Should I Do Exclusive Enteral Nutrition (EEN) before Starting a Therapeutic Diet?

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Many choose to complete a course of EEN before starting a therapeutic diet. Exclusive Enteral Nutrition has been proven to be very effective for inducing remission in children with Crohn’s disease, with the added benefits of improvements in nutritional parameters, weight gain, bone health, and tissue mucosal healing with minimal or no side effects. For more information about EEN and the research behind it, visit our EEN page.

It is often easier to begin a therapeutic diet after achieving remission because a wider range of foods will be tolerated from the start. It can also be easier to determine which foods are tolerated and which are not when starting a therapeutic diet in remission. However, this option is not right for everyone. Below are some considerations you should take into account. Consult with your medical team to determine the best path for your healing.

  1. Children vs Adults: Exclusive Enteral Nutrition has been best studied in children. Some studies have shown that EEN is less effective in adults, but this could be due to compliance issues. Other studies have shown EEN to be effective in adults even when complications of disease are present.

  2. Crohn’s Disease vs Ulcerative Colitis: Exclusive Enteral Nutrition has been shown to be very effective in children with Crohn’s disease, but it has not been well studied in patients with ulcerative colitis. It is postulated that it may have a similar benefit in ulcerative colitis, but studies are needed to determine its efficacy.

  3. Crohn’s Disease Exclusion Diet (CDED): If you are planning to implement the CDED, a period of either short course EEN (2 weeks) or partial enteral nutrition (PEN) combined with CDED is part of the treatment plan. The purpose of this design is to circumvent the long 6 to 8 week course of EEN. This method has been shown to be effective to induce remission in children with Crohn’s disease. However, it has not been directly compared to EEN or evaluated yet for mucosal healing as has been done for EEN therapy.

  4. Ingredients: Many health-conscious individuals are frustrated with the poor ingredients found in the commercial EEN formulas. It is important to understand that despite those ingredients, EEN is very effective. When the alternative is either active disease or steroids, often the poor-quality ingredients are the lesser concern. Those who strongly object to the ingredients may want to try to induce remission in other ways. Some have had success with untested formulas with better ingredients like Kate Farms and Orgain.

  5. Compliance Difficulty: Exclusive Enteral Nutrition duration is generally 6 to 8 weeks, and can last as long as 12 weeks. It can be difficult to give up solid foods for such a long period of time. Some find EEN easier than eating solid foods when they are very symptomatic, but others may find it impossibly difficult.

  6. Steroid Side Effects: Steroids are sometimes utilized to induce remission. Although many will tolerate the steroids, some will experience significant side effects and may wish to consider switching to EEN.

Transitioning from EEN to a Therapeutic Diet

There is no established protocol for transitioning from EEN to a therapeutic diet. However, the experts at Seattle Children Hospitals have provided some insight. According to the Nimbal website, at Seattle Children’s Hospital, if remission is achieved on EEN, it is recommended to transition to the full array of foods allowed on the therapeutic diet (in their case SCD). If still symptomatic after EEN, then they are more likely to use a staged approach to adding foods back in, with less risky foods being introduced first.

There is also a question about how long the transition period should last. Again, there is no defined protocol and research is needed to provide guidance. In this video presentation by Dale Lee, MD, MSCE, of Seattle Children’s Hospital, two methods are proposed. The first is a graded transition that moves more gradually to the therapeutic diet over a period of a few weeks. This approach takes advantage of the fact that the effects of EEN will continue to linger for a while after discontinuing and uses that period to transition cautiously to a therapeutic diet. The second approach is a much quicker transition to solid foods. This approach acknowledges the fact that the EEN formula is not compliant with any of the therapeutic diets, and recognizes that the therapeutic diet can’t start working to its full potential until the formula is discontinued.

Nutritional Therapy for IBD

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