) and a therapeutic option. Nutritional therapy incorporates therapeutic diets composed of anti-inflammatory foods to modulate the microbiome and its metabolic byproducts (Tilg H and Moschen AR) (Thorburn AN et al) (Lavelle A and Sokol H), a hypothesized mechanism to explain their benefits of improving symptoms, reducing inflammation, and aiding in mucosal healing.
Diet is a powerful tool when used as part of a comprehensive medical management plan. Expanding research shows a number of dietary IBD therapies to be effective, and while many have commonalities, some also have subtle to significant differences. Given patients' microbial and genetic diversity, the optimal therapeutic approach is often contingent on the individual, and as a result, is best achieved through a process of personalization. Considering all of these factors, dietary therapy can prove challenging to navigate. A closer investigation will provide a framework to become familiar with the options available in nutritional therapy for IBD.
As a result of the Specific Carbohydrate Diet Curriculum – Patient and Caretaker’s Outlooks (SCRUMPTIOUS) Study, Stanford Children’s Health released a host of SCD resources available to both study participants and the public. This new webpage was designed based on their findings from SCRUMPTIOUS: that patients and families desired evidenced-based, reliable diet education.
In 2017, Kelly Issokoson, MS, RD, of Cedars-Sinai spearheaded the #EENChallenge as a way to raise awareness and show support for EEN therapy in patients with IBD. The EEN challenge consists of one day of consuming only enteral nutrition formula, ideally the same formula Crohn's Disease patients on EEN consume every day while on the therapeutic diet.
Digestive Disease Week was held virtually this year, May 21-23. Some of the dietary highlights for IBD include:
Nutritional therapy consists of the use of therapeutic diets and/or enteral nutrition in patients with IBD, with the goal of both improving clinical symptoms and reducing inflammation, leading to induction and/or maintenance of remission. It can be utilized as primary therapy when medically appropriate or as adjunctive therapy with immune suppression and biologics and is well tolerated, with patients reporting improved quality of life (Sandell A et al). Progress should be evaluated using the same standard and techniques as pharmaceutical therapy, by monitoring inflammation via laboratory work and endoscopy, as well as assessing clinical symptoms.
Therapeutic diets are whole-food based, nutritionally balanced dietary plans that improve symptoms, reduce inflammation, and aid in mucosal healing. Items that have been shown to be harmful (processed foods and additives) are eliminated and items with potential deleterious effects in IBD (gluten, sugar, and dairy) are either eliminated or limited, while the quantity and variety of beneficial fruits and vegetables are increased.
Enteral nutrition involves the use of a nutritionally complete liquid diet, often formula-based. It includes Exclusive Enteral Nutrition (EEN), which consists solely (exclusively) of a liquid diet with no solid food for 6-8 weeks, sometimes up to 12 weeks, and Partial Enteral Nutrition (PEN), in which a combination of liquid nutrition and solid foods is consumed.
The term microbiome is used to collectively describe all of the microorganisms living in a specific environment or community. The gut microbiome encompasses the bacteria, viruses, and fungi, as well as their genes, that reside within the lining of the gastrointestinal tract.
The microbiome is becoming increasingly recognized for its importance in human health and disease and is one of the hottest topics in medicine right now, with IBD being the most extensively studied among disease states (Lloyd-Price J et al) (Integrative HMP [iHMP] Research Network Consortium). Microbiome disturbances are commonly found in IBD and are increasingly implicated in the onset and development of IBD (Khan I et al) (Kostic AD et al). As diet has the greatest impact on the microbiome, it may offer the most manipulatable lever to modulate it for therapeutic benefit (Sonnenburg ED and Sonnenburg JL) (Serban DE).
Nutritional therapy offers the ability to affect the microbiome upstream at a potential source of inflammation, while medications target the immune system downstream. When using the therapies in combination, this two-pronged approach may offer a potential advantage for improved outcomes (Green N et al) (Lee D et al).
The role of nutrition in IBD is moving beyond the simplicity of its utilization to treat malnourished patients, although malnutrition remains a common IBD complication. Dietary intake is now recognized for its central role in defining the gut microbiome which directly influences the underlying immune system and the integrity of the gastrointestinal lining. Metabolomics research is further uncovering complex metabolic pathways in digestion and important byproducts produced, like short-chain fatty acids (SCFAs), which are integral in reducing inflammation and achieving balanced immune function. Current research is placing nutrition on the cutting edge of medicine, making nutritional therapy a novel and exciting new approach for the management of IBD.
Patients recognize the influence of diet on symptoms and are seeking to utilize diet as a therapeutic tool under the guidance of medical professionals (Zangara et al). Many professional publications establish the critical connection between diet and IBD and describe the rationale for integrating nutritional therapy into clinical practice.
Patients with IBD suffer disproportionally higher rates of depression and anxiety, which are associated with a lower quality of life (Bernstein CN) (Byrne G et al) and correlated with active disease (Marrie RA et al). Furthermore, anxiety, depression, and fatigue are reported to be the most common severe symptoms of IBD in a recent international survey of patients (Rubin DT et al). Can diet impact the gut microbiota to influence the gut-brain axis and subsequently our mental health?
Are you or is someone you love a patient with IBD looking for more information on nutritional therapy? Visit the Patient Pathway for helpful resources.
Are you a medical professional looking for more information on integrating nutritional therapy into your practice? Visit our Clinician Resources.
Although univariate analyses revealed that all three treatment strategies had significant effects on surgical recurrence in patients with CD, multivariate analysis revealed that only ED therapy was significantly associated with surgical recurrence rates. Thus, ED therapy plays an important role in the management of CD, even in the era of biological therapies.
Surg Today . 2021 Feb;51(2):250-257. doi: 10.1007/s00595-020-02112-5. Epub 2020 Aug 18.
Authors: Shinozaki M et al
We review findings from studies of the effects of dietary patterns, single micronutrients, and food additives in inducing and maintaining remission in patients with IBD. We discuss future directions for research and propose a framework for studies of dietary interventions in the treatment of IBD.
Clin Gastroenterol Hepatol . 2021 Mar;19(3):425-435.e3. doi: 10.1016/j.cgh.2019.11.054. Epub 2019 Dec 5.
Authors: Sasson AN et al
In this review, the authors look at the increasing number of studies investigating the role the microbiome and other biomes play in pediatric patients with IBD, particularly changes associated with IBD, varying disease states, and therapeutics.
Fitzgerald, R.S., Sanderson, I.R. & Claesson, M.J. Paediatric Inflammatory Bowel Disease and its Relationship with the Microbiome. Microb Ecol (2021). https://doi.org/10.1007/s00248-021-01697-9
Authors: Fitzgerald, RS, et. al
Nutritional Therapy for IBD is a new 501c3 established to promote awareness of dietary options for the treatment of inflammatory bowel disease, providing educational resources to assist in the implementation of nutritional therapy into clinical practice. It is an independent organization with no affiliations to industry, corporations, or advocacy groups.
PEN
Elemental Diet Therapy Plays a Significant Role in Preventing Surgical Recurrence of Crohn's Disease in the Era of Biologics
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