Treating Crohn s disease with Diet

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1 Treating Crohn s disease with Diet Dr Alan Desmond Consultant Gastroenterologist Torbay & South Devon NHS Foundation Trust.com

GI tract Patients can develop chronic diarrhoea,

2 Crohn s Disease: A type of Inflammatory Bowel Disease (IBD) Damaging inflammation affecting any part of the GI tract Patients can develop chronic diarrhoea, weight loss, infection, malnutrition and failure to thrive

Most patients diagnosed aged 20-40 years 10% enjoy long-term and sustained remission 50% of patients require surgery within 10 years of diagnosis

3 Most patients diagnosed aged years 10% enjoy long-term and sustained remission 50% of patients require surgery within 10 years of diagnosis 45-55% of patients have recurrent Crohn s within 10 years of first surgery The American Journal Of Gastroenterology

Economic and Health-related Impact of Crohn's Disease in the United States: Evidence

4 Impact of Crohn s disease Work absenteeism 38% School absenteeism 64% Excellent or very good health 24% Treatments have improved a lot in the last 20 years The Economic and Health-related Impact of Crohn's Disease in the United States: Evidence from a Nationally Representative Survey Carrie Johnson USA Olympic Kayaker 2008 & 2012

5 What causes Crohn s disease? In genetically-susceptible individuals there is an aberrant immunological response to intestinal microbiota

6 What causes Crohn s disease? Genetics load the gun, diet pulls the trigger, immune system causes the damage

7 What causes Crohn s disease? Genetics load the gun, diet pulls the trigger, immune system causes the damage

8 Adapted from Frontiers in Paediatrics, 2017

9 Crohn s disease was a rare diagnosis in 1932 (Crohn, Oppenheimer & Ginzburg) Exploded in Western Countries during the latter 20 th century 21 st Century figures Now stable in North America and Europe Germany 1 in 310 people Canada 1 in 313 people Ng et al, Lancet 2017; 390:

10 Since 1990 increasing cases in newly industrialised countries Africa, Asia, South America Brazil +11% cases per annum Taiwan +4% cases per annum Most patients do not have a genetically loaded gun Ng et al, Lancet 2017; 390:

11 How do we treat Crohn s disease? Current medical treatments focus on the immune response

12 How do we treat Crohn s disease? medications & surgery High dose steroids Prednisolone, hydrocortisone Immune suppressants Azathioprine and mercaptopurine Methotrexate Biologics Infliximab Adalimumab Vedolizumab Ustekinumab Surgical resection in >50% Drug treatments are very good but costly, incur side-effects and do not work forever Globaldata.com Report GDHC160PIDR. September 2017

13 Newly diagnosed with Crohn s disease: Endoscopy, scans, inflammation, surgery, drugs etc. What about diet, doc... Low fibre? Dairy free? Eat what I like? We need to have evidence-based answers!

17 What we know: Fibre protects from Crohn s disease Women with higher fibre intake (26g/d) have a 40% reduced risk of developing Crohn s disease Harvard Nurse s Study 170,776 women followed for 26 years Fibre from fruit particularly protective Ananthakrishnan et al Gastroenterology Children with higher fibre intake also appear to be protected from Crohn s disease University of Montreal 130 patients v 202 matched healthy children D Souza et al Inflamm Bowel Dis High intake of : Fibre Veg Fruits Fish Omega-3 FAs Risk Reduction: 88% 31% 51% 54% 44%

What we know: Why fibre protects from Crohn s disease Soluble fibre reduces inflammation 1 Fermentable fibre is metabolized by intestinal bacteria to SCFAs which inhibit NF-κβ and transcription of

18 What we know: Why fibre protects from Crohn s disease Soluble fibre reduces inflammation 1 Fermentable fibre is metabolized by intestinal bacteria to SCFAs which inhibit NF-κβ and transcription of pro-inflammatory mediators Fibre maintains the integrity of the epithelial barrier 2 Demonstrably reduces translocation of bacteria into small bowel lining (more on this later) Phytonutrients may also have a role 3 Indole-3-carbinol found in fruits and cruciferous veg reduces gut inflammation in models of Crohn s disease 1. Galvez, J., Rodriguez-Cabezas, M. E. & Zarzuelo, A. Effects of dietary fiber on inflammatory bowel disease. Mol. Nutr. Food Res. 49, (2005). 2. Roberts, C. L. et al. Translocation of Crohn s disease Escherichia coli across M-cells: contrasting effects of soluble plant fibres and emulsifiers. Gut 59, (2010). 3. Ananthakrishnan, A. N. et al. A prospective study of long-term intake of dietary fiber and risk of Crohn s disease and ulcerative colitis. Gastroenterology 145, (2013).

19 What we know: Patients with Crohn s disease tolerate fibre 11 patients with mildly active Crohn s disease All on traditional low-fibre diet Education given on overall benefits of fibre Breakfast cereal per serving 3g insoluble 9g soluble Dietary fiber information for individuals with Crohn disease: reports of gastrointestinal effects. Gastroenterol Nurs. 2013;36(5):

What we know: Patients with Crohn s disease tolerate fibre All 11 reported positive effects Reduction and/or elimination of diarrhoea pain/cramping urgency Incontinence Borborygmus Improved quality

20 What we know: Patients with Crohn s disease tolerate fibre All 11 reported positive effects Reduction and/or elimination of diarrhoea pain/cramping urgency Incontinence Borborygmus Improved quality of life Yet low-fibre diet is standard advice for patients with Crohn s disease Dietary fiber information for individuals with Crohn disease: reports of gastrointestinal effects. Gastroenterol Nurs. 2013;36(5):

What we know: No evidence for Low Fibre Diet 1985: Low residue or normal diet in Crohn's disease: a prospective controlled study in Italian patients. Gut.

21 What we know: No evidence for Low Fibre Diet 1985: Low residue or normal diet in Crohn's disease: a prospective controlled study in Italian patients. Gut Oct; 26(10): : Controlled multicentre therapeutic trial of an unrefined carbohydrate, fibre rich diet in Crohn s disease. British Medical Journal. 1987;295:

22 Translocation of E coli across M-cells is reduced up to 70% by soluble plant fibres, particularly plantain and broccoli, but increased 2-fold by the emulsifier Polysorbate-80 Roberts et al. Gut, 2010

24 Nickerson et al, PloS One, 2012

What we know: Animal Fat & Protein linked to Crohn s disease Changing dietary patterns in Japan 1966-1985 Increasing incidence of Crohn s disease strongly associated with increased consumption of:

25 What we know: Animal Fat & Protein linked to Crohn s disease Changing dietary patterns in Japan Increasing incidence of Crohn s disease strongly associated with increased consumption of: Total Fat r=0.91 Animal fat r=0.88 Omega-6 r=0.88 Animal protein r=0.90 Milk protein r=0.92 Increased dietary intake of animal protein and n-6 PUFAS with less n-3 PUFAs may contribute to the development of Crohn s disease Shoda et al, Am J Clin Nutr 1996

What we know: Animal Fat & Protein linked to Crohn s disease Animal protein and the risk of inflammatory bowel disease: The E3N Prospective Study 2010 Women living in France, aged 40 65 years Free of

26 What we know: Animal Fat & Protein linked to Crohn s disease Animal protein and the risk of inflammatory bowel disease: The E3N Prospective Study 2010 Women living in France, aged years Free of major diseases at inclusion 67,581 participants, mean follow-up 10.4 years High total protein intake (esp. meat & fish) independently associated with a significantly increased risk of IBD Top tertile for protein consumption = HR for developing IBD: 3.3 Jantchou et a, Am J Gastroenterology 2010

27 Penagini et al, J Hum Nutr Food Sci 2015 What we know: Animal Fat & Protein linked to Crohn s disease Dietary Intakes in Children and Adolescents with IBD versus Healthy Controls, Department of Paediatrics, University of Milan High intakes of animal protein, omega-6 lipids, and iron are likely to be involved in the pathogenesis of paediatric IBD

What we know: Dairy consumption linked to Crohn s disease High fat and high milk-fat diets can induce or exacerbate Crohn s and colitis-type disease states by multiple mechanisms 1, 2, 3 reducing

28 What we know: Dairy consumption linked to Crohn s disease High fat and high milk-fat diets can induce or exacerbate Crohn s and colitis-type disease states by multiple mechanisms 1, 2, 3 reducing mucus layer increasing intestinal permeability increasing TNFa secretion increasing invasion of harmful E coli (AIEC) inducing unfavourable changes in microbiota Rising incidence of Crohn s disease correlates with consumption of total fat, animal fat and milk protein 4 1. Martinez-Medina et al. Gut De la Serre at al. Am J Physiol Gastrointest Liver Physiol Devkota et al. Nature Shoda et al, Am J Clin Nutr 1996

What we know: Lactose Intolerance common in Crohn s disease Meta-analysis of 1,935 IBD patients and 761 healthy controls In countries with low overall incidence of

29 What we know: Lactose Intolerance common in Crohn s disease Meta-analysis of 1,935 IBD patients and 761 healthy controls In countries with low overall incidence of Lactose Intolerance (such as the UK), patients with SB Crohn s disease have increased risk of Lactose Intolerance Odds Ratio = 6.2 Szilagyi et al. Nutrition Journal, 2016

30 Has anyone published data on treating Crohn s disease with a diet that excludes these harmful foods?

The no food approach is proven to induce remission Exclusive enteral nutrition with a formula diet is first line therapy for newly diagnosed paediatric patients 1 Originally

Induces mucosal healing and prolongs clinical remission Better than steroids in paediatric CD (response rates >80%) Also works really well in adults 2 Not immune-suppressing BUT

31 The no food approach is proven to induce remission Exclusive enteral nutrition with a formula diet is first line therapy for newly diagnosed paediatric patients 1 Originally developed by NASA Basic building blocks of foods which are easily absorbed Simple sugars, single amino acids or short chain peptides, vegetable oils with added vitamins and minerals Induces mucosal healing and prolongs clinical remission Better than steroids in paediatric CD (response rates >80%) Also works really well in adults 2 Not immune-suppressing BUT poorly tolerated therefore not a long term solution Can we get the same effect with a restricted whole-food diet? 1. Critch Et al. J Paediatr Gastroenterol Nut Heerasing et al. APT 2017

32 What we know: You can treat active Crohn s disease successfully with a diet that restricts animal protein, animal fat, n-6 PUFAs, dairy, emulsifiers and food additives while providing dietary fibre

33 What we know: You can treat active Crohn s disease successfully with a diet that restricts animal protein, animal fat, n-6 PUFAs, dairy, emulsifiers and food additives while providing dietary fibre Reported combined experience with 68 patients 47 with newly diagnosed Crohn s disease 21 with established Crohn s disease proving very difficult to treat (resistant to immune suppression and anti-tnf medications All in a severe or moderate flare of their disease 50% of calories from Enteral Nutrition formula 50% of calories from whole-food diet Some patients refused the formula and just had whole-food diet

34 Sigall-Boneh et al, Inflamm Bowel Dis 2014 What we know: You can treat active Crohn s disease successfully with a whole food diet Newly diagnosed patients 78.7% significant clinical response at week % in complete clinical remission at week 6 Results maintained to week 12

35 What we know: You can treat active Crohn s disease successfully with a whole food diet Established patients with difficult-to-treat disease 90.4% significant clinical response at week 6 62% in complete clinical remission at week 6 Report a total of 18 patients treated with whole-food only of whom 14/18 (77%) achieved remission Sigall-Boneh et al, Journal of Crohn s and Colitis 2017

remission rates better than any reported drug trial in

36 What we know: You can maintain Crohn s disease remission with a Semi-Vegetarian Diet Long-term remission rates better than any reported drug trial in Crohn s Disease Chiba et al, World Journal of Gastroenterology, 2010

37 What we know: You can maintain Crohn s disease remission with a Semi-Vegetarian Diet Chiba et al, Letter to The Permenante Journal/Fall2014/Volume 18 No. 4

38 Evidence-based dietary advice for patients with Crohn s disease: Dietary fibre Soluble: oats, psyllium, pulses Insoluble (as tolerated): whole grains & nuts Fruits & vegetables Sources of n-3 PUFAs Fish, nuts, flaxseeds, walnuts, soyabeans, pumpkin seeds, rapeseed oil and olive oil No strong evidence for Gluten-free or low FODMAP diets Soya or yeast exclusion diets Meat Saturated fat, animal protein & haem iron Dairy and dairy fats (cheese) Rich sources of N-6 PUFAs poultry, eggs, beef, dairy, pork, processed food, fast-food, salad dressings and mayonnaise, corn oil & safflower oil Excess fruit juices and juices with high fructose content Food emulsifiers (PS-80, CG, CMX) and maltodextrin

40 Treating Crohn s disease with Diet Dr Alan Desmond Consultant Gastroenterologist Torbay & South Devon NHS Foundation Trust.com

walnuts, soyabeans, pumpkin seeds, rapeseed oil and olive oil No strong evidence for Gluten-free or low FODMAP diets

sources of N-6 PUFAs poultry, eggs, beef, dairy, pork, processed food, fast-food, salad dressings and mayonnaise,

41 Evidence-based dietary advice for patients with Crohn s disease: Dietary fibre Soluble: oats, psyllium, pulses Insoluble (as tolerated): whole grains & nuts Fruits & vegetables Sources of n-3 PUFAs Fish, nuts, flaxseeds, walnuts, soyabeans, pumpkin seeds, rapeseed oil and olive oil No strong evidence for Gluten-free or low FODMAP diets Soya or yeast exclusion diets Meat Saturated fat, animal protein & haem iron Dairy and dairy fats (cheese) Rich sources of N-6 PUFAs poultry, eggs, beef, dairy, pork, processed food, fast-food, salad dressings and mayonnaise, corn oil & safflower oil Excess fruit juices and juices with high fructose content Food emulsifiers (PS-80, CG, CMX) and maltodextrin

Dietary Options for Inflammatory Bowel Disease

Dietary Options for Inflammatory Bowel Disease Michael J. Rosen, MD, MSCI Schubert-Martin Inflammatory Bowel Disease Center Learning objectives Worldwide rise in the incidence of IBD The relationship between