What is the role of the environment (exposome) in IBD?

Presented by: Professor James Lindsay from Barts and the London School of Medicine and Dentistry, Queen Mary University of London. Professor Lindsay is a gastroenterologist leading the adolescent and adult IBD services at The Royal London Hospital.

Professor Lindsay describes the increasing global incidence and prevalence of IBD, suggesting a more significant role for the environment in the pathogenesis of IBD. He explains the multi-factorial environmental exposome, including diet, geography, and lifestyle. Professor Lindsay reviews epidemiological studies, including the Nurse’s Health study that indicates a relationship between ultra-processed food intake with Crohn’s disease, but not ulcerative colitis, and additional epidemiological data that suggest a higher intake of inflammatory foods is associated with the development of Crohn’s disease.

Professor Lindsay describes pathways that mediate environmental exposure, including alteration in the composition of intestinal microbiota, changes in intestinal permeability, signaling through “environmental sensors,” and epigenetic gene transcription. He indicates the GEM study provides early insight into the relationship between microbiota and intestinal permeability in the development of Crohn’s disease. Professor Lindsay offers some interesting findings from basic science research of dietary factors, such as intake of cruciferous vegetables, acting as a ligand for the Aryl hydrocarbon receptor that may favorably impact the gut immune environmental sensing mechanisms for a protective effect. In contrast, the intake of food additives may negatively impact mucosa thickness and permeability. He concludes that environmental exposure has a major impact on the risk of developing IBD, and well-designed intervention studies are required to assess the impact of the exposome.

Interventional trials addressing environmental factors in IBD

Presented by: Professor João Sabino, MD, Ph.D. Assistant Professor, Dept of Gastroenterology and Hepatology, University Hospitals of Leuven, Belgium

Professor Sabino describes the role environmental factors play in combination with genetic factors in the pathogenesis of IBD. In relation to modifiable risk factors, he advises smoking cessation to all IBD patients. He further recommends increasing physical exercise to improve overall health and longevity, although no changes in inflammatory markers or disease activity are observed with exercise. Professor Sabino reviews many recent dietary trials, including FACES, CDED, CRAFT UC, DINE CD, and CD TREAT diet. As a primary investigator, he provides an overview of the ongoing OATS trial (COmbinAtion therapy of diet with biologicalS for Crohn’s disease), where eligible patients on biologics are randomized to six months of the FIT diet with assessment at 24 and 54 weeks.

What can we learn about the role of diet in IBD from across the globe?

Presented by: Lihi Godny, RD, Ph.D. Rabin Medical Center Petah-Tikva, Israel

Dr. Godny describes the increasing prevalence of IBD associated with the growing westernization of diet and the global increases in ultra-processed food intake, which has been associated with the development of IBD. She explains the Western diet is hypothesized to drive dysbiosis and impair intestinal permeability and immune function. In contrast, the Mediterranean diet, high in fruits and vegetables, drives increased biodiversity and may improve gut barrier and immune function.

Dr. Godny reviews some of the benefits of the MED diet and its associations with overall improved quality of life, lower mortality, lower incidence of development of Crohn’s disease, and beneficial effects in IBD to improve microbial diversity and lower inflammation. She explains that IBDMED is a MED diet adapted to IBD patients, including lifestyle components. This intervention is currently under study in patients with Crohn’s disease in Israel and India.

Micronutrient Sufficiency

Presented by: Catherine Wall, Ph.D. RD University of Otago, Christchurch, New Zealand

Dr. Wall describes the essential role of dietitians in promoting sufficient intake of nutrients. Many patients with Crohn’s disease or ulcerative colitis have a deficient intake of micronutrient-rich foods like dairy, fruits, vegetables, and grains. Compared to healthy controls, they have a lower intake of calcium, vitamin C, Vitamin D, and iron. She explains that although insufficient intake is more significant in active disease, inadequate intake is still observed in remission.

Dr. Wall reviews micronutrients' importance, including folate and B vitamins for cellular function, Vitamin C for iron absorption, and Vitamin D for iron transport. She explains that a registered dietitian's annual assessment for micronutrient sufficiency is essential and that dietary education has been shown to improve intake. Lastly, she suggests that discussions with patients should consider the patient’s dietary beliefs, attitudes, and values.

Beware of Dietary Therapy: Practicalities and Pitfalls

Presented by: Dearbhaile O’Hanlon, RD Guy’s and St. Thomas Hospital, London, UK

Ms. O’Hanlon emphasizes that patients believe and experience a relationship between food and their symptoms and notes that many patients are already making changes to their diet. She explains that food-related quality of life is impaired with IBD and is associated with reduced intake of key nutrients. She describes that food avoidance is common with restrictive eating behavior and is associated with a fear of negative consequences of eating.

Ms. O’Hanlon explains that avoidant restrictive food intake disorder (ARFID) is a new term applied to the IBD population. One study shows a 17% positive ARFID risk score in IBD patients, with active symptoms and inflammation associated with a higher risk. She describes the need to determine if it’s a reasonable response due to symptoms or true ARFID. She recommends that patients be seen by an RD IBD specialist to assess nutritional status, monitor food restrictions, and assist patients to open their diets as much as possible.

CD-TREAT diet induces remission and improves the quality of life in an open-label trial in children and adults with active Crohn’s disease.

Presented by: Vaios Svolos, RD, PhD University of Glasgow, Scotland

Dr. Svolos defines the CD-TREAT diet as a food-based diet with a similar profile to exclusive enteral nutrition (EEN). He provides an overview of the open-label trial including sixty children and adults with active luminal Crohn’s disease characterized by symptoms (elevated HBI >5 or PCDAI > 12.5 and elevated fecal calprotectin >250 ug/g in most patients) who were given catered CD-TREAT diet for four weeks to induce remission. Those that responded were followed for another four weeks and assessed at eight weeks.

Dr. Svolos describes the results of twenty-two adults and seventeen children who completed eight weeks of the trial, with an 85% response rate and 78% remission rate by disease activity indexes, which was highly significant, p<0.001 in both children and adults. Quality of life (QoL) measured by SIBDQ in adults and Impact III in children improved significantly at four and eight weeks. A fifty percent reduction in fecal calprotectin, p<0.005, was observed in a subset of patients with no detectable fecal gluten immunogenic peptide (GIP), a marker of adherence, as the diet is a gluten-free diet. These results are similar to those observed in patients treated with exclusive enteral nutrition. Dr. Svolos concluded that the CD TREAT diet improved disease activity indices and quality of life in the majority of patients who completed treatment and decreased fecal calprotectin in those most likely to be compliant.

Report on the 7th D-ECCO Workshop at ECCO'22

The Report on the 7th D-ECCO Workshop was drafted by Lihi Godny, RD, Ph.D

Nestlé Health Science Nutritional Symposium.

Role of Foods in Crohn's Disease: Impact on Inflammation and Recovery

Presenter(s): Rotem Sigall Boneh, RD; Prof. Johan van Limbergen; Dr. Benoit Chassaing; Prof. Eytan Wine

  • Recent Findings on the Use of Crohn's Disease Exclusion Diet in Clinical Practice: Rotem Sigall Boneh, Israel
  • How Do Microbes Play a Role in Inflammation and Recovery?: Prof. Johan van Limbergen, The Netherlands
  • How Do Food Additives Play a Role in Inflammation?: Dr. Benoit Chassaing, France
  • How Do Fibres Play a Role in Inflammation and Recovery? Prof. Eytan Wine, Canada

Poster Presentations

The Effect of the Crohn's Disease Exclusion Diet (CDED) on pouch inflammation: an interventional pilot study

Presenter: Naomi Fliss Isakov

15 patients with pouchitis starting CDED were followed and assessed at 12 and 24 weeks. PDAI and endoscopic scores were significantly improve at 12 weeks. Patients with perfect adherence (n=8) had significant reductions in CRP and Fcal at 12 weeks.

Click Image to Download PDF.

The effect of compliance during exclusive enteral nutrition on fecal calprotectin levels in children with Crohn's disease

Presenter: Shona Mckirdy

To evaluate if suboptimal response to EEN can be explained by poor compliance, gluten immunogenic peptide (GIP) is assessed in 45 children undergoing treatment with EEN. Poor response to EEN might be in part explained by diminished compliance. Faecal GIP may be a useful proxy marker of EEN compliance.

Full details can be found in the recently published paper. Click on image to access the Poster PDF.

Crohn's Disease Exclusion Diet (CDED) for the treatment of Crohn's disease: real world experience

Presenter: Naomi Fliss Isakov

A retrospective analysis of 220 patients with Crohn's disease shows CDED may be effective for a wide range of clinical presentations. High adherence but not disease characteristics was associated with achieving clinical remission.

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Pre-operative oral enteral nutrition optimisation for Crohn's disease in a UK tertiary IBD centre

Presenter: Susanna Meade

Oral EN is well tolerated and insertion of NG tube is not required to achieve nutritional goals. Nutritional optimisation is associated with reduced post operative complications within 30 days.

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The effect of commonly consumed dietary fibres on the gut microbiome and its fibre fermentative capacity in adults with IBD in remission

Presenter: Konstantinos Gerasimidis

Fecal samples from 40 adults with IBD (20 CD and 20 UC) compared to 20 controls were evaluated to measure production of SCFA. Despite dysbiosis, patients with IBD had similar capacity to ferment and release SCFA. Fibre supplementation alone may be unlikely to restore a healthy status to compositional shifts characteristic of IBD.

Full details can be found in the recently published paper. Click the image to access the Poster PDF.


Nutritional Therapy for IBD

Improving the Care of Patients with Crohn’s Disease and Ulcerative Colitis through Nutrition


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