What to Eat For a Healthy Gut

Transcription

1 What to Eat For a Healthy Gut CHOP IBD Education Day 2018 LINDSEY ALBENBERG, DO NATALIE L. ADLER, RD, CSP, LDN

2 Does diet play a role in the development of IBD?

3 Hou JK et al. American Journal of Gastro 2011;106: Diet is Associated with New Onset IBD High dietary intakes of total fats, PUFAs, omega-6 and meat were associated with an increased risk of CD and UC High fiber and fruit intake were associated with decreased CD risk High vegetable intake was associated with decreased UC risk.

4 What should I do now that I have been diagnosed with IBD?

5 Nutrition in Pediatric IBD: A Position Paper on Behalf of the Porto IBD Group of ESPGHAN A group of 20 European experts in pediatric IBD addressed 41 predefined questions regarding nutrition in IBD in 7 different sections Nutritional assessment Macronutrient needs Trace elements, minerals, vitamins Nutrition as a primary therapy for pediatric IBD Probiotics and prebiotics Specific dietary restrictions Dietary compounds and the risk of IBD Miele et al. Journal of Pediatric Gastroenterology, Hepatology, and Nutrition

6 Nutritional Assessment: When and How? Which method of dietary assessment is preferable and how often should it be performed? Yes, the assessment of dietary intake should be an integral part of the followup of pediatric IBD patients Patients with IBD tend to self-impose elimination diets to control symptoms Studies have shown that the diet of IBD patients differs from healthy controls (lower calories, lower fiber and carbohydrates, lower fat soluble vitamins and vitamin C, lower Ca, P, Mg, Fe) Poor dietary intake is common in both CD and UC and in patients with active disease and in remission Miele et al. Journal of Pediatric Gastroenterology, Hepatology, and Nutrition

7 Patient-reported foods that improve / worsen symptoms Food Items CD (n=1121) (B, W) UC (n=597) (B, W) CD-O (n=405) (B, W) UC-P (n=206) (B, W) Improved Symptoms Yogurt 108, 7* 54, 3* 26, 0* 19, 0* Rice 59, 3* 30, 3* 20, 3 16, 0* Bananas NR NR NR 14, 0* Worsened Symptoms Non-Leafy Vegetables 28, 221* 29, 81* 7, 90* 3, 36* Spicy Foods 1, 145* 3, 79* 0, 46* 0, 33* Fruit 50, 136* 40, 63 22, 51 15, 24 Nuts 3, 120* 1, 33* 0, 52* 0, 21* Leafy Vegetables 6, 115* 2, 50* 2, 29* 1, 14 Fried Foods 0, 105* 0, 53* 0, 22* 0, 11 Milk 6, 105* 0, 49* 5, 28* 2, 14 Red Meat 6, 103* 7, 47* 2, 24* NR Soda 11, 99* 0, 46* 0, 33* 0, 28* Popcorn 2, 97* NR 0, 27* 0, 18* Dairy 3, 94* 1, 56* NR 0, 12 Alcohol 0, 90* 0, 54* NR 0, 23* High Fiber 19, 87* 19, 35 7, 46* NR Corn 0, 77* 0, 31* 0, 29* NR Fatty Foods 0, 62* NR NR NR Seeds NR NR 0, 22* NR Coffee NR 4, 37* NR NR Beans NR 5, 30* NR NR P values from the sign test. Bonferroni method p< (i.e., 0.05/127) identified with an asterisk (*). Items with a P value between 0.05 and are identified with. Cohen AB Dig. Dis. Sci. 2012

8 Nutritional Assessment: When and How? Is there a need for regular dietary assessment in children with IBD? Good quality evidence that a 3-5 day dietary record analyzed by a registered dietician is the best method for dietary assessment Dietary record should be performed twice per year in children 5 years of age and younger and once per year in children over the age of 5 This is the minimum and more frequent dietary records should be performed whenever deemed necessary by the physician and/or dietician Miele et al. Journal of Pediatric Gastroenterology, Hepatology, and Nutrition

9 Nutritional Assessment: Why? Malnutrition: Abdominal pain / poor appetite Adult height Bone health Reduced lean body mass Delayed puberty Obesity: 10-30% of patients with IBD have obesity at the time of diagnosis and obese patients with IBD may have suboptimal response to therapy Collaboration with RD Miele et al. Journal of Pediatric Gastroenterology, Hepatology, and Nutrition

10 Dietary Therapies for Active IBD

11 Enteral Nutritional Therapy For Crohn s Disease (CD) A therapy which has been used for almost 4 decades Involves the use of a specific formula as nutritional therapy (food = medicine) Replacing all or the majority of daily calories with formula and excluding or limiting food First-line treatment for Crohn s disease in many parts of the world with similar or even better remission rates than many medications Disease location initially thought to be important, but more recent evidence suggests that this may not be true Not effective for ulcerative colitis Whitten et al. Journal of Digestive Diseases

12 Enteral Nutritional Therapy: How Does it Work? Possible mechanisms of action Formula providing something beneficial that is not provided by regular food Diet excluding something harmful from the usual diet Beneficial effects on the gut microbiome Multifactorial (combinations of above)

13 Enteral Therapy: Nutritionally Complete Formula Provided overnight through NG tube using a pump Consumed orally during the day Combination of these methods

14 CHOP Enteral Nutritional Therapy Protocol Induction 8-12 weeks 80-90% of estimated needs from formula 10-20% food Need to be strict Not all food considered equal NG tube/oral/combo Maintenance Post induction to...? Lower % calories from formula by 10-15% # of days volume Simultaneously increase % of calories from food Closely monitor!

15 Example: 2000 calorie diet 80% of calories from formula 20 % of calories from food 1600 calories ~4-5 cans of concentrated (1.5 kcal/ml) formula 400 calories 3-4 snacks or mini meals

16 Feeding tube or no feeding tube? Downsides of oral (drinking) nutritional therapy Flavor fatigue Difficult to tolerate the amount that is required Up to 6-8 bottles per day Expensive $$ Downsides of feeding tube Taping Unsightly

17 Other Exclusion Diets Specific Carbohydrate Diet Semi-vegetarian diet IBD-AID Crohn s Disease Exclusion Diet Paleolithic diet Low FODMAP diet UC diet

18 Autoimmune Protocol Diet Recently published study, collaboration between Scripps clinica, San Diego State, Upenn Enrolled 15 adults with active CD with abnormal endoscopy and/or FCP 6 week elimination diet with staged elimination of grains, legumes, nightshades, dairy, eggs, coffee, alcohol, nuts and seeds, refined/processed sugars, oils, and food additives followed by 5 weeks of maintenance Similar to Paleo diet with a focus on providing fresh, nutrient dense foods, bone broth, and fermented foods and focusing on sleep, stress management, and physical activity Improvement in disease activity score and FCP, no change in CRP Improvement in endoscopic score in 6/7 Konijeti et al, Inflamm Bowel Disease, Nov 201

19 UC Diet (UCD) Stop by the IBD research table and speak to Lindsay Woodcock!

20 DINE-CD Multiple study sites including UPenn Clinical trial of Specific Carbohydrate Diet and Mediterranean Diet in adults with mild to moderate Crohn s disease Food provided for 6 weeks, follow diet on your own for 6 weeks Can stay on stable Crohn s disease medications during the trial Collect disease activity score, blood work, FCP baseline, week 6, week 12 SCD: No grains No sugar or sweeteners except honey No starchy vegetables No milk Limited legumes No canned vegetables No bread or pasta Mediterranean Diet: No processed sugars No refined grains No processed meats Limited red meat Increased intake of fruits, veggies, nuts, seafood, beans and legumes At least 4 tbsp. of olive oil per day

21 My disease is in remission, now what? Semi-vegetarian/anti-inflammatory/Mediterranean style Fiber PEN Limit red meat? Limit certain types of fat, emulsifiers?

22 Semi-vegetarian diet/antiinflammatory/mediterranean diets Semi Vegetarian: eggs and meat allowed, small amounts of meat offered once ever two weeks fish weekly Mediterranean: high in fiber-rich-plant foods (cereals, fruits, vegetables, legumes, nuts, seeds), olive oil, high to moderate intake of fish/seafood, moderate intake of eggs, poultry, dairy, wine and low consumption of red meat. Anti-inflammatory diet: well balanced diet including nutrient dense plant foods, whole grains, lean proteins, herbs/spices and avoidance of processed foods and meats Goal: Aim for a balanced diet that includes all food groups

23 Partial EN for maintenance of remission Partial enteral nutrition (PEN) is defined as providing patients with a nutritionally balanced liquid formula while continuing to eat an unrestricted or exclusion diet. A recent prospective study of children initiating PEN, EEN, or anti-tnf therapy for active CD, confirmed that each therapy improved symptoms, but EEN and anti-tnf therapies were significantly superior to PEN providing between 80-90% of estimated calories needed for inducing mucosal healing. For maintenance of remission, some evidence that a diet of formula overnight and low-fat food during the day can reduce postoperative recurrence of disease (small numbers) Miele et al. Journal of Pediatric Gastroenterology, Hepatology, and Nutrition Yamamoto et al. Int Journal Colorectal Dis and Aliment Pharmacol Ther. 2007

24 Avoidance of Fiber is Associated with Greater Risk of CD Flare in 6- Month Period Brotherton et al. Clinical Gastroenterology and Hepatology

25 Does a Diet Low in Red Meat Decrease the Risk of Flares? Study of 191 patients with UC in remission Followed over 1 year 52% of patients relapsed during this time period Consumption of meat, particularly red and processed meat increased the likelihood of relapse FACES Study in Adults with CD In patients with CD in remission, there was no difference in time to relapse in patients assigned to a high vs. low red and processed meat diet, although adherence was only modest in the low meat group. Jowett et al. Gut

26 Emulsifiers and Hydrogenated Fats Emulsifiers lead to increased gut permeability and increased bacterial translocation and promote colitis in an animal model of IBD (Chassaing et al. Nature. 2015). Roberts and colleagues highlighted recently that they observed a clear correlation between annual emulsifier consumption (in food and beverages) and the incidence of IBD, in line with previous studies. Western diet (fast food and sweet beverages) rich in emulsifiers. High margarine (rich in emulsifying agents and hydrogenated fats) was identified by independent studies as being positively correlated with the development of UC and in some studies with CD.

27 Conclusions: What do we tell our patients? IBD dieticians are critical members of the treatment team! Enteral nutritional therapy is an effective therapy for certain patients with CD Other general messages The typical Western diet is probably not good. Emulsifiers, preservatives, long shelf life Diets high in animal fats Fiber is likely beneficial Exclusion diets may be appropriate for certain patients, but we need well designed controlled trials