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Enteral nutrition outcomes reveal diet, microbiome and pediatric IBD link
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ORLANDO, Fla. — Evidence supports partial enteral nutrition therapy and Crohn’s disease exclusion diet for treatment of pediatric Crohn’s disease, and these data can improve understanding of the link between diet, dysbiosis and pediatric IBD, according to a presenter at the Advances in IBD meeting.
“Exclusive enteral nutrition is the most obvious and ignored clue to the effect of diet as an environmental factor of IBD,” Robert N. Baldassano, MD, director of the Center for Pediatric IBD at the Children’s Hospital of Philadelphia, said in a presentation. There is evidence that a regular Western diet itself contains inflammatory components, he explained.
Robert N. Baldassano
Citing the findings from the Pediatric Longitudinal Study of Semi-Elemental Diet and Stool Microbiome (PLEASE), Baldassano demonstrated that greater mucosal healing was achieved in CD patients on exclusive enteral nutrition compared with partial enteral nutrition therapy. In this prospective cohort study, 38 children received enteral therapy with defined formula diet and 52 controls received anti-TNF-alpha therapy. The enteral nutrition group was further stratified to evaluate mucosal healing on a more restrictive diet; one subgroup received 80% to 90% of total caloric needs from enteral therapy, of which 14% achieved induction of remission at 8 weeks, the other subgroup received 90% to 100% of total caloric needs from enteral therapy, of which 45% achieved remission, and 62% of controls achieved remission.
“Clearly the kids who ate more table food did not do as well as the other two groups,” Baldassano said. “Both groups actually had gotten a lot of formula, so if there was something special about this formula … you would think both groups would have done well, but that wasn’t true, and our conclusion was that enteral nutrition therapy is effective due to the exclusion of table food.”
In another study he discussed, partial enteral nutrition with a Crohn’s disease exclusion diet was also shown to be effective for induction of remission. Of 53 children with Crohn’s disease on a partial enteral nutrition diet of 50% formula plus Crohn’s disease exclusion diet, 70% achieved remission at 8 weeks, and of the children who refused partial enteral nutrition but followed just the Crohn’s disease exclusion diet, six out of seven achieved remission.
Additional studies discussed in his presentation demonstrated efficacy of enteral nutrition and semi-vegetarian diet in maintenance of Crohn’s disease remission.
While the exact components in a regular diet that can cause inflammation are unclear, Baldassano cited various studies pointing to total fats, polyunsaturated fatty acids, omega-6, milk fat and meat, while fiber, fruits and vegetables were associated with decreased disease risk. One study of 191 ulcerative colitis patients in remission demonstrated that the 52% of patients who relapsed over 1 year of follow-up consumed more meat, particularly red and processed meat.
According to Baldassano, a possible explanation for the impact of diet on IBD is that diet alters the gut microbiome which leads to inflammation. In the Cross-sectional Study of Diet and Stool Microbiome Composition (COMBO), he said, “We asked the question: are nutrients associated with specific bacterial taxa?” The results demonstrated that a Bacteroides enterotype was highly associated with animal protein and saturated fats, while a Prevotella enterotype was highly associated with carbohydrates and simple sugars. “Many studies have shown that Bacteroides are associated with … many different diseases,” he said.
In summary, there is evidence “to show that partial nutrition … is capable of keeping people in remission,” he said, adding that while “there is limited evidence to support this Crohn’s disease exclusion diet,” studies are currently underway.
“The challenge moving forward will be to provide evidence for dietary influences on the intestinal microbiome that have meaningful effects on human physiology. Changing the intestinal microbiome through dietary modifications may ultimately prove a powerful approach to disease prevention and therapy,” Baldassano said.
For more information:
Baldassano RN. Presented at: 2014 Advances in Inflammatory Bowel Diseases, Dec. 4-6, 2014; Orlando, Fla.
Disclosures: Baldassano reports financial relationships with AbbVie, Avaxia Biologics, Janssen and Takeda.