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Chirayath S, Bahirwani J, Pandey A, Memel Z, Park S, Schneider Y. Inpatient Nutritional Considerations in Inflammatory Bowel Disease. Curr Gastroenterol Rep 2025; 27:9. [PMID: 39760825 DOI: 10.1007/s11894-024-00958-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2024] [Indexed: 01/07/2025]
Abstract
PURPOSE OF REVIEW This review aims to explain the causes, diagnosis, and treatment of malnutrition in hospitalized patients with inflammatory bowel disease (IBD), focusing on both adults and children. RECENT FINDINGS Malnutrition is common among IBD patients, affecting up to 85% of individuals, and is linked to higher rates of illness, death, and longer hospital stays. Recent studies highlight the importance of early detection using tools like the Subjective Global Assessment (SGA) and handgrip strength tests. Nutritional interventions-such as exclusive enteral nutrition (EEN) and parenteral nutrition (PN)-have proven effective in inducing remission and improving patient outcomes, especially in pediatric Crohn's disease. New evidence suggests that optimizing nutrition before and after surgery, as well as using immunonutrition, may reduce postoperative complications. Early identification and management of malnutrition in hospitalized IBD patients may be important for improving clinical outcomes. Using appropriate nutritional screening tools and creating personalized nutrition plans can help with recovery, decrease hospital stays, and improve quality of life. Further research is needed to develop standard protocols for nutritional assessment and treatment in this patient population.
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Affiliation(s)
| | | | - Akash Pandey
- Pediatric Gastroenterology, Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Zoe Memel
- University of California Medical Center, San Francisco, CA, USA
| | - Sunhee Park
- University of California Irvine Health Center, Orange, CA, USA
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2
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Frydrych A, Kulita K, Jurowski K, Piekoszewski W. Lipids in Clinical Nutrition and Health: Narrative Review and Dietary Recommendations. Foods 2025; 14:473. [PMID: 39942064 PMCID: PMC11816940 DOI: 10.3390/foods14030473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2024] [Revised: 01/28/2025] [Accepted: 01/29/2025] [Indexed: 02/16/2025] Open
Abstract
Lipids are essential components of human health, serving as critical structural elements of cell membranes, energy sources, and precursors for bioactive molecules. This narrative review aims to examine the multifaceted roles of lipids in clinical nutrition and health, focusing on their impact on chronic disease prevention, management, and the potential of lipid-based therapies. A narrative review was conducted utilizing Scopus, Google Scholar, and Web of Science databases. Key terms such as lipids, dietary fats, and cholesterol were used to identify and analyze relevant studies. A total of 145 articles meeting inclusion criteria were reviewed for their insights into lipid metabolism, dietary sources, and clinical implications. The analysis highlighted the metabolic significance of various lipid classes-saturated, monounsaturated, and polyunsaturated fatty acids-along with evidence-based recommendations for their dietary intake. Lipids were shown to play a pivotal role in managing chronic diseases such as cardiovascular disease, obesity, and metabolic syndrome. Emerging therapies, including omega-3 fatty acids and medium-chain triglycerides, demonstrated potential benefits in clinical practice. By synthesizing current knowledge, this narrative review provides healthcare professionals with an updated understanding of the roles of lipids in clinical nutrition. The findings emphasize the importance of tailored dietary interventions and lipid-based therapies in optimizing health and managing chronic diseases effectively. Additionally, this review successfully presents practical dietary recommendations to guide clinical practice.
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Affiliation(s)
- Adrian Frydrych
- Laboratory of Innovative Toxicological Research and Analyses, Faculty of Medicine, Medical College, University of Rzeszów, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland; (A.F.); (K.J.)
| | - Kamil Kulita
- Toxicological Science Club ‘Paracelsus’, Faculty of Medicine, Medical College, University of Rzeszów, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland;
| | - Kamil Jurowski
- Laboratory of Innovative Toxicological Research and Analyses, Faculty of Medicine, Medical College, University of Rzeszów, Al. mjr. W. Kopisto 2a, 35-959 Rzeszów, Poland; (A.F.); (K.J.)
- Department of Regulatory and Forensic Toxicology, Institute of Medical Expertise, Łódź, ul. Aleksandrowska 67/93, 91-205 Łódź, Poland
| | - Wojciech Piekoszewski
- Laboratory of High Resolution of Mass Spectrometry, Faculty of Chemistry, Jagiellonian University, R. Ingardena 3, 30-060 Krakow, Poland
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Chun M, Tun KM, Vongsavath T, Verma R, Batra K, Limsui D, Jenkins E. Fecal Microbiota Transplantation for Chronic Pouchitis: A Systematic Review and Meta-Analysis. Microorganisms 2024; 12:2430. [PMID: 39770634 PMCID: PMC11676736 DOI: 10.3390/microorganisms12122430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2024] [Revised: 11/22/2024] [Accepted: 11/23/2024] [Indexed: 01/11/2025] Open
Abstract
Pouchitis is a common complication after ileal-pouch anal anastomosis in patients with medically refractory ulcerative colitis. There has been a lack of high-level evidence focusing on the safety and efficacy outcomes of fecal microbiota transplantation (FMT). We aim to evaluate outcomes and complications of fecal microbiota transplantation (FMT) for chronic pouchitis. Databases were systematically searched to retrieve English-only, original studies, published from inception to 31 March 2024, investigating chronic pouchitis only. Primary outcomes included overall remission, clinical response, remission, relapse, and complications. Seven studies with 94 patients were included. The pooled overall remission rate was 15% (95% CI: 0-29%, p < 0.001), the clinical response rate was 33% (95% CI: 19-46%, p = 0.14), the clinical remission rate was 14% (95% CI: 19-46%, p < 0.001), and the clinical relapse rate was 36% (95% CI: 16-55%, p = 0.11). The pooled proportion of patients with mild adverse events after FMT treatment was 39% (95% CI: 6-71%, p < 0.001). No severe adverse events or deaths were reported. Although FMT is an effective treatment for chronic pouchitis, there is still a high rate of mild adverse events. High-level evidence for FMT is still sparse, limiting recommendations for clinical use.
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Affiliation(s)
- Magnus Chun
- Department of Internal Medicine, Kirk Kerkorian School of Medicine at UNLV, University of Nevada, Las Vegas, NV 89106, USA; (T.V.); (R.V.)
| | - Kyaw Min Tun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Creighton University, Omaha, NE 68178, USA; (K.M.T.); (E.J.)
| | - Tahne Vongsavath
- Department of Internal Medicine, Kirk Kerkorian School of Medicine at UNLV, University of Nevada, Las Vegas, NV 89106, USA; (T.V.); (R.V.)
| | - Renuka Verma
- Department of Internal Medicine, Kirk Kerkorian School of Medicine at UNLV, University of Nevada, Las Vegas, NV 89106, USA; (T.V.); (R.V.)
| | - Kavita Batra
- Department of Medical Education, Kirk Kerkorian School of Medicine at UNLV, University of Nevada, Las Vegas, NV 89106, USA
- Office of Research, Kirk Kerkorian School of Medicine at UNLV, University of Nevada, Las Vegas, NV 89106, USA
| | - David Limsui
- Division of Gastroenterology and Hepatology, Department of Medicine, School of Medicine, Stanford University, Palo Alto, CA 94305, USA;
| | - Erin Jenkins
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Creighton University, Omaha, NE 68178, USA; (K.M.T.); (E.J.)
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Deas J, Shah ND, Konijeti GG, Lundin A, Lanser O, Magavi P, Ali S. Dietary therapies for adult and pediatric inflammatory bowel disease. Nutr Clin Pract 2024; 39:530-545. [PMID: 38505875 DOI: 10.1002/ncp.11146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/21/2024] Open
Abstract
Diet is an environmental exposure implicated in the development of inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC). Dietary therapy is also a tool for management of these conditions. Nutrition therapy for IBD has been shown to reduce intestinal inflammation, promote healing, and alleviate symptoms, as well as improve patients' nutrition status. Although the mechanisms of action of most nutrition therapies for IBD are not well understood, the diets are theorized to eliminate triggers for gut dysbiosis and mucosal immune dysfunction associated with the typical Western diet. Exclusive enteral nutrition and the Crohn's disease exclusion diet are increasingly being used as the primary treatment modality for the induction of remission and/or maintenance therapy in children, and in some adults, with CD. Several other diets, such as the Mediterranean diet, anti-inflammatory diet for IBD, and diets excluding gluten, FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), lactose, or other compounds, may be helpful in symptom management in both CD and UC, though evidence for biochemical efficacy is limited. In this review, we discuss the role of diet components in IBD pathogenesis and examine diets currently used in the management of children and adults with IBD. We also address practical, psychosocial, and cultural considerations for dietary therapy across diverse populations.
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Affiliation(s)
- Jessica Deas
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Neha D Shah
- Colitis and Crohn's Disease Center, University of California San Francisco, San Francisco, California, USA
| | - Gauree G Konijeti
- Division of Gastroenterology & Hepatology, Scripps Clinic, La Jolla, California, USA
| | - Abigail Lundin
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Benioff Children Hospitals, University of California San Francisco, San Francisco, California, USA
| | - Olivia Lanser
- Division of Gastroenterology & Hepatology, Scripps Clinic, La Jolla, California, USA
| | - Pooja Magavi
- Division of Gastroenterology & Hepatology, Scripps Clinic, La Jolla, California, USA
| | - Sabina Ali
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Benioff Children Hospitals, University of California San Francisco, San Francisco, California, USA
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Xu D, Peng Z, Li Y, Hou Q, Peng Y, Liu X. Progress and Clinical Applications of Crohn's Disease Exclusion Diet in Crohn's Disease. Gut Liver 2024; 18:404-413. [PMID: 37842728 PMCID: PMC11096903 DOI: 10.5009/gnl230093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 07/07/2023] [Accepted: 07/24/2023] [Indexed: 10/17/2023] Open
Abstract
Crohn's disease is a chronic intestinal inflammatory disorder of unknown etiology. Although the pharmacotherapies for Crohn's disease are constantly updating, nutritional support and adjuvant therapies have recently gained more attention. Due to advancements in clinical nutrition, various clinical nutritional therapies are used to treat Crohn's disease. Doctors treating inflammatory bowel disease can now offer several diets with more flexibility than ever. The Crohn's disease exclusion diet is a widely used diet for patients with active Crohn's disease. The Crohn's disease exclusion diet requires both exclusion and inclusion. Periodic exclusion of harmful foods and inclusion of wholesome foods gradually improves a patient's nutritional status. This article reviews the Crohn's disease exclusion diet, including its structure, mechanisms, research findings, and clinical applications.
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Affiliation(s)
- Duo Xu
- Departments of Gastroenterology, Xiangya Hospital of Central South University, Changsha, China
| | - Ziheng Peng
- Departments of Gastroenterology, Xiangya Hospital of Central South University, Changsha, China
| | - Yong Li
- Departments of Gastroenterology, Xiangya Hospital of Central South University, Changsha, China
| | - Qian Hou
- Departments of Clinical Nutrition, Xiangya Hospital of Central South University, Changsha, China
| | - Yu Peng
- Departments of Gastroenterology, Xiangya Hospital of Central South University, Changsha, China
- Hunan Key Laboratory of Organ Fibrosis, Changsha, China
- Hunan International Scientific and Technological Cooperation Base of Artificial Intelligence Computer Aided Diagnosis and Treatment for Digestive Disease, Changsha, China
| | - Xiaowei Liu
- Departments of Gastroenterology, Xiangya Hospital of Central South University, Changsha, China
- Hunan International Scientific and Technological Cooperation Base of Artificial Intelligence Computer Aided Diagnosis and Treatment for Digestive Disease, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, China
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Manski S, Noverati N, Policarpo T, Rubin E, Shivashankar R. Diet and Nutrition in Inflammatory Bowel Disease: A Review of the Literature. CROHN'S & COLITIS 360 2024; 6:otad077. [PMID: 38213632 PMCID: PMC10782214 DOI: 10.1093/crocol/otad077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Indexed: 01/13/2024] Open
Abstract
Diet is thought to contribute to the development of inflammatory bowel disease (IBD) and may act as a mediator of inflammation in patients with IBD. Patients commonly associate their diet with symptoms and inquire about dietary modifications to manage their IBD. Without clinical guidelines and well-established nutritional data, healthcare providers managing patients with IBD may find it difficult to provide recommendations. Strong evidence for enteral nutrition, particularly in the pediatric population, has been established in Crohn's disease (CD) as a therapeutic option. Enteral nutrition may also serve as an adjunct to an exclusion diet. Recent studies such as the randomized trial comparing the Specific Carbohydrate Diet to a Mediterranean Diet in CD patients provide additional insights in forming dietary plans. A low-fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet in quiescent IBD and an anti-inflammatory diet have also been explored as adjunctive therapies. In this review, we discuss the latest evidence for the role of diet in IBD both as a therapeutic modality and as an opportunity to provide patient-centered care.
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Affiliation(s)
- Scott Manski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nicholas Noverati
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Tatiana Policarpo
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Emily Rubin
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Raina Shivashankar
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA, USA
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Catalán-Serra I, Ricanek P, Grimstad T. "Out of the box" new therapeutic strategies for Crohn´s disease: moving beyond biologics. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:614-634. [PMID: 35748460 DOI: 10.17235/reed.2022.9010/2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
New treatment options beyond immunosuppression have emerged in recent years for patients with Crohn´s disease (CD), a chronic systemic condition affecting primarily the gut with great impact in the quality of life. The cause of CD is largely unknown, and a curative treatment is not yet available. In addition, despite the growing therapeutic armamentarium in recent years almost half of the patients don´t achieve a sustained response over time. Thus, new therapeutic strategies are urgently needed. In this review, we discuss the current state of promising new "out of the box" possibilities to control chronic inflammation beyond current pharmacological treatments, including: exclusive enteral nutrition, specific diets, cell therapies using T regs, hyperbaric oxygen, fecal microbiota transplantation, phage therapy, helminths, cannabis and vagal nerve stimulation. The exploration of original and novel therapeutic modalities is key to address their potential as main or complementary treatments in selected CD populations in order to increase efficacy, minimize side effects and improve quality of life of patients.
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Yan D, Ye S, He Y, Wang S, Xiao Y, Xiang X, Deng M, Luo W, Chen X, Wang X. Fatty acids and lipid mediators in inflammatory bowel disease: from mechanism to treatment. Front Immunol 2023; 14:1286667. [PMID: 37868958 PMCID: PMC10585177 DOI: 10.3389/fimmu.2023.1286667] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 09/25/2023] [Indexed: 10/24/2023] Open
Abstract
Inflammatory Bowel Disease (IBD) is a chronic, relapsing inflammatory disorder of the gastrointestinal tract. Though the pathogenesis of IBD remains unclear, diet is increasingly recognized as a pivotal factor influencing its onset and progression. Fatty acids, essential components of dietary lipids, play diverse roles in IBD, ranging from anti-inflammatory and immune-regulatory functions to gut-microbiota modulation and barrier maintenance. Short-chain fatty acids (SCFAs), products of indigestible dietary fiber fermentation by gut microbiota, have strong anti-inflammatory properties and are seen as key protective factors against IBD. Among long-chain fatty acids, saturated fatty acids, trans fatty acids, and ω-6 polyunsaturated fatty acids exhibit pro-inflammatory effects, while oleic acid and ω-3 polyunsaturated fatty acids display anti-inflammatory actions. Lipid mediators derived from polyunsaturated fatty acids serve as bioactive molecules, influencing immune cell functions and offering both pro-inflammatory and anti-inflammatory benefits. Recent research has also highlighted the potential of medium- and very long-chain fatty acids in modulating inflammation, mucosal barriers, and gut microbiota in IBD. Given these insights, dietary intervention and supplementation with short-chain fatty acids are emerging as potential therapeutic strategies for IBD. This review elucidates the impact of various fatty acids and lipid mediators on IBD and delves into potential therapeutic avenues stemming from these compounds.
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Affiliation(s)
- Dong Yan
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Shuyu Ye
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, Changsha, China
- Hunan Key Laboratory of Non-Resolving Inflammation and Cancer, Cancer Research Institute, Central South University, Changsha, China
| | - Yue He
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Sidan Wang
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, Changsha, China
- Hunan Key Laboratory of Non-Resolving Inflammation and Cancer, Cancer Research Institute, Central South University, Changsha, China
| | - Yi Xiao
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, Changsha, China
- Hunan Key Laboratory of Non-Resolving Inflammation and Cancer, Cancer Research Institute, Central South University, Changsha, China
| | - Xin Xiang
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Minzi Deng
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, Changsha, China
- Hunan Key Laboratory of Non-Resolving Inflammation and Cancer, Cancer Research Institute, Central South University, Changsha, China
| | - Weiwei Luo
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, Changsha, China
- Hunan Key Laboratory of Non-Resolving Inflammation and Cancer, Cancer Research Institute, Central South University, Changsha, China
| | - Xuejie Chen
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, Changsha, China
- Hunan Key Laboratory of Non-Resolving Inflammation and Cancer, Cancer Research Institute, Central South University, Changsha, China
| | - Xiaoyan Wang
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, Changsha, China
- Hunan Key Laboratory of Non-Resolving Inflammation and Cancer, Cancer Research Institute, Central South University, Changsha, China
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9
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Lomer MCE, Wilson B, Wall CL. British Dietetic Association consensus guidelines on the nutritional assessment and dietary management of patients with inflammatory bowel disease. J Hum Nutr Diet 2023; 36:336-377. [PMID: 35735908 PMCID: PMC10084145 DOI: 10.1111/jhn.13054] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 06/07/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Despite increased awareness of diet and nutrition being integral to the management of patients with inflammatory bowel disease (IBD), there are gaps in the knowledge of IBD healthcare providers regarding nutrition. Furthermore, high quality evidence on nutritional assessment and dietary management of IBD is limited. A Delphi consensus from a panel of experts allows for best-practice guidelines to be developed, especially where high quality evidence is limited. The aim was to develop guidelines for the nutritional assessment and dietary management of IBD using an eDelphi online consensus agreement platform. METHODS Seventeen research topics related to IBD and nutrition were systematically reviewed. Searches in Cochrane, Embase®, Medline® and Scopus® electronic databases were performed. GRADE was used to develop recommendations. Experts from the IBD community (healthcare professionals and patients with IBD) were invited to vote anonymously on the recommendations in a custom-built online platform. Three rounds of voting were carried out with updated iterations of the recommendations and evaluative text based on feedback from the previous round. RESULTS From 23,824 non-duplicated papers, 167 were critically appraised. Fifty-five participants completed three rounds of voting and 14 GRADE statements and 42 practice statements achieved 80% consensus. Comprehensive guidance related to nutrition assessment, nutrition screening and dietary management is provided. CONCLUSIONS Guidelines on the nutritional assessment and dietary management of IBD have been developed using evidence-based consensus to improve equality of care. The statements and practice statements developed demonstrate the level of agreement and the quality and strength of the guidelines.
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Affiliation(s)
- Miranda C E Lomer
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Nutritional Sciences, King's College London, London, UK
| | - Bridgette Wilson
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Nutritional Sciences, King's College London, London, UK
| | - Catherine L Wall
- Department of Nutritional Sciences, King's College London, London, UK.,Department of Medicine, University of Otago, Christchurch, New Zealand
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Otley A, Day AS, Zachos M. Nutritional Management of Inflammatory Bowel Disease. PEDIATRIC INFLAMMATORY BOWEL DISEASE 2023:355-383. [DOI: 10.1007/978-3-031-14744-9_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Luo J, Xie YM, Wu M, Zhao JG, Hu LL. Global attitudes on and the status of enteral nutrition therapy for pediatric inflammatory bowel disease. Front Med (Lausanne) 2022; 9:1036793. [PMID: 36569124 PMCID: PMC9773139 DOI: 10.3389/fmed.2022.1036793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022] Open
Abstract
Enteral nutrition (EN) is a diet-remission therapy for inflammatory bowel disease (IBD) that plays a more important role in children than adults. EN includes exclusive enteral nutrition (EEN), partial enteral nutrition (PEN), and maintenance enteral nutrition (MEN). However, EEN remains an unstandardized treatment for pediatric IBD. The types and methods of EN differ around the world. The current study reviewed the EN literature on children with IBD. A total of 12 survey studies were identified that analyzed the current state of EN use, including clinical opinions, implementation methods, treatment course, EEN formula, IBD classification, progress, dietary reintroduction, and patient feedback. The findings revealed that EEN has a strong effect on mild to moderate Crohn's disease (CD). The usage rates of this treatment in different sites were ileum/colon (Paris classification L3) > ileum (L1) > upper digestive tract (L4) > colon (L2) > perianal disease (P) > ulcerative colitis (UC) > extraintestinal lesions. The polymeric formula was the most used EN formulation. New EN diets include a CD exclusion diet (CDED), a specific carbohydrate diet (SCD), and a CD treatment-with-eating (CD-TREAT) diet. Children with IBD responded similarly to EEN administered orally or using a feeding tube. Most guidelines recommended 6-8 weeks of EEN treatment to induce remission. Many clinicians preferred to combine drug medications during EEN and recommended that MEN accounts for at least 25-35% of daily caloric intake. EN remains an unstandardized therapy that requires teamwork across disciplines.
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Affiliation(s)
- Juan Luo
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
| | - Yong-Mei Xie
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China,*Correspondence: Yong-Mei Xie,
| | - Mei Wu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
| | - Jin-Gui Zhao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
| | - Liang-Liang Hu
- Department of Pediatrics, Luzhou People’s Hospital, Luzhou, Sichuan, China
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12
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Jiménez-Sánchez A, Martínez-Ortega AJ, Remón-Ruiz PJ, Piñar-Gutiérrez A, Pereira-Cunill JL, García-Luna PP. Therapeutic Properties and Use of Extra Virgin Olive Oil in Clinical Nutrition: A Narrative Review and Literature Update. Nutrients 2022; 14:nu14071440. [PMID: 35406067 PMCID: PMC9003415 DOI: 10.3390/nu14071440] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 02/06/2023] Open
Abstract
Extra virgin olive oil (EVOO) is a cornerstone of the Mediterranean diet (MedD). In this narrative review, we synthesize and illustrate the various characteristics and clinical applications of EVOO and its components—such as oleic acid, hydroxytyrosol, and oleuropein—in the field of clinical nutrition and dietetics. The evidence is split into diet therapy, oleic acid-based enteral nutrition formulations and oral supplementation formulations, oleic acid-based parenteral nutrition, and nutraceutical supplementation of minor components of EVOO. EVOO has diverse beneficial health properties, and current evidence supports the use of whole EVOO in diet therapy and the supplementation of its minor components to improve cardiovascular health, lipoprotein metabolism, and diabetes mellitus in clinical nutrition. Nevertheless, more intervention studies in humans are needed to chisel specific recommendations for its therapeutic use through different formulations in other specific diseases and clinical populations.
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Affiliation(s)
- Andrés Jiménez-Sánchez
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Avda. Manuel Siurot s/n, 41013 Seville, Spain; (P.J.R.-R.); (A.P.-G.); (J.L.P.-C.)
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013 Seville, Spain;
- Correspondence: (A.J.-S.); (P.P.G.-L.)
| | - Antonio Jesús Martínez-Ortega
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013 Seville, Spain;
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Torrecárdenas, C. Hermandad de Donantes de Sangre, s/n, 04009 Almería, Spain
| | - Pablo Jesús Remón-Ruiz
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Avda. Manuel Siurot s/n, 41013 Seville, Spain; (P.J.R.-R.); (A.P.-G.); (J.L.P.-C.)
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013 Seville, Spain;
| | - Ana Piñar-Gutiérrez
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Avda. Manuel Siurot s/n, 41013 Seville, Spain; (P.J.R.-R.); (A.P.-G.); (J.L.P.-C.)
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013 Seville, Spain;
| | - José Luis Pereira-Cunill
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Avda. Manuel Siurot s/n, 41013 Seville, Spain; (P.J.R.-R.); (A.P.-G.); (J.L.P.-C.)
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013 Seville, Spain;
| | - Pedro Pablo García-Luna
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Avda. Manuel Siurot s/n, 41013 Seville, Spain; (P.J.R.-R.); (A.P.-G.); (J.L.P.-C.)
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013 Seville, Spain;
- Correspondence: (A.J.-S.); (P.P.G.-L.)
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13
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de Sire R, Nardone OM, Testa A, Calabrese G, Caiazzo A, Castiglione F. Exclusive Enteral Nutrition in Adult Crohn's Disease: an Overview of Clinical Practice and Perceived Barriers. Clin Exp Gastroenterol 2021; 14:493-501. [PMID: 35002274 PMCID: PMC8720860 DOI: 10.2147/ceg.s267172] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 12/10/2021] [Indexed: 12/11/2022] Open
Abstract
Recently, the role of nutrition in the management of Crohn's disease (CD) is of increasing interest and the exploration of novel nutritional interventions to improve long-term management of the disease is challenging. So far, the majority of the studies on the role of exclusive enteral nutrition (EEN) in CD are conducted in the pediatric population and have highlighted the efficacy of EEN for achieving mucosal healing. This implicates that a similar approach would be beneficial in adult patients. However, the evidence for EEN in adults is heterogeneous, with meta-analyses reporting it as inferior to steroids while growing data demonstrate improvement in complicated CD. Currently, EEN is less used in adult patients with IBD. Indeed, the lack of palatability of enteral formula leads to difficulties in acceptance and compliance. The search for more tolerable and still effective diets has become an intense area of research aiming to explore the potential role of diet to control inflammation in patients with CD. Thus, this narrative review provides the state-of-the-art on the use of EEN treatment in CD and highlights the perceived barriers to its implementation in adult CD patients.
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Affiliation(s)
- Roberto de Sire
- Department of Clinical Medicine and Surgery, University Federico II of Naples, Naples, Italy
| | - Olga Maria Nardone
- Department of Clinical Medicine and Surgery, University Federico II of Naples, Naples, Italy
| | - Anna Testa
- Department of Clinical Medicine and Surgery, University Federico II of Naples, Naples, Italy
| | - Giulio Calabrese
- Department of Clinical Medicine and Surgery, University Federico II of Naples, Naples, Italy
| | - Anna Caiazzo
- Department of Clinical Medicine and Surgery, University Federico II of Naples, Naples, Italy
| | - Fabiana Castiglione
- Department of Clinical Medicine and Surgery, University Federico II of Naples, Naples, Italy
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14
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Antoniussen CS, Rasmussen HH, Holst M, Lauridsen C. Reducing Disease Activity of Inflammatory Bowel Disease by Consumption of Plant-Based Foods and Nutrients. Front Nutr 2021; 8:733433. [PMID: 34957174 PMCID: PMC8696360 DOI: 10.3389/fnut.2021.733433] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/07/2021] [Indexed: 01/04/2023] Open
Abstract
Inflammatory bowel disease is a chronic and recurring inflammatory condition of the gastrointestinal tract encompassing ulcerative colitis and Crohn's disease. Although the pathogenesis of inflammatory bowel disease remains to be fully elucidated, environmental factors such as diet are believed to play a pivotal role in the onset and management of inflammatory bowel disease. Diet is thought to play an essential role in intestinal inflammation due to its regulatory effects on the microbiota, gut immune system, and epithelial barrier function. Although the evidence remains insufficient to draw firm conclusions on the role of specific dietary components in gastrointestinal diseases, studies have suggested that a Western diet with high intakes of total fats, omega-6 fatty acids, and meat have been associated with intestinal inflammation and relapse of inflammatory bowel disease. In contrast to a Western diet, plant-based diets often result in a reduced intake of total fats and meats and an increased intake of plant fibers which may contribute to reduced intestinal inflammation. This review critically examines the influence of plant-based dietary components on the clinical disease course of inflammatory bowel disease. Furthermore, this review discusses the benefits and possible limitations of plant-derived dietary components in the treatment of inflammatory bowel disease while addressing the principal type of disease and the anatomic site of inflammation within the gastrointestinal tract. Finally, this review points out important directions for future research on the role of diet in inflammatory bowel disease. A better understanding of the role of diet and intestinal inflammation may pave the way for novel dietary interventions and specific foods- or food supplements, which can support the treatment of inflammatory bowel disease.
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Affiliation(s)
| | - Henrik H Rasmussen
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark.,Department of Gastroenterology, Center for Nutrition and Bowel Disease, Aalborg University Hospital, Aalborg, Denmark
| | - Mette Holst
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark.,Department of Gastroenterology, Center for Nutrition and Bowel Disease, Aalborg University Hospital, Aalborg, Denmark
| | - Charlotte Lauridsen
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark.,Department of Animal Science, Faculty of Technical Sciences, Aarhus University, Foulum, Denmark
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15
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Piotrowska M, Binienda A, Fichna J. The role of fatty acids in Crohn's disease pathophysiology - An overview. Mol Cell Endocrinol 2021; 538:111448. [PMID: 34480991 DOI: 10.1016/j.mce.2021.111448] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/30/2021] [Indexed: 12/14/2022]
Abstract
Crohn's disease (CD) is an inflammatory bowel disease (IBD) which is characterized by chronic and relapsing inflammation of the gastrointestinal (GI) tract. The etiology of CD is unknown, but factors such as epithelial barrier dysfunction, immune system imbalance, microbiota dysbiosis and environmental influences are thought to be involved in its pathogenesis. Recent studies have shown that short chain fatty acids (SCFAs) and long chain fatty acids (LCFAs) play a vital role in pathophysiology and development of CD by various mechanisms affecting pro- and anti-inflammatory mediators, and maintaining the intestinal homeostasis and regulation of gene expression. SCFAs and LCFAs activate signaling cascades that control immune functions through interaction with cell surface free fatty acid receptors (FFARs), i.e. FFAR1, FFAR2, FFAR3, and FFAR4. This review highlights the role of fatty acids in maintenance of intestinal and immune homeostasis and supports the supplementation of fatty acids as a promising adjunctive treatment for CD.
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Affiliation(s)
- Marta Piotrowska
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, 92-215, Lodz, Poland.
| | - Agata Binienda
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, 92-215, Lodz, Poland.
| | - Jakub Fichna
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, 92-215, Lodz, Poland.
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16
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Ramaswamy PK. Exclusive enteral nutrition with oral polymeric diet helps in inducing clinical and biochemical remission in adults with active Crohn's Disease. JPEN J Parenter Enteral Nutr 2021; 46:423-432. [PMID: 34618355 DOI: 10.1002/jpen.2273] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND AIMS Exclusive enteral nutrition (EEN) is not routinely used as induction therapy for adults with active Crohn's Disease (CD). The aim of this study was to assess the effectiveness of EEN with oral polymeric formula as an adjunct for inducing clinical and biochemical remission in adults with active CD. METHODS We performed a retrospective analysis of data from January 2018 to September 2019 on all patients with active CD who commenced EEN. Primary endpoint was clinical remission (CDAI ≤150) or response (100-point decrease in CDAI) at 8 weeks. Secondary endpoint was achievement of biochemical remission (CRP ≤5 mg/L or faeces calprotectin ≤150 mcg/g) at 8 weeks in those whose baseline values were elevated. We also aimed to identify predictors of response to EEN therapy. RESULTS Sixty-six patients commenced EEN, 53/66 (80.3%) completed the prescribed EEN course. At 8 weeks, 42/66 (63.6%) patients achieved primary endpoint and secondary endpoint was achieved in 30/53 (56.6%) of patients. Patients receiving EEN for ≥ 6 weeks achieved primary (72% vs 47.8%, OR 2.8, p = 0.047, CI 0.97 -8.16) and secondary endpoint (67.6% vs 36.8%, OR 3.58, p = 0.035, CI 1.1- 11.63) more frequently when compared with patients who received EEN for <6 weeks. Nine patients reported adverse effects (4 nausea,3 diarrhoea,1 constipation and 1 abdominal pain), none of whom ceased therapy. CONCLUSION Polymeric EEN is well tolerated, safe and effective in inducing clinical and biochemical remission in adults with active CD. EEN duration of ≥ 6 weeks has better outcomes. This article is protected by copyright. All rights reserved.
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Affiliation(s)
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- Department of Digestive Health, Gold Coast University Hospital.,Department of Nutrition and Food Services, Gold Coast University Hospital.,Faculty of Health Sciences and Medicine, Bond University
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17
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Mitrev N, Huang H, Hannah B, Kariyawasam VC. Review of exclusive enteral therapy in adult Crohn's disease. BMJ Open Gastroenterol 2021; 8:e000745. [PMID: 34580154 PMCID: PMC8477235 DOI: 10.1136/bmjgast-2021-000745] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/07/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Exclusive enteral nutrition (EEN) is a potentially effective but underused therapy for Crohn's disease (CD) in adults. It is first-line induction treatment for paediatric patients but remains a second-line or third-line therapy in adults. OBJECTIVE To analyse the evidence for EEN in adult patients with CD, and summarise this in a narrative review. METHODS In April/May 2020 and July 2021, a literature search was performed using the Medical Subject Headings (MeSH) terms: 'Crohn's disease', 'CD', 'inflammatory bowel disease', 'IBD', 'exclusive enteral nutrition', 'enteral nutrition', 'EEN', in PubMed, Scopus, Cochrane. Additional studies were obtained from references of search result articles as well as general reading. Studies with adult patients with CD treated with EEN were selected. 79 articles of relevance were found. Where data in adults were lacking, data from paediatric studies as extrapolated with care. RESULTS EEN in adult patients been shown to improve clinical, biomarker, endoscopic and radiologic measures of disease activity. EEN avoids the potential adverse effects of recurrent corticosteroids for induction such as metabolic derangements and opportunistic infections. EEN has also demonstrated benefits among adult patients with fistulising and stricturing CD. It may avoid surgery in such patients. Preoperative EEN has also been shown to reduce postoperative complications and recurrence. There appears to be benefits in combing EEN with antitumour necrosis factor agents, however, benefits of combination therapy with other biologics are less clear. A major drawback of EEN therapy in adults has been poor compliance. More palatable polymeric formulations improved patient education and dietitian support may overcome this. Evidence in adults is limited to small studies, often with suboptimal control arms and lack of blinding. Larger scale studies with improved study design are needed to confirm these beneficial effects. CONCLUSION Despite limitations in evidence EEN should be considered in treating adults with CD.
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Affiliation(s)
- Nikola Mitrev
- Department of Gastroenterology, Blacktown Hospital, Blacktown, New South Wales, Australia
- Western Sydney University Blacktown Mount Druitt Medical School, Blacktown, New South Wales, Australia
| | - Hin Huang
- Western Sydney University Blacktown Mount Druitt Medical School, Blacktown, New South Wales, Australia
| | - Barbara Hannah
- Department of Gastroenterology, Blacktown Hospital, Blacktown, New South Wales, Australia
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18
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Food and Food Groups in Inflammatory Bowel Disease (IBD): The Design of the Groningen Anti-Inflammatory Diet (GrAID). Nutrients 2021; 13:nu13041067. [PMID: 33806061 PMCID: PMC8064481 DOI: 10.3390/nu13041067] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 12/19/2022] Open
Abstract
Diet plays a pivotal role in the onset and course of inflammatory bowel disease (IBD). Patients are keen to know what to eat to reduce symptoms and flares, but dietary guidelines are lacking. To advice patients, an overview of the current evidence on food (group) level is needed. This narrative review studies the effects of food (groups) on the onset and course of IBD and if not available the effects in healthy subjects or animal and in vitro IBD models. Based on this evidence the Groningen anti-inflammatory diet (GrAID) was designed and compared on food (group) level to other existing IBD diets. Although on several foods conflicting results were found, this review provides patients a good overview. Based on this evidence, the GrAID consists of lean meat, eggs, fish, plain dairy (such as milk, yoghurt, kefir and hard cheeses), fruit, vegetables, legumes, wheat, coffee, tea and honey. Red meat, other dairy products and sugar should be limited. Canned and processed foods, alcohol and sweetened beverages should be avoided. This comprehensive review focuses on anti-inflammatory properties of foods providing IBD patients with the best evidence on which foods they should eat or avoid to reduce flares. This was used to design the GrAID.
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19
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Zheng L, Wen XL. Gut microbiota and inflammatory bowel disease: The current status and perspectives. World J Clin Cases 2021; 9:321-333. [PMID: 33521100 PMCID: PMC7812881 DOI: 10.12998/wjcc.v9.i2.321] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/20/2020] [Accepted: 12/06/2020] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic immune-mediated disease that affects the gastrointestinal tract. It is argued that environment, microbiome, and immune-mediated factors interact in a genetically susceptible host to trigger IBD. Recently, there has been increased interest in the development, progression, and treatment of IBD because of our understanding of the microbiome. Researchers have proved that some factors can alter the microbiome and the pathogenesis of IBD. As a result, there has been increasing interest in the application of probiotics, prebiotics, antibiotics, fecal microbiota transplantation, and gene manipulation in treating IBD because of the possible curative effect of microbiome-modulating interventions. In this review, we summarize the findings from human and animal studies and discuss the effect of the gut microbiome in treating patients with IBD.
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Affiliation(s)
- Lie Zheng
- Department of Gastroenterology, Shaanxi Provincial Hospital of Traditional Chinese Medicine, Xi’an 730000, Shaanxi Province, China
| | - Xin-Li Wen
- Department of Gastroenterology, Shaanxi Provincial Hospital of Traditional Chinese Medicine, Xi’an 730000, Shaanxi Province, China
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20
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Herrador-López M, Martín-Masot R, Navas-López VM. EEN Yesterday and Today … CDED Today and Tomorrow. Nutrients 2020; 12:nu12123793. [PMID: 33322060 PMCID: PMC7764146 DOI: 10.3390/nu12123793] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 12/11/2022] Open
Abstract
The treatment of Pediatric Crohn’s Disease (CD) requires attention both to achieve mucosal healing and to optimize growth, while also maintaining proper bone health. Exclusive Enteral Nutrition (EEN) is recommended as first-line treatment in luminal CD. The therapeutic mechanisms of EEN are being discovered by advances in the study of the gut microbiota. Although the total exclusion of a normal diet during the time of EEN continues to be of high importance, new modalities of dietary treatment suggest a successful future for the nutritional management of CD. In this sense, Crohn’s Disease Exclusion Diet (CDED) is a long-term strategy, it apparently acts on the mechanisms that influence the appearance of inflammation (reducing dietary exposure to products negatively affecting the microbiota), but does so using specific available whole foods to achieve this goal, increases the time of clinical remission and promotes healthy lifestyle habits. The development of CDED, which partly minimizes the problems of EEN, has enabled a turnaround in the treatment of pediatric CD. This review highlights the role of enteral nutrition in the treatment of Crohn’s disease with special emphasis on newer dietary modalities such as CDED.
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21
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de Laffolie J, Schwerd T, Simon A, Pauli M, Broekaert I, Classen M, Posovszky C, Schmidt-Choudhury A. [Crohn's Disease Exclusion Diet - an alternative to exlusive enteral nutritional therapy in children and adolescents with Crohn's disease? Statement of the GPGE working groups CEDATA and Nutrition/Nutrition Medicine]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2020; 58:890-894. [PMID: 32947634 DOI: 10.1055/a-1199-6751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Epidemiological an clinical observations as well as results from animal studies indicate that nutrition can play a role in the development of inflammatory bowel disease (IBD). Exclusive enteral nutrition therapy represents an example for modulating inflammatory responses solely through diet modification. Therefore, caretakers, patients, families, doctors and nutritionists seek for more dietary options to control IBD. These options include partial enteral nutrition therapy as for example the socalled Crohn's disease exclusion diet. The following statement summarizes existing data and provides recommendations for the current management of enteral nutrition therapy in pediatric Crohn's disease.
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Affiliation(s)
- Jan de Laffolie
- Zentrum für Kinderheilkunde, Justus Liebig Universität Gießen, Germany
| | - Tobias Schwerd
- Kindergastroenterologie, Dr. von Haunersches Kinderspital, Kinderklinik und Kinderpoliklinik der Ludwig-Maximilians-Universität München, München, Germany
| | - Annette Simon
- Zentrum für Kinderheilkunde, Justus Liebig Universität Gießen, Germany
| | | | | | | | | | - Anjona Schmidt-Choudhury
- Klinik für Kinder- und Jugendmedizin der Ruhr-Universität Bochum im St. Josef-Hospital, Katholisches Klinikum Bochum, Germany
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22
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Guo D, Yang J, Ling F, Tu L, Li J, Chen Y, Zou K, Zhu L, Hou X. Elemental Diet Enriched with Amino Acids Alleviates Mucosal Inflammatory Response and Prevents Colonic Epithelial Barrier Dysfunction in Mice with DSS-Induced Chronic Colitis. J Immunol Res 2020; 2020:9430763. [PMID: 32855978 PMCID: PMC7443247 DOI: 10.1155/2020/9430763] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/08/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Clinical data suggest that enteral nutrition (EN) effectively decreases disease activity and maintains remission in patients with inflammatory bowel disease (IBD). However, the modulatory effects of EN on the intestinal mucosal immune system remain unclear. AIMS This study first aimed at comparing the therapeutic effects of three EN formulas on ameliorating dextran sulfate sodium- (DSS-) induced chronic colitis; with the most effective formula, we then examined its influence on the mucosal inflammatory response and epithelial barrier function. METHODS The effect of EN formulas on colitis in mice was assessed by body weight, disease activity index scores, colon length, and H&E staining for pathological examination. Colonic and circulating cytokine expression levels and the frequencies of immune cells were also analyzed. Intestinal epithelial barrier function was evaluated by detecting tight junction proteins. RESULTS We found that among the three EN formulas, an elemental diet (ED) containing enriched amino acids restored the colitis-related reduction in body weight better than the other two EN formulas. ED amino acids suppressed the release of colonic proinflammatory mediators and maintained the expression of tight junction proteins in these mice. ED amino acid treatment mitigated the colitis-induced increase in CD103+CD11b+ dendritic cells and CD4+ and CD8+ T cells and inhibited the predominant Th1/Th17 responses particularly in the colonic mucosal lamina propria of mice with colitis. CONCLUSIONS We showed that ED amino acids can be an effective immunomodulatory agent to reduce colitis-related inflammation by inhibiting proinflammatory mediators and Th1/Th17 cell responses and by repairing the disrupted epithelial barrier.
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Affiliation(s)
- Di Guo
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 Hubei, China
| | - Jun Yang
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 Hubei, China
| | - Fangmei Ling
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 Hubei, China
| | - Lei Tu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 Hubei, China
| | - Junrong Li
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 Hubei, China
| | - Yidong Chen
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 Hubei, China
| | - Kaifang Zou
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 Hubei, China
| | - Liangru Zhu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 Hubei, China
| | - Xiaohua Hou
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 Hubei, China
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23
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Glassner KL, Abraham BP, Quigley EMM. The microbiome and inflammatory bowel disease. J Allergy Clin Immunol 2020; 145:16-27. [PMID: 31910984 DOI: 10.1016/j.jaci.2019.11.003] [Citation(s) in RCA: 522] [Impact Index Per Article: 104.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 02/06/2023]
Abstract
Inflammatory bowel disease (IBD) is a chronic immune-mediated disease affecting the gastrointestinal tract. IBD consists of 2 subtypes: ulcerative colitis and Crohn disease. IBD is thought to develop as a result of interactions between environmental, microbial, and immune-mediated factors in a genetically susceptible host. Of late, the potential role of the microbiome in the development, progression, and treatment of IBD has been a subject of considerable interest and enquiry. Indeed, studies in human subjects have shown that the gut microbiome is different in patients with IBD compared with that in healthy control subjects. Other evidence in support of a fundamental role for the microbiome in patients with IBD includes identification of mutations in genes involved in microbiome-immune interactions among patients with IBD and epidemiologic observations implicating such microbiota-modulating risk factors as antibiotic use, cigarette smoking, levels of sanitation, and diet in the pathogenesis of IBD. Consequently, there has been much interest in the possible benefits of microbiome-modulating interventions, such as probiotics, prebiotics, antibiotics, fecal microbiota transplantation, and gene manipulation in the treatment of IBD. In this review we will discuss the role of the gut microbiome in patients with IBD; our focus will be on human studies.
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Affiliation(s)
- Kerri L Glassner
- Fondren IBD Program, Lynda K. and David M. Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Tex.
| | - Bincy P Abraham
- Fondren IBD Program, Lynda K. and David M. Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Tex
| | - Eamonn M M Quigley
- Fondren IBD Program, Lynda K. and David M. Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Tex
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24
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Kucharski MA, Wierzbicka A, Tsibulski A, Sotiri E, Dobrowolska A, Mańkowska-Wierzbicka D. Parenteral and Enteral Nutrition: A Bridge to Healing and Biological Therapy in a Patient With Enterocutaneous Fistula and Sepsis Complicated Crohn's Disease. JPEN J Parenter Enteral Nutr 2020; 45:430-433. [PMID: 32386252 DOI: 10.1002/jpen.1875] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/01/2020] [Indexed: 12/14/2022]
Abstract
Inflammatory bowel disease (IBD) patients with severe infections, abscess, or sepsis are ineligible for standard treatment using biological and immunosuppressive drug regimens. We report a case of complicated Crohn's disease with ruptured abdominal abscess, presence of enterocutaneous fistula, and sepsis. We also report and discuss patient management with parenteral nutrition (PN) and enteral nutrition (EN) and treatment outcomes. We report a case of a 31-year-old female with a 10-year history of IBD in clinical remission, who, after previous total proctocolectomy with J-pouch, presented to the clinic with severe abdominal pain of 2 days, unintentional weight loss, fatigue, fever, and abdominal abscess, which ruptured, and her clinical state became complicated by sepsis. PN was initiated using individually prepared admixture according to patient requirements, because of inability to tolerate any oral intake. Following the remittance of ileus symptoms, EN was added using a semielemental formula via a nasojejunal tube. Upon completion of the treatment, the fistula resolved, the wound had healed, and Crohn's Disease Activity Index score showed remission. This qualified the patient for initiation of biological therapy with infliximab. Patients with severe infections, abscesses, or sepsis are ineligible for standard IBD treatment using biological and immunosuppressive drug regimens. Furthermore, usually patients' nutrition condition prevents them from combating infection and initiating proper healing process. This case demonstrates the importance of considering nutrition therapy-PN and EN-in unstable patients who cannot be treated with standard pharmacological therapy. Nutrition therapy offers a bridge that allows patients to stabilize and heal before starting standard pharmacological treatment with immunosuppressive agents or biological therapy.
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Affiliation(s)
- Marcin A Kucharski
- Department of Gastroenterology, Metabolic Diseases, Internal Medicine and Dietetics, Heliodor Swiecicki Clinical Hospital, Poznan University of Medical Sciences, Poznan, Poland
| | - Adrianna Wierzbicka
- Department of Gastroenterology, Metabolic Diseases, Internal Medicine and Dietetics, Heliodor Swiecicki Clinical Hospital, Poznan University of Medical Sciences, Poznan, Poland
| | - Alexander Tsibulski
- Department of Gastroenterology, Metabolic Diseases, Internal Medicine and Dietetics, Heliodor Swiecicki Clinical Hospital, Poznan University of Medical Sciences, Poznan, Poland
| | - Emianka Sotiri
- Department of Gastroenterology, Metabolic Diseases, Internal Medicine and Dietetics, Heliodor Swiecicki Clinical Hospital, Poznan University of Medical Sciences, Poznan, Poland
| | - Agnieszka Dobrowolska
- Department of Gastroenterology, Metabolic Diseases, Internal Medicine and Dietetics, Heliodor Swiecicki Clinical Hospital, Poznan University of Medical Sciences, Poznan, Poland
| | - Dorota Mańkowska-Wierzbicka
- Department of Gastroenterology, Metabolic Diseases, Internal Medicine and Dietetics, Heliodor Swiecicki Clinical Hospital, Poznan University of Medical Sciences, Poznan, Poland
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25
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Chande N, Costello SP, Limketkai BN, Parker CE, Nguyen TM, Macdonald JK, Feagan BG. Alternative and Complementary Approaches for the Treatment of Inflammatory Bowel Disease: Evidence From Cochrane Reviews. Inflamm Bowel Dis 2020; 26:843-851. [PMID: 31560744 DOI: 10.1093/ibd/izz223] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Indexed: 12/12/2022]
Abstract
The Cochrane IBD Group presented a symposium at Digestive Diseases Week 2018 entitled “Alternative and Complementary Approaches for the Treatment of IBD: Evidence from Cochrane Reviews.” This article summarizes the data presented at this symposium.
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Affiliation(s)
- Nilesh Chande
- Division of Gastroenterology, Department of Medicine, University of Western Ontario, London, Ontario, Canada.,Cochrane IBD Group, University of Western Ontario, London, Ontario, Canada
| | - Samuel P Costello
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Berkeley N Limketkai
- Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, California, USA
| | | | - Tran M Nguyen
- Robarts Clinical Trials Inc. London, Ontario, Canada
| | - John K Macdonald
- Division of Gastroenterology, Department of Medicine, University of Western Ontario, London, Ontario, Canada.,Cochrane IBD Group, University of Western Ontario, London, Ontario, Canada
| | - Brian G Feagan
- Division of Gastroenterology, Department of Medicine, University of Western Ontario, London, Ontario, Canada.,Cochrane IBD Group, University of Western Ontario, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
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26
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Levine A, Rhodes JM, Lindsay JO, Abreu MT, Kamm MA, Gibson PR, Gasche C, Silverberg MS, Mahadevan U, Boneh RS, Wine E, Damas OM, Syme G, Trakman GL, Yao CK, Stockhamer S, Hammami MB, Garces LC, Rogler G, Koutroubakis IE, Ananthakrishnan AN, McKeever L, Lewis JD. Dietary Guidance From the International Organization for the Study of Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2020; 18:1381-1392. [PMID: 32068150 DOI: 10.1016/j.cgh.2020.01.046] [Citation(s) in RCA: 179] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 12/21/2019] [Accepted: 01/24/2020] [Indexed: 02/07/2023]
Abstract
Recent evidence points to a plausible role of diet and the microbiome in the pathogenesis of both Crohn's disease (CD) and Ulcerative Colitis (UC). Dietary therapies based on exclusion of table foods and replacement with nutritional formulas and/or a combination of nutritional formulas and specific table foods may induce remission in CD. In UC, specific dietary components have also been associated with flare of disease. While evidence of varying quality has identified potential harmful or beneficial dietary components, physicians and patients at the present time do not have guidance as to which foods are safe, may be protective or deleterious for these diseases. The current document has been compiled by the nutrition cluster of the International Organization for the Study of Inflammatory Bowel Diseases (IOIBD) based on the best current evidence to provide expert opinion regarding specific dietary components, food groups and food additives that may be prudent to increase or decrease in the diet of patients with inflammatory bowel diseases to control and prevent relapse of inflammatory bowel diseases.
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Affiliation(s)
- Arie Levine
- Pediatric IBD Center, Wolfson Medical Center Holon, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan M Rhodes
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - James O Lindsay
- Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Maria T Abreu
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Michael A Kamm
- St Vincent's Hospital and University of Melbourne, Melbourne, Australia
| | - Peter R Gibson
- Monash University and Alfred Health, Melbourne, Australia
| | | | - Mark S Silverberg
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Uma Mahadevan
- University of California, San Francisco, San Francisco, California
| | - Rotem Sigall Boneh
- Pediatric IBD Center, Wolfson Medical Center Holon, Tel Aviv University, Tel Aviv, Israel
| | - Eyton Wine
- Department of Pediatrics, University of Alberta, Alberta, Canada; Department of Physiology, University of Alberta, Alberta, Canada
| | - Oriana M Damas
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Graeme Syme
- The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Gina L Trakman
- St Vincent's Hospital and University of Melbourne, Melbourne, Australia
| | - Chu Kion Yao
- Monash University and Alfred Health, Melbourne, Australia
| | - Stefanie Stockhamer
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | | | - Luis C Garces
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | | | | | | | - Liam McKeever
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Lewis
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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27
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Comeche JM, Caballero P, Gutierrez-Hervas A, García-Sanjuan S, Comino I, Altavilla C, Tuells J. Enteral Nutrition in Patients with Inflammatory Bowel Disease. Systematic Review, Meta-Analysis, and Meta-Regression. Nutrients 2019; 11:nu11112657. [PMID: 31689999 PMCID: PMC6893586 DOI: 10.3390/nu11112657] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/23/2019] [Accepted: 10/25/2019] [Indexed: 02/07/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic disease mediated by the immune system and is characterized by inflammation of the gastrointestinal tract. One of the possible treatments for this pathology is a change in the type of diet, of which enteral nutrition (EN) is one. This study is to understand how the use of EN can affect the adult population diagnosed with IBD. We conducted a systematic review, meta-analysis, and a meta-regression. On the different databases (MEDLINE, Scopus, Cochrane, LILACS, CINAHL, WOS), we found 363 registers with an accuracy of 12% (44 registers). After a full-text review, only 30 research studies were selected for qualitative synthesis and 11 for meta-analysis and meta-regression. The variables used were Crohn's disease activity index (CDAI), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). EN has been shown to have efficacy for the treatment of Crohn's disease and is compatible with other medicines. As for the CDAI or rates of remission, there were no differences between enteral and parenteral nutrition. Polymeric formulas have shown better results with respect to the CRP. The long-term treatment could dilute the good CDAI results that are obtained at the start of the EN treatment.
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Affiliation(s)
- Jose M Comeche
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Pablo Caballero
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Ana Gutierrez-Hervas
- Department of Nursing (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Sofia García-Sanjuan
- Department of Nursing (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Iris Comino
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Cesare Altavilla
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Jose Tuells
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
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28
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Mańkowska-Wierzbicka D, Karczewski J, Swora-Cwynar E, Dobrowolska A, Stelmach-Mardas M. The Clinical Importance of 21-Day Combined Parenteral and Enteral Nutrition in Active Inflammatory Bowel Disease Patients. Nutrients 2019; 11:E2246. [PMID: 31540473 PMCID: PMC6770879 DOI: 10.3390/nu11092246] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 12/13/2022] Open
Abstract
The aim of the study was to show the clinical magnitude of short-term feeding: enteral nutrition (EN) combined with parenteral nutrition (PN) in active Crohn's disease and ulcerative colitis patients. Among 122 eligible inflammatory bowel disease (IBD) patients, 65 met the inclusion criteria. Combined EN and PN was administered for 21 days, wherein over the first 3-5 days of treatment, trophic enteral nutrition (300 kcal/day) was used with an energy increase of up to 1500 kcal. An EN was administered using a nasogastric tube or, in case of intolerance, using a naso-jejunal tube. For PN, the "All in One" system was used according to individually prepared admixtures (ESPEN Guidelines). In addition to routine blood measurement (i.e., ALAT, ASPAT, GGTP, creatinine, lipid profile), the following parameters were assessed: adiponectin, leptin, (hs)TNF-α, hsIL-6 and hsIL-10, TSH, NT-proBNP, serum vitamin B12 concentration, and tHcy. The results showed a considerable improvement in all clinically significant parameters (p < 0.05), showing the benefits and importance of short-term well-balanced EN combined with PN for nutritional and clinical status in IBD patients with active disease. The daily work at hospitals with active IBD patients demonstrates the potential of continued administration of home-based nutrition by patients.
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Affiliation(s)
- Dorota Mańkowska-Wierzbicka
- Department of Gastroenterology, Metabolic Diseases, Internal Medicine and Dietetics, Poznan University of Medical Sciences, Poznan 60-355, Poland.
| | - Jacek Karczewski
- Department of Gastroenterology, Metabolic Diseases, Internal Medicine and Dietetics, Poznan University of Medical Sciences, Poznan 60-355, Poland.
- Department of Environmental Medicine, Poznan University of Medical Sciences, Poznan 60-806, Poland.
| | - Ewelina Swora-Cwynar
- Department of Gastroenterology, Metabolic Diseases, Internal Medicine and Dietetics, Poznan University of Medical Sciences, Poznan 60-355, Poland.
| | - Agnieszka Dobrowolska
- Department of Gastroenterology, Metabolic Diseases, Internal Medicine and Dietetics, Poznan University of Medical Sciences, Poznan 60-355, Poland.
| | - Marta Stelmach-Mardas
- Department of Biophysics, Poznan University of Medical Sciences, Poznan 60-780, Poland.
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29
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Di Caro S, Fragkos KC, Keetarut K, Koo HF, Sebepos-Rogers G, Saravanapavan H, Barragry J, Rogers J, Mehta SJ, Rahman F. Enteral Nutrition in Adult Crohn's Disease: Toward a Paradigm Shift. Nutrients 2019; 11:E2222. [PMID: 31540038 PMCID: PMC6770416 DOI: 10.3390/nu11092222] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/05/2019] [Accepted: 09/08/2019] [Indexed: 02/06/2023] Open
Abstract
Medical and surgical treatments for Crohn's disease are associated with toxic effects. Medical therapy aims for mucosal healing and is achievable with biologics, immunosuppressive therapy, and specialised enteral nutrition, but not with corticosteroids. Sustained remission remains a therapeutic challenge. Enteral nutrition, containing macro- and micro-nutrients, is nutritionally complete, and is provided in powder or liquid form. Enteral nutrition is a low-risk and minimally invasive therapy. It is well-established and recommended as first line induction therapy in paediatric Crohn's disease with remission rates of up to 80%. Other than in Japan, enteral nutrition is not routinely used in the adult population among Western countries, mainly due to unpalatable formulations which lead to poor compliance. This study aims to offer a comprehensive review of available enteral nutrition formulations and the literature supporting the use and mechanisms of action of enteral nutrition in adult Crohn's disease patients, in order to support clinicians in real world decision-making when offering/accepting treatment. The mechanisms of actions of enteral feed, including their impact on the gut microbiome, were explored. Barriers to the use of enteral nutrition, such as compliance and the route of administration, were considered. All available enteral preparations have been comprehensively described as a practical guide for clinical use. Likewise, guidelines are reported and discussed.
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Affiliation(s)
- Simona Di Caro
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Konstantinos C Fragkos
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Katie Keetarut
- Department of Dietetics, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Hui Fen Koo
- UCL Medical School, 74 Huntley Street, Bloomsbury, London WC1E 6DE, UK.
| | - Gregory Sebepos-Rogers
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Hajeena Saravanapavan
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - John Barragry
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Jennifer Rogers
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Shameer J Mehta
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Farooq Rahman
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
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30
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Mack DR, Benchimol EI, Critch J, deBruyn J, Tse F, Moayyedi P, Church P, Deslandres C, El-Matary W, Huynh H, Jantchou P, Lawrence S, Otley A, Sherlock M, Walters T, Kappelman MD, Sadowski D, Marshall JK, Griffiths A. Canadian Association of Gastroenterology Clinical Practice Guideline for the Medical Management of Pediatric Luminal Crohn's Disease. J Can Assoc Gastroenterol 2019; 2:e35-e63. [PMID: 31294379 PMCID: PMC6619414 DOI: 10.1093/jcag/gwz018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND & AIMS We aim to provide guidance for medical treatment of luminal Crohn's disease in children. METHODS We performed a systematic search of publication databases to identify studies of medical management of pediatric Crohn's disease. Quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. We developed statements through an iterative online platform and then finalized and voted on them. RESULTS The consensus includes 25 statements focused on medical treatment options. Consensus was not reached, and no recommendations were made, for 14 additional statements, largely due to lack of evidence. The group suggested corticosteroid therapies (including budesonide for mild to moderate disease). The group suggested exclusive enteral nutrition for induction therapy and biologic tumor necrosis factor antagonists for induction and maintenance therapy at diagnosis or at early stages of severe disease, and for patients failed by steroid and immunosuppressant induction therapies. The group recommended against the use of oral 5-aminosalicylate for induction or maintenance therapy in patients with moderate disease, and recommended against thiopurines for induction therapy, corticosteroids for maintenance therapy, and cannabis in any role. The group was unable to clearly define the role of concomitant immunosuppressants during initiation therapy with a biologic agent, although thiopurine combinations are not recommended for male patients. No consensus was reached on the role of aminosalicylates in treatment of patients with mild disease, antibiotics or vedolizumab for induction or maintenance therapy, or methotrexate for induction therapy. Patients in clinical remission who are receiving immunomodulators should be assessed for mucosal healing within 1 year of treatment initiation. CONCLUSIONS Evidence-based medical treatment of Crohn's disease in children is recommended, with thorough ongoing assessments to define treatment success.
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Affiliation(s)
- David R Mack
- Children's Hospital of Eastern Ontario Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
| | - Eric I Benchimol
- Children's Hospital of Eastern Ontario Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Jeff Critch
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Faculty of Medicine, Memorial University, St John's, Newfoundland and Labrador, Canada
| | - Jennifer deBruyn
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Section of Pediatric Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Frances Tse
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Paul Moayyedi
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Peter Church
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- IBD Centre, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Colette Deslandres
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Centre Hospitalier Universitaire, Sainte-Justine, Montréal, Quebec, Canada
| | - Wael El-Matary
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Section of Pediatric Gastroenterology, Department of Pediatrics, Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - Hien Huynh
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Department of Pediatrics (Gastroenterology), Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Prévost Jantchou
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Centre Hospitalier Universitaire, Sainte-Justine, Montréal, Quebec, Canada
| | - Sally Lawrence
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anthony Otley
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Division of Gastroenterology and Nutrition, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Mary Sherlock
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- Division of Pediatric Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Thomas Walters
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- IBD Centre, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, University of North Carolina, Hospital-Children's Specialty Clinic, Chapel Hill, North Carolina
| | - Dan Sadowski
- Division of Gastroenterology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - John K Marshall
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Anne Griffiths
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
- IBD Centre, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
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31
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Mack DR, Benchimol EI, Critch J, deBruyn J, Tse F, Moayyedi P, Church P, Deslandres C, El-Matary W, Huynh H, Jantchou P, Lawrence S, Otley A, Sherlock M, Walters T, Kappelman MD, Sadowski D, Marshall JK, Griffiths A. Canadian Association of Gastroenterology Clinical Practice Guideline for the Medical Management of Pediatric Luminal Crohn's Disease. Gastroenterology 2019; 157:320-348. [PMID: 31320109 DOI: 10.1053/j.gastro.2019.03.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/28/2019] [Accepted: 03/02/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS We aim to provide guidance for medical treatment of luminal Crohn's disease in children. METHODS We performed a systematic search of publication databases to identify studies of medical management of pediatric Crohn's disease. Quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. We developed statements through an iterative online platform and then finalized and voted on them. RESULTS The consensus includes 25 statements focused on medical treatment options. Consensus was not reached, and no recommendations were made, for 14 additional statements, largely due to lack of evidence. The group suggested corticosteroid therapies (including budesonide for mild to moderate disease). The group suggested exclusive enteral nutrition for induction therapy and biologic tumor necrosis factor antagonists for induction and maintenance therapy at diagnosis or at early stages of severe disease, and for patients failed by steroid and immunosuppressant induction therapies. The group recommended against the use of oral 5-aminosalicylate for induction or maintenance therapy in patients with moderate disease, and recommended against thiopurines for induction therapy, corticosteroids for maintenance therapy, and cannabis in any role. The group was unable to clearly define the role of concomitant immunosuppressants during initiation therapy with a biologic agent, although thiopurine combinations are not recommended for male patients. No consensus was reached on the role of aminosalicylates in treatment of patients with mild disease, antibiotics or vedolizumab for induction or maintenance therapy, or methotrexate for induction therapy. Patients in clinical remission who are receiving immunomodulators should be assessed for mucosal healing within 1 year of treatment initiation. CONCLUSIONS Evidence-based medical treatment of Crohn's disease in children is recommended, with thorough ongoing assessments to define treatment success.
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Affiliation(s)
- David R Mack
- Children's Hospital of Eastern Ontario Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada; Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada
| | - Eric I Benchimol
- Children's Hospital of Eastern Ontario Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada; Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Jeff Critch
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Faculty of Medicine, Memorial University, St John's, Newfoundland and Labrador, Canada
| | - Jennifer deBruyn
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Section of Pediatric Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Frances Tse
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Paul Moayyedi
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Peter Church
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; IBD Centre, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Colette Deslandres
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Centre Hospitalier Universitaire, Sainte-Justine, Montréal, Quebec, Canada
| | - Wael El-Matary
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Section of Pediatric Gastroenterology, Department of Pediatrics, Health Sciences Centre, Winnipeg, Manitoba, Canada
| | - Hien Huynh
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Department of Pediatrics (Gastroenterology), Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Prévost Jantchou
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Centre Hospitalier Universitaire, Sainte-Justine, Montréal, Quebec, Canada
| | - Sally Lawrence
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anthony Otley
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Division of Gastroenterology and Nutrition, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Mary Sherlock
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; Division of Pediatric Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Thomas Walters
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; IBD Centre, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, University of North Carolina, Hospital-Children's Specialty Clinic, Chapel Hill, North Carolina
| | - Dan Sadowski
- Division of Gastroenterology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - John K Marshall
- Division of Gastroenterology and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Anne Griffiths
- Ch.I.L.D. Foundation Canadian Children IBD Network, Vancouver, British Columbia, Canada; IBD Centre, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada.
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32
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Chen JM, He LW, Yan T, Guo XF, Hu PJ, Peng JS, Cheng WJ, Li LL, He Q. Oral exclusive enteral nutrition induces mucosal and transmural healing in patients with Crohn's disease. Gastroenterol Rep (Oxf) 2019; 7:176-184. [PMID: 31217981 PMCID: PMC6573804 DOI: 10.1093/gastro/goy050] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/16/2018] [Accepted: 12/05/2018] [Indexed: 12/21/2022] Open
Abstract
Background and aims Mucosal healing is regarded as a clinical endpoint of Crohn’s disease (CD), and transmural healing is correlated to the concept of deep remission. Current therapies to induce mucosal and transmural healing in CD are not satisfactory. Exclusive enteral nutrition (EEN) is underestimated therapy and its value has not been fully evaluated. Our aim was to investigate the efficacy of oral EEN for inducing mucosal and transmural healing in CD patients. Methods This was a prospective, single-center, open-label study including diagnosed CD children and adults conducted between January 2015 and December 2016 in the Sixth Affiliated Hospital of Sun Yat-sen University. All patients were treated with oral EEN and underwent paired assessment at baseline and completion using C-reaction protein, erythrocyte sedimentation rate, platelets, hemoglobin, body mass index, CD activity index, simple endoscopic score for CD and bowel sonography. Azathioprine was combined to prevent relapse. Results In this prospective observational study, 29 CD patients with an average age of 28.9 years were identified. After oral EEN treatment, 23 patients (79%) achieved complete mucosal healing, and the mean time to reach mucosal healing was 123 days (ranged from 50 to 212 days). Although only five patients (17%) achieved transmural healing, a significant reduction was observed in bowel-wall thickness (9.41 ± 3.06 vs 4.97 ± 1.76 mm, P < 0.001) and a significant improvement was observed in complications (including fistulas, abscess, ascites, stricture) assessed by bowel sonography (all P < 0.05). Conclusions Oral EEN therapy is highly effective for inducing mucosal healing in CD patients. Both CD patients at active stage and those at clinical remission show excellent clinical response to oral EEN.
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Affiliation(s)
- Jia-Min Chen
- Department of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| | - Li-Wen He
- Department of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| | - Ting Yan
- Department of Clinical Nutrition, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| | - Xue-Feng Guo
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| | - Pin-Jin Hu
- Department of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| | - Jun-Sheng Peng
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| | - Wen-Jie Cheng
- Department of Medical Ultrasound, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| | - Ling-Ling Li
- Department of Clinical Nutrition, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| | - Qing He
- Department of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China.,Department of Clinical Nutrition, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
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Stoner PL, Kamel A, Ayoub F, Tan S, Iqbal A, Glover SC, Zimmermann EM. Perioperative Care of Patients with Inflammatory Bowel Disease: Focus on Nutritional Support. Gastroenterol Res Pract 2018; 2018:7890161. [PMID: 30344603 PMCID: PMC6174741 DOI: 10.1155/2018/7890161] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/28/2018] [Indexed: 12/16/2022] Open
Abstract
Patients with inflammatory bowel disease (IBD) commonly require surgery despite the availability of an increasingly large repertoire of powerful immunosuppressive medications for the treatment of IBD. Optimizing patients' care preoperatively is crucial to obtaining good surgical outcomes. This review discusses preoperative assessment and management principles including assessing disease location and activity with cross-sectional or endoscopic imaging, addressing modifiable risk factors (i.e., stopping smoking, weaning steroids, and correcting anemia), and properly managing medications. The major focus of our literature review is the evaluation for malnutrition, a common finding that affects up to 70% of patients with IBD and a well-known, independent risk factor for adverse postoperative outcomes. Our review confirms that whenever feasible, oral or enteral nutrition (EN) is the preferred method of nutritional support; parenteral nutrition (PN) should be reserved for nutritionally deficient IBD patients unable to tolerate EN. In selected patients, recent data demonstrated that the use of preoperative PN resulted in improved nutritional status, fewer postoperative complications, and reduced disease severity. Our review highlights the need for well-designed, prospective trials investigating perioperative nutritional support in patients with IBD. Future studies should perform modern nutritional assessment, standardize for diet, and include patients with UC since this subset of patients is underrepresented in existing studies. In addition, relevant outcome of interest specific to Crohn's disease (CD) patients such as length of small bowel resected, number of anastomoses, and need for an ostomy should be included as these patients may require repeated small bowel resections.
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Affiliation(s)
- Patrick L. Stoner
- Department of Medicine, Division of Gastroenterology, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Amir Kamel
- Department of Pharmacotherapy, College of Pharmacy, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Fares Ayoub
- Department of Medicine, Division of Gastroenterology, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Sanda Tan
- Department of Surgery, Division of Colorectal Surgery, College of Medicine, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Atif Iqbal
- Department of Surgery, Division of Colorectal Surgery, College of Medicine, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Sarah C. Glover
- Department of Medicine, Division of Gastroenterology, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Ellen M. Zimmermann
- Department of Medicine, Division of Gastroenterology, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
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Levine A, Sigall Boneh R, Wine E. Evolving role of diet in the pathogenesis and treatment of inflammatory bowel diseases. Gut 2018; 67:1726-1738. [PMID: 29777041 DOI: 10.1136/gutjnl-2017-315866] [Citation(s) in RCA: 250] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/16/2018] [Accepted: 04/17/2018] [Indexed: 12/12/2022]
Abstract
Recent advances in basic and clinical science over the last 3 years have dramatically altered our appreciation of the role of diet in inflammatory bowel diseases (IBD). The marked increase in incidence of these diseases along with the important role of non-genetic susceptibility among patients with IBD has highlighted that these diseases have a strong environmental component. Progress in the field of microbiome and IBD has demonstrated that microbiome appears to play an important role in pathogenesis, and that diet may in turn impact the composition and functionality of the microbiome. Uncontrolled clinical studies have demonstrated that various dietary therapies such as exclusive enteral nutrition and newly developed exclusion diets might be potent tools for induction of remission at disease onset, for patients failing biologic therapy, as a treatment for disease complications and in reducing the need for surgery. We review these advances from bench to bedside, along with the need for better clinical trials to support these interventions.
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Affiliation(s)
- Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, Edith Wolfson Medical Center, Holon, Israel.,Tel Aviv University, Tel Aviv, Israel
| | - Rotem Sigall Boneh
- Pediatric Gastroenterology and Nutrition Unit, Edith Wolfson Medical Center, Holon, Israel.,Tel Aviv University, Tel Aviv, Israel
| | - Eytan Wine
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Miele E, Shamir R, Aloi M, Assa A, Braegger C, Bronsky J, de Ridder L, Escher JC, Hojsak I, Kolaček S, Koletzko S, Levine A, Lionetti P, Martinelli M, Ruemmele F, Russell RK, Boneh RS, van Limbergen J, Veereman G, Staiano A. Nutrition in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto Inflammatory Bowel Disease Group of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 66:687-708. [PMID: 29570147 DOI: 10.1097/mpg.0000000000001896] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS A growing body of evidence supports the need for detailed attention to nutrition and diet in children with inflammatory bowel disease (IBD). We aimed to define the steps in instituting dietary or nutritional management in light of the current evidence and to offer a useful and practical guide to physicians and dieticians involved in the care of pediatric IBD patients. METHODS A group of 20 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to Nutrition Committee of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition Porto, IBD Interest, and Nutrition Committee. A list of 41 predefined questions was addressed by working subgroups based on a systematic review of the literature. RESULTS A total of 53 formal recommendations and 47 practice points were endorsed with a consensus rate of at least 80% on the following topics: nutritional assessment; macronutrients needs; trace elements, minerals, and vitamins; nutrition as a primary therapy of pediatric IBD; probiotics and prebiotics; specific dietary restrictions; and dietary compounds and the risk of IBD. CONCLUSIONS This position paper represents a useful guide to help the clinicians in the management of nutrition issues in children with IBD.
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Affiliation(s)
- Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II," Naples, Italy
| | - Raanan Shamir
- Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Amit Assa
- Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Christian Braegger
- Division of Gastroenterology and Nutrition, University Children's Hospital Zurich, Zurich, Switzerland
| | - Jiri Bronsky
- Gastroenterology and Nutrition Unit, Department of Paediatrics, 2nd Faculty of Medicine, Charles, University and Motol University Hospital, Prague, Czech Republic
| | - Lissy de Ridder
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Johanna C Escher
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Iva Hojsak
- Department of Gastroenterology, Children Hospital Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Sanja Kolaček
- Department of Gastroenterology, Children Hospital Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Sibylle Koletzko
- Dr. von Hauner Children's Hospital, Ludwig Maximilians University, Munich, Germany
| | - Arie Levine
- Wolfson Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Paolo Lionetti
- Meyer Children Hospital, University of Florence, Florence, Italy
| | - Massimo Martinelli
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II," Naples, Italy
| | - Frank Ruemmele
- Université Sorbonne Paris Cité, Université Paris Descartes, and Assistance publique-hôpitaux de Paris, Hôpital Necker-Enfants malades, Service de gastroentérologie pédiatrique, Paris, France
| | - Richard K Russell
- Department of Paediatric Gastroenterology, The Royal Hospital for Children, Glasgow, Scotland
| | | | - Johan van Limbergen
- Department of Pediatrics, Division of Pediatric Gastroenterology & Nutrition, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Gigi Veereman
- Department of Paediatric Gastroenterology and Nutrition, University Hospital Brussels, Free University Brussels, Brussels, Belgium
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II," Naples, Italy
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Narula N, Dhillon A, Zhang D, Sherlock ME, Tondeur M, Zachos M. Enteral nutritional therapy for induction of remission in Crohn's disease. Cochrane Database Syst Rev 2018; 4:CD000542. [PMID: 29607496 PMCID: PMC6494406 DOI: 10.1002/14651858.cd000542.pub3] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Corticosteroids are often preferred over enteral nutrition (EN) as induction therapy for Crohn's disease (CD). Prior meta-analyses suggest that corticosteroids are superior to EN for induction of remission in CD. Treatment failures in EN trials are often due to poor compliance, with dropouts frequently due to poor acceptance of a nasogastric tube and unpalatable formulations. This systematic review is an update of a previously published Cochrane review. OBJECTIVES To evaluate the effectiveness and safety of exclusive EN as primary therapy to induce remission in CD and to examine the importance of formula composition on effectiveness. SEARCH METHODS We searched MEDLINE, Embase and CENTRAL from inception to 5 July 2017. We also searched references of retrieved articles and conference abstracts. SELECTION CRITERIA Randomized controlled trials involving patients with active CD were considered for inclusion. Studies comparing one type of EN to another type of EN or conventional corticosteroids were selected for review. DATA COLLECTION AND ANALYSIS Data were extracted independently by at least two authors. The primary outcome was clinical remission. Secondary outcomes included adverse events, serious adverse events and withdrawal due to adverse events. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (CI). A random-effects model was used to pool data. We performed intention-to-treat and per-protocol analyses for the primary outcome. Heterogeneity was explored using the Chi2 and I2 statistics. The studies were separated into two comparisons: one EN formulation compared to another EN formulation and EN compared to corticosteroids. Subgroup analyses were based on formula composition and age. Sensitivity analyses included abstract publications and poor quality studies. We used the Cochrane risk of bias tool to assess study quality. We used the GRADE criteria to assess the overall quality of the evidence supporting the primary outcome and selected secondary outcomes. MAIN RESULTS Twenty-seven studies (1,011 participants) were included. Three studies were rated as low risk of bias. Seven studies were rated as high risk of bias and 17 were rated as unclear risk of bias due to insufficient information. Seventeen trials compared different formulations of EN, 13 studies compared one or more elemental formulas to a non-elemental formula, three studies compared EN diets of similar protein composition but different fat composition, and one study compared non-elemental diets differing in glutamine enrichment. Meta-analysis of 11 trials (378 participants) demonstrated no difference in remission rates. Sixty-four per cent (134/210) of patients in the elemental group achieved remission compared to 62% (105/168) of patients in the non-elemental group (RR 1.02, 95% CI 0.88 to 1.18; GRADE very low quality). A per-protocol analysis (346 participants) produced similar results (RR 1.04, 95% CI 0.91 to 1.18). Subgroup analyses performed to evaluate the different types of elemental and non-elemental diets (elemental, semi-elemental and polymeric) showed no differences in remission rates. An analysis of 7 trials including 209 patients treated with EN formulas of differing fat content (low fat: < 20 g/1000 kCal versus high fat: > 20 g/1000 kCal) demonstrated no difference in remission rates (RR 1.03; 95% CI 0.85 to 1.26). Very low fat content (< 3 g/1000 kCal) and very low long chain triglycerides demonstrated higher remission rates than higher content EN formulas. There was no difference between elemental and non-elemental diets in adverse event rates (RR 1.00, 95% CI 0.63 to 1.60; GRADE very low quality), or withdrawals due to adverse events (RR 1.29, 95% CI 0.80 to 2.09; GRADE very low quality). Common adverse events included nausea, vomiting, diarrhea and bloating.Ten trials compared EN to steroid therapy. Meta-analysis of eight trials (223 participants) demonstrated no difference in remission rates between EN and steroids. Fifty per cent (111/223) of patients in the EN group achieved remission compared to 72% (133/186) of patients in the steroid group (RR 0.77, 95% CI 0.58 to 1.03; GRADE very low quality). Subgroup analysis by age showed a difference in remission rates for adults but not for children. In adults 45% (87/194) of EN patients achieved remission compared to 73% (116/158) of steroid patients (RR 0.65, 95% CI 0.52 to 0.82; GRADE very low quality). In children, 83% (24/29) of EN patients achieved remission compared to 61% (17/28) of steroid patients (RR 1.35, 95% CI 0.92 to 1.97; GRADE very low quality). A per-protocol analysis produced similar results (RR 0.93, 95% CI 0.75 to 1.14). The per-protocol subgroup analysis showed a difference in remission rates for both adults (RR 0.82, 95% CI 0.70 to 0.95) and children (RR 1.43, 95% CI 1.03 to 1.97). There was no difference in adverse event rates (RR 1.39, 95% CI 0.62 to 3.11; GRADE very low quality). However, patients on EN were more likely to withdraw due to adverse events than those on steroid therapy (RR 2.95, 95% CI 1.02 to 8.48; GRADE very low quality). Common adverse events reported in the EN group included heartburn, flatulence, diarrhea and vomiting, and for steroid therapy acne, moon facies, hyperglycemia, muscle weakness and hypoglycemia. The most common reason for withdrawal was inability to tolerate the EN diet. AUTHORS' CONCLUSIONS Very low quality evidence suggests that corticosteroid therapy may be more effective than EN for induction of clinical remission in adults with active CD. Very low quality evidence also suggests that EN may be more effective than steroids for induction of remission in children with active CD. Protein composition does not appear to influence the effectiveness of EN for the treatment of active CD. EN should be considered in pediatric CD patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient adherence with this therapy.
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Affiliation(s)
- Neeraj Narula
- McMaster UniversityDivision of Gastroenterology1280 Main Street WestHamiltonONCanadaL8S 4K1
| | - Amit Dhillon
- Northern Ontario School of MedicineDepartment of Internal MedicineSudburyONCanada
| | - Dongni Zhang
- University of Western OntarioSchulich School of Medicine & DentistryLondonONCanada
| | - Mary E Sherlock
- McMaster Children's HospitalDivision of Gastroenterology & NutritionHamilton Health Sciences1280 Main Street WestHamiltonONCanada
| | - Melody Tondeur
- The Hospital for Sick ChildrenCentre for Global Child Health525 University AveTorontoONCanadaM5G 2L3
| | - Mary Zachos
- McMaster Children’s HospitalDivision of Gastroenterology & Nutrition1280 Main St. WestHamiltonONCanadaL8S 4K1
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Ajabnoor SM, Forbes A. Effect of fat composition in enteral nutrition for Crohn's disease in adults: A systematic review. Clin Nutr 2017; 38:90-99. [PMID: 29310893 DOI: 10.1016/j.clnu.2017.12.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 11/10/2017] [Accepted: 12/20/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND & AIMS The role of enteral nutrition (EN) fat composition in regulating inflammation in Crohn's disease (CD) is not clear. There is, moreover, insufficient evidence to guide the choice of EN in CD with any confidence. We have reanalysed the findings of previous studies in a systematic review focussing on the relationship between EN fat content and remission rates (RR). METHODS A systematic search with no language restriction was undertaken in Medline and Embase databases supplemented by a manual search in the reference lists of identified studies. The selection criteria were: clinical trial, exclusive EN, adults and CD. Data on the type of EN, its fat composition, achieved RR, and study design were extracted. An established assessment tool was used to assess the quality of the studies. RESULTS A total of 29 clinical trials are included in this review. The quality of the studies was highly variable. No fewer than 27 formulations of enteral feed were identified including 4 elemental and 23 non-elemental preparations. There was a positive correlation between the total n-6 fatty acid content and response rates, which was significant when expressed as the ratio between n-6 and n-3 fatty acids (r = 0.378, p = 0.018). A non-significant positive trend was founded (r = 0.072; p = 0.643) between medium chain triglycerides (MCT) delivery as a percentage of the total energy provision and RR. While a non-significant negative trend was reported for the delivery of monounsaturated fatty acids (MUFA) (r = -0.23, p = 0.13). A qualitative advantage to regimens based on safflower oil suggest that optimised therapeutic approaches are within reach.
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Affiliation(s)
- Sarah M Ajabnoor
- Norwich Medical School, University of East Anglia, Norwich Research Park, UK; Clinical Nutrition Department, Faculty of Applied Medical Sciences, King Abdulaziz University, Saudi Arabia
| | - Alastair Forbes
- Norwich Medical School, University of East Anglia, Norwich Research Park, UK.
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Vasudevan A, Gibson PR, Langenberg DRV. Time to clinical response and remission for therapeutics in inflammatory bowel diseases: What should the clinician expect, what should patients be told? World J Gastroenterol 2017; 23:6385-6402. [PMID: 29085188 PMCID: PMC5643264 DOI: 10.3748/wjg.v23.i35.6385] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/03/2017] [Accepted: 08/15/2017] [Indexed: 02/06/2023] Open
Abstract
An awareness of the expected time for therapies to induce symptomatic improvement and remission is necessary for determining the timing of follow-up, disease (re)assessment, and the duration to persist with therapies, yet this is seldom reported as an outcome in clinical trials. In this review, we explore the time to clinical response and remission of current therapies for inflammatory bowel disease (IBD) as well as medication, patient and disease related factors that may influence the time to clinical response. It appears that the time to therapeutic response varies depending on the indication for therapy (Crohn's disease or ulcerative colitis). Agents with the most rapid time to clinical response included corticosteroids, calcineurin inhibitors, exclusive enteral nutrition, aminosalicylates and anti-tumor necrosis factor therapy which will work in most patients within the first 2 mo. Vedolizumab, methotrexate and thiopurines had a longer time to clinical response and can take several months to achieve maximal efficacy. Factors affecting the time to clinical response of therapies included use of concomitant therapy, disease duration, smoking status, disease phenotype and advanced age. There appears to be marked variation in time to clinical response for therapies used in IBD which is further influenced by disease and patient related factors. Understanding the expected time to therapeutic response is integral to inform further decision making, maintain a patient-centered approach and ensure treatment is given an appropriate timeframe to achieve maximal benefit prior to cessation.
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Affiliation(s)
- Abhinav Vasudevan
- Department of Gastroenterology and Hepatology, Eastern Health, Box Hill Hospital, Box Hill, Victoria 3128, Australia
- Monash University, Eastern Health Clinical School, Box Hill, Victoria 3128, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Health and Monash University, Victoria 3004, Australia
| | - Daniel R van Langenberg
- Department of Gastroenterology and Hepatology, Eastern Health, Box Hill Hospital, Box Hill, Victoria 3128, Australia
- Monash University, Eastern Health Clinical School, Box Hill, Victoria 3128, Australia
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Heerasing N, Thompson B, Hendy P, Heap GA, Walker G, Bethune R, Mansfield S, Calvert C, Kennedy NA, Ahmad T, Goodhand JR. Exclusive enteral nutrition provides an effective bridge to safer interval elective surgery for adults with Crohn's disease. Aliment Pharmacol Ther 2017; 45:660-669. [PMID: 28105752 DOI: 10.1111/apt.13934] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 11/20/2016] [Accepted: 12/18/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Few studies have reported the systematic use of exclusive enteral nutrition in the perioperative setting. AIM To test the hypothesis that exclusive enteral nutrition provides a safe and effective bridge to surgery and reduces post-operative complications, in adult patients with Crohn's disease requiring urgent surgery for stricturing or penetrating complications. METHODS Patients treated with exclusive enteral nutrition prior to surgery were each matched with two control patients for disease behaviour, type of surgery, age at diagnosis and disease duration. Data on disease phenotype, nutritional status, operative course and post-operative complications were obtained. RESULTS Twenty-five per cent [13/51] patients treated with exclusive enteral nutrition avoided surgery. Exclusive enteral nutrition had no effect on pre-operative weight, but it significantly reduced serum CRP [median at baseline 36 (interquartile range, IQR: 13-91] vs. pre-operation 8 (4-31) mg/L, P = 0.02]. The median (IQR) length of surgery was shorter in patients pre-optimised with exclusive enteral nutrition than controls [3.0 (2.5-3.5) vs. 3.5 (3.0-4.0) hours respectively, P < 0.001]. Multivariable logistic regression analysis confirmed that going straight-to-surgery compared exclusive enteral nutrition pre-optimisation was associated with a ninefold increase in the incidence of post-operative abscess and/or anastomotic leak [OR 9.1; 95% CI (1.2-71.2), P = 0.04]. CONCLUSIONS Exclusive enteral nutrition frequently down-stages the need for surgery in patients presenting with stricturing or penetrating complications of Crohn's disease; it is associated with a reduction in systemic inflammation, operative times and the incidence of post-operative abscess or anastomotic leak. Further trials are needed to elucidate how exclusive enteral nutrition may improve operative outcomes.
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Affiliation(s)
- N Heerasing
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - B Thompson
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - P Hendy
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - G A Heap
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - G Walker
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - R Bethune
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - S Mansfield
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - C Calvert
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - N A Kennedy
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - T Ahmad
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - J R Goodhand
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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Otley AR, Day AS, Zachos M. Nutritional Management of Inflammatory Bowel Disease. PEDIATRIC INFLAMMATORY BOWEL DISEASE 2017:333-356. [DOI: 10.1007/978-3-319-49215-5_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Forbes A, Escher J, Hébuterne X, Kłęk S, Krznaric Z, Schneider S, Shamir R, Stardelova K, Wierdsma N, Wiskin AE, Bischoff SC. ESPEN guideline: Clinical nutrition in inflammatory bowel disease. Clin Nutr 2016; 36:321-347. [PMID: 28131521 DOI: 10.1016/j.clnu.2016.12.027] [Citation(s) in RCA: 414] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 12/28/2016] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The ESPEN guideline presents a multidisciplinary focus on clinical nutrition in inflammatory bowel disease (IBD). METHODOLOGY The guideline is based on extensive systematic review of the literature, but relies on expert opinion when objective data were lacking or inconclusive. The conclusions and 64 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required. RESULTS IBD is increasingly common and potential dietary factors in its aetiology are briefly reviewed. Malnutrition is highly prevalent in IBD - especially in Crohn's disease. Increased energy and protein requirements are observed in some patients. The management of malnutrition in IBD is considered within the general context of support for malnourished patients. Treatment of iron deficiency (parenterally if necessary) is strongly recommended. Routine provision of a special diet in IBD is not however supported. Parenteral nutrition is indicated only when enteral nutrition has failed or is impossible. The recommended perioperative management of patients with IBD undergoing surgery accords with general ESPEN guidance for patients having abdominal surgery. Probiotics may be helpful in UC but not Crohn's disease. Primary therapy using nutrition to treat IBD is not supported in ulcerative colitis, but is moderately well supported in Crohn's disease, especially in children where the adverse consequences of steroid therapy are proportionally greater. However, exclusion diets are generally not recommended and there is little evidence to support any particular formula feed when nutritional regimens are constructed. CONCLUSIONS Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 64 recommendations, of which 9 are very strong recommendations (grade A), 22 are strong recommendations (grade B) and 12 are based only on sparse evidence (grade 0); 21 recommendations are good practice points (GPP).
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Affiliation(s)
- Alastair Forbes
- Norwich Medical School, University of East Anglia, Bob Champion Building, James Watson Road, Norwich, NR4 7UQ, United Kingdom.
| | - Johanna Escher
- Erasmus Medical Center - Sophia Children's Hospital, Office Sp-3460, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands.
| | - Xavier Hébuterne
- Gastroentérologie et Nutrition Clinique, CHU de Nice, Université Côte d'Azur, Nice, France.
| | - Stanisław Kłęk
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, 15 Tyniecka Street, 32-050, Skawina, Krakau, Poland.
| | - Zeljko Krznaric
- Clinical Hospital Centre Zagreb, University of Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia.
| | - Stéphane Schneider
- Gastroentérologie et Nutrition Clinique, CHU de Nice, Université Côte d'Azur, Nice, France.
| | - Raanan Shamir
- Tel-Aviv University, Schneider Children's Medical Center of Israel, 14 Kaplan St., Petach-Tikva, 49202, Israel.
| | - Kalina Stardelova
- University Clinic for Gastroenterohepatology, Clinical Centre "Mother Therese", Mother Therese Str No 18, Skopje, Republic of Macedonia.
| | - Nicolette Wierdsma
- VU University Medical Center, Department of Nutrition and Dietetics, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Anthony E Wiskin
- Paediatric Gastroenterology & Nutrition Unit, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8BJ, United Kingdom.
| | - Stephan C Bischoff
- Institut für Ernährungsmedizin (180) Universität Hohenheim, Fruwirthstr. 12, 70593 Stuttgart, Germany.
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MacDonald TT, Di Sabatino A, DiSabatino A, Gordon JN. Immunopathogenesis of Crohn's Disease. JPEN J Parenter Enteral Nutr 2016; 29:S118-24; discussion S124-5, S184-8. [PMID: 15980273 DOI: 10.1177/01486071050290s4s118] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
This review highlights the huge advances made in the understanding of Crohn's disease in the last 15 years. The pathogenic immune response in the gut wall is a highly polarised T helper cell type 1 response, probably directed against antigens of the commensal flora. There is marked over-expression of pro-inflammatory cytokines such as tumor necrosis factor (TNF)-alpha and increased production of matrix degrading enzymes by fibroblasts and macrophages, which are probably responsible for ulceration and fistula formation. Crohn's disease runs in families and the susceptibility genes identified so far are associated with innate recognition of microbial products (Nod2) or epithelial barrier function (OCTN cation transporter genes and DLG5). Endogenous healing pathways mediated by transforming growth factor (TGF)-beta1 are inhibited because mucosal inflammatory cells express Smad7, the endogenous intracellular inhibitor of TGF-beta signalling. This makes it unlikely that enteral feeds containing TFG-beta are therapeutic by means of direct anti-inflammatory effects, however TGF-beta may still be involved because it is a well known epithelial motogen and may promote mucosal healing, in synergy with changes in mucosal bacterial populations as a result of the change in the diet.
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Affiliation(s)
- Thomas T MacDonald
- Division of Infection, Inflammation and Repair, University of Southampton School of Medicine, Southampton, United Kingdom.
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Kim HJ, Kim Y, Cho JM, Oh SH, Kim KM. Therapeutic Efficacy of Oral Enteral Nutrition in Pediatric Crohn's Disease: A Single Center Non-Comparative Retrospective Study. Yonsei Med J 2016; 57:1185-91. [PMID: 27401650 PMCID: PMC4960385 DOI: 10.3349/ymj.2016.57.5.1185] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 12/04/2015] [Accepted: 03/11/2016] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Exclusive enteral nutrition (EEN) therapy effectively induces clinical remission in Crohn's disease (CD). It remains unclear, however, whether partial enteral nutrition (PEN) can maintain remission. This study was performed to determine the abilities of oral EEN and oral PEN to induce and maintain clinical remission in pediatric patients with CD, respectively. MATERIALS AND METHODS Pediatric patients with CD who received oral EEN at a single center in 2000-2014 were identified retrospectively. Remission rates of the EEN and PEN during the 2 years study period were determined. Risk factors for EEN and PEN failure were identified. RESULTS Of the 66 patients who started EEN, 61 (92%) completed the course. Clinical remission was achieved in 88% (58/66) of the patients. All 58 patients with remission continued with PEN: 43 (74%) were treatment adherent. The cumulative remission rates at 1 and 2 years were 67% and 52%, respectively. Differing from EEN, limited therapeutic efficacy of PEN was shown in severe CD patients. Female gender associated significantly with non-adherence. CONCLUSION Oral EEN and PEN effectively induced and maintained remission in a pediatric population. Non-adherence was a limiting factor in the success of therapy.
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Affiliation(s)
- Hyun Jin Kim
- Department of Pediatrics, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Young Kim
- Department of Pediatrics, Kwangju Christian Hospital, Gwangju, Korea
| | - Jin Min Cho
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seak Hee Oh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea.
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44
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Basson A. Nutrition management in the adult patient with Crohn’s disease. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2016. [DOI: 10.1080/16070658.2012.11734423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Wędrychowicz A, Zając A, Tomasik P. Advances in nutritional therapy in inflammatory bowel diseases: Review. World J Gastroenterol 2016; 22:1045-1066. [PMID: 26811646 PMCID: PMC4716019 DOI: 10.3748/wjg.v22.i3.1045] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 07/22/2015] [Accepted: 09/13/2015] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel diseases (IBD), including ulcerative colitis and Crohn's disease are chronic, life-long, and relapsing diseases of the gastrointestinal tract. Currently, there are no complete cure possibilities, but combined pharmacological and nutritional therapy may induce remission of the disease. Malnutrition and specific nutritional deficiencies are frequent among IBD patients, so the majority of them need nutritional treatment, which not only improves the state of nutrition of the patients but has strong anti-inflammatory activity as well. Moreover, some nutrients, from early stages of life are suspected as triggering factors in the etiopathogenesis of IBD. Both parenteral and enteral nutrition is used in IBD therapy, but their practical utility in different populations and in different countries is not clearly established, and there are sometimes conflicting theories concerning the role of nutrition in IBD. This review presents the actual data from research studies on the influence of nutrition on the etiopathogenesis of IBD and the latest findings regarding its mechanisms of action. The use of both parenteral and enteral nutrition as therapeutic methods in induction and maintenance therapy in IBD treatment is also extensively discussed. Comparison of the latest research data, scientific theories concerning the role of nutrition in IBD, and different opinions about them are also presented and discussed. Additionally, some potential future perspectives for nutritional therapy are highlighted.
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46
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Kaakoush NO. Insights into the Role of Erysipelotrichaceae in the Human Host. Front Cell Infect Microbiol 2015; 5:84. [PMID: 26636046 PMCID: PMC4653637 DOI: 10.3389/fcimb.2015.00084] [Citation(s) in RCA: 530] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/09/2015] [Indexed: 12/27/2022] Open
Affiliation(s)
- Nadeem O Kaakoush
- School of Biotechnology and Biomolecular Sciences, Faculty of Science, University of New South Wales Sydney, NSW, Australia
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47
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Shah ND, Parian AM, Mullin GE, Limketkai BN. Oral Diets and Nutrition Support for Inflammatory Bowel Disease: What Is the Evidence? Nutr Clin Pract 2015; 30:462-73. [PMID: 26084506 DOI: 10.1177/0884533615591059] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Inflammatory bowel disease (IBD), which primarily includes Crohn's disease and ulcerative colitis, involves chronic inflammation of the gastrointestinal tract. The mechanisms of IBD pathogenesis are not well understood at this time, but likely involve an interaction between genetic, gut microbial, immune, and environmental factors. Emerging epidemiologic studies have suggested a relationship between specific dietary nutrients as an environmental factor and IBD risk. Clinical trials have also shown oral diets to have variable efficacy in affecting clinical outcomes for IBD. This review discusses the key studies that evaluated the use of various oral diets as well as nutrition support in the management of IBD.
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Affiliation(s)
- Neha D Shah
- Digestive Health Center, Stanford Health Care, Palo Alto, California Division of Gastroenterology & Hepatology, Stanford University School of Medicine, Stanford, California
| | - Alyssa M Parian
- Division of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gerard E Mullin
- Division of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Berkeley N Limketkai
- Digestive Health Center, Stanford Health Care, Palo Alto, California Division of Gastroenterology & Hepatology, Stanford University School of Medicine, Stanford, California Division of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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48
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Altomare R, Damiano G, Abruzzo A, Palumbo VD, Tomasello G, Buscemi S, Lo Monte AI. Enteral nutrition support to treat malnutrition in inflammatory bowel disease. Nutrients 2015; 7:2125-33. [PMID: 25816159 PMCID: PMC4425135 DOI: 10.3390/nu7042125] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 01/06/2015] [Indexed: 12/14/2022] Open
Abstract
Malnutrition is a common consequence of inflammatory bowel disease (IBD). Diet has an important role in the management of IBD, as it prevents and corrects malnutrition. It is well known that diet may be implicated in the aetiology of IBD and that it plays a central role in the pathogenesis of gastrointestinal-tract disease. Often oral nutrition alone is not sufficient in the management of IBD patients, especially in children or the elderly, and must be combined with oral supplementation or replaced with tube enteral nutrition. In this review, we describe several different approaches to enteral nutrition-total parenteral, oral supplementation and enteral tube feeding-in terms of results, patients compliance, risks and and benefits. We also focus on the home enteral nutrition strategy as the future goal for treating IBD while focusing on patient wellness.
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Affiliation(s)
- Roberta Altomare
- School in Surgical Biotechnology and Regenerative Medicine, School of Medicine, School of Biotechnology, University of Palermo, Via del Vespro 129, Palermo 90127, Italy.
| | - Giuseppe Damiano
- AUOP "P.Giaccone", Universitary Hospital, Via del Vespro 129, Palermo 90127, Italy.
| | - Alida Abruzzo
- School in Surgical Biotechnology and Regenerative Medicine, School of Medicine, School of Biotechnology, University of Palermo, Via del Vespro 129, Palermo 90127, Italy.
| | - Vincenzo Davide Palumbo
- School in Surgical Biotechnology and Regenerative Medicine, School of Medicine, School of Biotechnology, University of Palermo, Via del Vespro 129, Palermo 90127, Italy.
| | - Giovanni Tomasello
- AUOP "P.Giaccone", Universitary Hospital, Via del Vespro 129, Palermo 90127, Italy.
- GENURTO Department, School of Medicine and Biotechnology, University of Palermo, Via del Vespro 129, Palermo 90127, Italy.
| | - Salvatore Buscemi
- School in Surgical Biotechnology and Regenerative Medicine, School of Medicine, School of Biotechnology, University of Palermo, Via del Vespro 129, Palermo 90127, Italy.
| | - Attilio Ignazio Lo Monte
- AUOP "P.Giaccone", Universitary Hospital, Via del Vespro 129, Palermo 90127, Italy.
- GENURTO Department, School of Medicine and Biotechnology, University of Palermo, Via del Vespro 129, Palermo 90127, Italy.
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Triantafillidis JK, Vagianos C, Papalois AE. The role of enteral nutrition in patients with inflammatory bowel disease: current aspects. BIOMED RESEARCH INTERNATIONAL 2015; 2015:197167. [PMID: 25793189 PMCID: PMC4352452 DOI: 10.1155/2015/197167] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 10/13/2014] [Indexed: 12/15/2022]
Abstract
Enteral nutrition (EN) is considered to be of great importance in patients with inflammatory bowel disease (IBD) and nutritional problems. This comprehensive review is aiming to provide the reader with an update on the role of EN in IBD patients. EN can reduce Crohn's disease (CD) activity and maintain remission in both adults and children. Nutritional support using liquid formulas should be considered for CD patients and in serious cases of ulcerative colitis (UC), especially for those who may require prolonged cycles of corticosteroids. Given that the ultimate goal in the treatment of CD is mucosal healing, this advantage of EN over corticosteroid treatment is valuable in therapeutic decision-making. EN is indicated in active CD, in cases of steroid intolerance, in patient's refusal of steroids, in combination with steroids in undernourished individuals, and in patients with an inflammatory stenosis of the small intestine. No differences between the efficiency of elemental diets and nonelemental formulas have been noticed. EN must be the first choice compared to TPN. EN has a restricted value in the treatment of patients with large bowel CD. In conclusion, it seems important not to underestimate the role of nutrition as supportive care in patients with IBD.
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Affiliation(s)
- John K. Triantafillidis
- Inflammatory Bowel Disease Unit, IASO General Hospital, 264 Mesogeion Avenue, Holargos, 15562 Athens, Greece
| | - Costas Vagianos
- 1st Surgical Unit, Saint Panteleimon Hospital, D. Mantouvalou 3, 18454 Nicea, Greece
| | - Apostolos E. Papalois
- Experimental-Research Center, ELPEN Pharmaceuticals, 95 Marathonos Avenue, Pikermi, 19009 Athens, Greece
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50
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Kaakoush NO. Insights into the Role of Erysipelotrichaceae in the Human Host. Front Cell Infect Microbiol 2015. [PMID: 26636046 DOI: 10.3309/fcimb.2015.00004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Affiliation(s)
- Nadeem O Kaakoush
- School of Biotechnology and Biomolecular Sciences, Faculty of Science, University of New South Wales Sydney, NSW, Australia
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