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.
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. Many professional publications establish the critical connection between diet and IBD and describe the rationale for integrating nutritional therapy into clinical practice.
Are you or is someone you love a patient with IBD looking for more information on nutritional therapy? Visit our Patient Portal for helpful resources.
Are you a medical professional looking for more information on integrating nutritional therapy into your practice? Visit our Clinician Resources.
A significant reduction of malnutrition-related parameters and liver steatosis was observed in both CD and UC patients after short-term dietary intervention based on the adoption of Md, and this was associated with a spontaneous improvement of disease activity and inflammatory markers.
Inflamm Bowel Dis . 2020 May 22;izaa097. doi: 10.1093/ibd/izaa097. Online ahead of print.
Authors: Chicco F et al
This case-based narrative review will discuss the Crohn's disease exclusion diet (CDED) as monotherapy, combination therapy with drugs, as a rescue therapy in refractory patients and for de-escalation from medical therapy.
Nutrients . 2020 Mar 24;12(3):880. doi: 10.3390/nu12030880.
Authors: Levine A et al
Here, we review the literature for dietary considerations during hospitalizations and acute settings, as well as upon discharge. Patients with IBD benefit from screening and nutritional support for malnutrition and nutritional deficiencies. Enteral nutrition and exclusion diets are promising as induction and maintenance therapies, but no specific recommendations during hospitalization for adult patients are available currently. There are very few reasons to enforce bowel rest or clear liquids other than bowel obstruction, uncontrolled sepsis, or need for urgent or emergent surgery; most patients—including many with penetrating or stricturing disease—benefit from feeding in whichever capacity is tolerated, with enteral and parenteral nutrition used as needed to reach nutritional goals.
Crohn's & Colitis 360, Volume 2, Issue 4, October 2020, otaa059
Authors: Palchaudhuri S 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.
MD
Multidimensional Impact of Mediterranean Diet on IBD Patients