Hot Topics In Nutrition & IBD January 6, Kate Vance, RD Wael N. Sayej, MD

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1 Hot Topics In Nutrition & IBD January 6, 2018 Kate Vance, RD Wael N. Sayej, MD

2 Nutrients of Focus Calories Calcium Vitamin D Iron

3 Nutritional Treatment in IBD Improve nutritional status As primary therapy for active disease For maintenance of remission

4 Goals of Treatment Most diets focus on manipulating sugars and carbohydrates Impact the microbiome in the gut by promoting desirable bacteria Eliminate symptoms Normalize biomarkers (CRP, Sed rate, fecal calprotectin, nutritional labs) Achieve mucosal healing

5 Dietary Therapy Options Treatment Exclusive enteral nutrition Partial Enteral Nutrition Other Parenteral nutrition (TPN) Adjunct Therapy Specific Carbohydrate Diet Mediterranean/antiinflammatory - (U Mass) Semi vegetarian Gluten Free IBS/FODMAP Popular-Maker s, Paleo, Gaps

6 Treatment: Exclusive Enteral Nutrition (EEN) Exclusive enteral therapy-tube feeding or drinking formula only (no food) for 8-12 weeks is as effective as steroids in inducing remission in 75-85% of children/teens with newly diagnosed Crohn s disease First line therapy in other countries Some centers allow a small percentage of calories from foods Not as effective in people with Ulcerative colitis Critch et al. Use of Enteral nutrition for the control of intestinal inflammation in pediatric Crohn s disease. JPGN 2102;54:

7 Partial EN (PEN) Crohn s Disease Exclusion Diet (CDED) Pediatric studies- 50% of calories from formula and 50% from defined food choices for initial tx of Crohn s disease Results: 47 subjects treated for 6 weeks. 70% of pt. achieved clinical remission Pediatric and adult study of Crohn s patient failing biological therapy Treatment- PEN +CDED for 12 weeks Pediatric pts w/ severe flares received 14 days of EEN then PEN + CDED Results:

8 Specific Carbohydrate diet (SCD)-NIMBAL Retrospective review of 7 patients to review mucosal healing effect of SCD in Crohn s based on endo scopic finding before and after diet on SCD/mSCD for average of 26 months No active symptoms before repeat endoscopy, majority had consistently norml crp, alb, Hct, mildly elevated fecal cal protectin Results- 1 pt had complete ileocolic healing but persistent upper GI tract ulcerations. Complete macroscopic mucosal healing was not seen in any patient. Wahbeh,G, Ward,B et al, Lack of Mucosal Healing From Modified Specific Carbohydrate Diet in Pediatric Patients With Crohn s Disease. JPGN 2017;65:289-92

9 SCD vs Mediterranean Style Diet (MSD) CCFA Study run from 3/ Recruiting 194 people w/active Crohn s disease Assigned to SCD or MSD 1:1 for 6 weeks 3 meals and 2 snack delivered to patient for 6 weeks Review of CDAI, fecal calprotectin Diet followed additional 12 weeks - patient purchasing foods Review CDAI, fecal calprotectin

10 Supportive: Gluten Free Cross sectional study GFD questionnaire 1647 pt. w/ IBD participating in CCFA partners longitudinal internet-based cohort 314 (19.1%) reported having tried GFD, 135 (8.2%) report current use 65.6% of all patients who attempted GFD report improved GI symptoms 38.3% reported fewer or less severe IBD flares Excellent adherence was associated w/improvement of fatigue Herfarth H, Martin C et al Prevalence of a Gluten-free Diet and Improvement of Clinical Symptoms in Patients with Inflammatory Bowel Diseases. Inflamm Bowel Dis 2014;20:

11 Supportive: IBS/FODMAPs 52 consecutive patients w/ Crohn s and 20 w/ UC given dietary advise on FODMAPs Retrospective phone questionnaire Asked to recall: dietary advise, dietary adherence, change GI symptoms 70% reported being adherent to diet 1 in 2 responded to diet changes (defined as improvement of 5 of 10 in overall symptoms (abdominal pain, bloating, wind, diarrhea) No improvement w/ constipation Gearry R, Irving P et al Reduction of dietary poorly absorbed short chain carbohydrates (FODMAPs) improves abdominal pain in patients with inflammatory bowel disease- a pilot. J of Crohns and Colitis;3:8-14

12 Unproven: Maker s, Paleo, Gaps Most eliminate or limit carbohydrates There are no studies proving effectiveness in treating IBD Recommended supplements no proven value in IBD Concerns of major nutrients eliminated

13 Supplements and Nutraceuticals Calories Calcium Vitamin D Iron Probiotics Glutamine MVI

14 Calories No matter what diet your child is on, it should have adequate calories to promote age expected growth Calories need to come from a variety of sources In some cases oral supplements (Boost, Ensure, Pediasure, Pediasmart, homemade shakes)

15 Supplements USP verification

16 Calcium Essential for formation & health of bones and teeth Calcium is essential for muscle contraction including maintaining normal heart rhythm Childhood impacts adult bone health for a lifetime No more than ½ of daily calcium come from supplements Food sources: dairy, bok choy, collards, calcium fortified products

17 Calcium Recommended intake Age Male Female Tolerable Upper limit 1-3 years 700 mg 700 mg 2500 mg 4-8 years 1000 mg 1000 mg 2500 mg 9-18 years 1300 mg 1300 mg 3000 mg years 1000 mg 1000 mg 2500 mg

18 Vitamin D Vitamin D is involved in anti-inflammatory pathways in the body in addition to it s key role in bone health In mice, vitamin D has been shown to promote epithelial resistance to injury and suppress inflammatory response to antigens in the gut Food sources: dairy products (additive),eggs, fatty fish, shittake mushrooms, fortified cereal, sunlight Should be monitored 2 x year- supplements are often needed.

19 Iron Anemia is the most common systemic complication of IBD Iron deficiency -leading cause of anemia Iron deficiency anemia is associated with decreased physical activity, fatigue and decreased quality of life,? Decrease appetite Food sources: Red meats, Molasses, Seafood Fortified cereals, Baked beans Supplements- oral or IV repletion

20 Probiotics Faecalibacterium prausnitzii protective against IBD Currently not available as a supplement Provides energy to the colonocytes Control inflammation through inflammatory cytokine inhibition Mucosal protective properties High intake of foods with fermentable fibers in diet will increase bacteria population

21 Probiotics: VSL#3 There is no apparent benefit for probiotics in maintenance of remission in Crohn s disease based on clinical and/or endoscopic relapse rates. One study w/ VSL#3 showed no difference in endoscopic 90 days versus placebo. At 365 days lower mucosal levels of cytokines & recurrence Suggests some efficacy

22 Probiotics: UC-VSL#3 Two recent studies using VSL#3 as adjunct therapy (+ aminosalicylates or thiopurines) Study1-VSL#3 increase remission rate at 12 weeks (UCDAI) Study2-No difference in remission rate versus placebo (based on PGA & endoscopic findings)-showed improved clinical effects w/ reduction in rectal bleeding & stool frequency score

23 Probiotics: Pouchitis-VSL#3 VSL#3 highly effective in the primary prevention of pouchitis following an IPAA Also superior in maintaining remission after tx of pouchitis w/ antibiotics

24 L-glutamine Taking glutamine orally doesn't seem to improve symptoms of Crohn's disease (1,2). Neither supplemental glutamine 7 grams three times daily nor a glutamine-enriched diet seems to have any benefit in patients with Crohn's disease (1,2,3). 1.Den Hond E, Hiele M, Peeters M, et al. Effect of long-term oral glutamine supplements on small intestinal permeability in patients with Crohn's disease. J Parenter Enteral Nutr 1999;23: Akobeng AK, Miller V, Stanton J, et al. Double-blind, randomized, controlled trial of glutamine-enriched polymeric diet in the treatment of active Crohn's disease. J Pediatr Gastroenterol Nutr 2000;30: Zoli G, Care M, Falco F, et al. Effect of oral glutamine on intestinal permeability and nutritional status in Crohn's disease [abstract]. Gastroenterology 1995;108:A766.

25 Multivitamin A multivitamin with minerals is suggested Chewables are ok no matter how old you are! Gummies usually don t contain iron Taking vitamins at night may be more comfortable

26 Future Trends Likely not a single diet Designer diets based on genetics, microbiome, specific individually identified crucial nutrients Supplements of specific nutrients may be necessary

27 Take away tips IBD is not a static disease- different diets may be appropriate at different times Therapy is often individualized Liberalize diet restrictions as soon as feeling well Strive to consume minimally processed food choices Eat a variety of foods from all of the food groups Limit caffeine Avoid high intake of animal fats Buy organic at least for the Dirty Dozen