Diet-as-therapy in IBD relies on shared decision-making, compliance
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AUSTIN, Texas — Though clinical data for nutrition as therapy in IBD is limited, physicians should not be deterred from discussing it with patients if patients participate in the decision and comply as if the diet is a drug, according to an expert at the Crohn’s and Colitis Congress.
“There are limitations to the clinical data for dietary therapy in IBD, but that should not be a deterrent,” Lindsey Albenberg, DO, of the Children’s Hospital of Philadelphia, said during her presentation. “The key is shared decision making and following objective outcomes closely. This is really critical.”
Albenberg reviewed data for exclusive enteral nutrition and restriction diets, referring to diet as the biggest topic patients with Crohn’s disease want to discuss.
Research has linked high dietary intakes of total fats, PUFAs, omega 6 and meat with an increased risk for ulcerative colitis while the inverse was true for high fiber and fruit intakes for Crohn’s risk and high vegetable intake for UC risk.
The challenge in conducting dietary studies, unfortunately, are many, Albenberg said.
“Dietary trials are really difficult to undertake. When we perform dietary clinical trials, we are asking people to make a lifestyle change and we know from weight loss trials that it’s really difficult to get patients to change their behavior,” she said, also mentioning substitution effect and a lack of ability to blind participants to their food intake.
Exclusive enteral nutrition, though, allows for more effective management of a patient’s diet. In studies like the PLEASE study, Albenberg and colleagues showed rapid change in microbiota when adhering to an EEN formula, as judged by fecal calprotectin.
“The microbiome shifted in the exclusive enteral nutritional therapy group as early as week 1,” she said. “It does seem that there are changes that happen relatively quickly.”
Albenberg showed that the percentage of calories from formula can directly impact the changes on patient outcome. Partial enteral therapy, which should incorporate 80% of calories from formula, was in reality only about 50% formula and had a diluted effect as compared to EEN.
“Exclusive enteral nutritional therapy ... is at least as effective as steroids for induction of remission. It’s associated with mucosal healing. It works relatively quickly ... and importantly, there are no side effects,” Albenberg said. “I initially had on this slide that it is a difficult therapy, both for patients and for providers, and maybe difficult isn’t the right word but it is demanding. Enteral nutritional therapy demands resources, education and dedication but one of the bigger issues are what is the long-term benefit and what is the exit strategy?”
One of the strategic uses of EEN is as a bridge strategy to other treatments, including exclusion diets, Albenberg said. She reviewed CD-TREAT, a study that aimed to mimic enteral nutrition through diet, showing that four out of the five pediatric participants did improve.
More commonly used, the specific carbohydrate diet (SCD) restricts all grains, refined sugars, cow’s milk products and processed foods.
“It has had a popular following in the community for a variety of GI illnesses particularly IBD. There is a lot of anecdotal evidence ... but the scientific literature is quite limited,” Albenberg said. “There are some concerns such as elimination of whole food groups in this diet, inadequate calories and the emotional wellbeing of our patients. But I do think with the appropriate monitoring of our patients, there is a way forward.”
In a recently published study, the Crohn’s disease exclusion diet and enteral nutrition offered similar remission induction, but the exclusion diet was better tolerated, Albenberg said.
Though she said there are some unknowns such as mucosal healing, this was an encouraging study. Long-term outcomes are still unknown, she added, including whether the diet is sustainable.
“When I am prescribing a dietary therapy, I talk to my patients and families and I say, ‘This is your drug and I expect the same compliance with therapy, the same compliance with monitoring and your willingness to move on if it isn’t working,’” Albenberg said. – by Katrina Altersitz
Reference: Albenberg L. Sp 56. Presented at: Crohn’s and Colitis Congress; Jan. 23-25, 2020; Austin, TX.
Disclosures: Albenberg reports receiving honoraria from Nestle Health and research support from Seres Therapeutics.
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