ASPEN EDUCATION PROGRAM OUTLINE TEMPLATE Name, Title, Affiliation Kimberly Braly, RD, CD, CNSC Pediatric Dietitian Independent Consultant Seattle Children’s Hospital Presentation Title Exclusion Diets for Inflammatory Bowel Disease: Implementation, Monitoring, and Support Disclosures

o “I have no commercial relationships to disclose” Presentation Overview/Summary • One paragraph overview/summary of your presentation, highlighting the key points. This should be

thought of as an abstract of your presentation. This presentation will focus on how to practically implement, monitor and support a patient with inflammatory bowel disease that begins diet therapy of either exclusive enteral nutrition or the specific carbohydrate diet. Listeners will walk through the differences and similarities between the two diet therapies, and where to go to learn more about the practical tips and tools to make these therapies successful. Learning Objectives At the conclusion of the presentation, the learner will be able to:

1. Differentiate between Exclusive Enteral Nutrition, Partial Enteral Nutrition and the Specific Carbohydrate Diet

2. Discuss diet implementation for each exclusion diet 3. Understand clinic monitoring 4. Identify ways to support a patient on diet therapy for IBD

Key Takeaways/Fast Facts

• EEN and SCD can be and are used as therapy for IBD • Standardized monitoring and support by a multidisciplinary team is essential for success • Takeaways – how to practically implementation, monitor, and support a patient with IBD that begins

diet therapy on EEN or the SCD Learning Assessment Questions

1) Patient AJ presents to clinic with growth stunting. He dislikes eggs and produce and has an allergy to dairy. Which therapy, if any, would be most appropriate?

A. SCD B. EEN with polymeric formula C. EEN with hydrolyzed formula D. EEN with elemental formula

2) Both EEN and the SCD are used as primary and adjunct therapy in IBD? A. True B. False

ASPEN EDUCATION PROGRAM OUTLINE TEMPLATE

3) Polymeric, Hydrolyzed and Elemental formulas are equally effective for treatment with EEN A. True B. False 4) Circle the following foods that ARE allowed on the SCD A. Most fruits and vegetables B. Homemade yogurt and aged cheese C. Most whole grains D. Honey and turbinado sugar Learning Assessment Answers:

1. Answer = D; Rationale: Most appropriate therapy is EEN with elemental formula. SCD is not the most appropriate given patient dislikes produce and eggs which comprise a large portion of the diet. EEN with a polymeric or hydrolyzed formula are not the best options given patient’s milk allergy. Elemental formula is the safest option for the patient.

2. Answer = True. Both can be used as sole therapy or adjunct to other therapies such as medication

3. Answer = True. Studies have shown equal efficacy between the three classes of formula

4. Answer = A + B. C + D are NOT allowed on the SCD as grains are excluded as well as ALL sweeteners aside from honey. Turbinado sugar is not allowed.

Exclusion Diets for Inflammatory Bowel Disease: Implementation, Monitoring, and Support

ASPEN 2019 Nutrition Science & Practice Conference

Kimberly Braly, RD, CD, CNSCPediatric Dietitian

Independent ConsultantSeattle Children’s Hospital

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Disclosures

I have no commercial relationships to disclose

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Learning Objectives

1. Differentiate between Exclusive Enteral Nutrition, Partial Enteral Nutrition and the Specific Carbohydrate Diet

2. Discuss diet implementation for each exclusion diet3. Understand clinic monitoring

4. Identify ways to support a patient on diet therapy for IBD

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Diet Therapy in Inflammatory Bowel Disease

• Diet, microbiome in IBD• Research for diet therapy in IBD• Practical implementation

oExclusive enteral nutrition (EEN)oSpecific carbohydrate diet (SCD)

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Exclusion Diets: Exclusive Enteral Nutrition (EEN)

• Indicationo Therapy for inflammatory bowel disease (IBD) – Crohn’s Disease (CD)

• Brief overviewo Amenable patient and familyo Appropriate therapy for patient based on scope results/discussion with MDo Taken by mouth or via feeding tube (NG or G-tube)o 100% of energy and nutrient needs met with commercial formulao 6-12 weeks “liquid nutrition”

o Follow up per clinic standard of careo Support

1) Gupta et al. 2013

2) Borelli et al. 2006

3) Sigall-Boneh R et al. Inflamm Bowel Dis. 2014

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EEN: Practical Implementation

Presenting to a patient and/or family• At SCH

o RD vs. MD presents after diagnosis confirmedo RD – discuss with MD prior to meeting with family

- Is patient a good candidate for nutrition therapy based on disease and his/her goals of care?

- Does family want to minimize medication exposure?- Provide samples of formula for patient to try

o MD- Presents therapy options (medication vs. diet therapy)- If interested in nutrition, discusses with RD and notifies family

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EEN: Practical Implementation

• Energy Requirementso BMR x activity factor - inflammation, weight gain, athlete

• Transition to EENo Gradual over 5-10 days

- Start with 1-2 “shakes” per day, gradually increase

- Remove a snack or meal depending on caloric density of formulao Important to define timeline of transition

• Formula type and route of administrationo Polymeric, semi-elemental, elemental = equal efficacy o 1.0 cal vs 1.5 calo Oral (not covered by insurance) vs. tube (frequently covered by insurance)

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Exclusive Enteral Nutrition: Monitoring

SCH IBD

Exit plan

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EEN Pros and Cons

Challenges of EEN

• Palatability/Imposition on daily living

• Compliance▪40% adults fail to comply▪Children: up to 90%compliance reported▪Cost and social challenge

Advantages of EEN

• Prevents/treats nutritionaldeficits

• Improves growth/development• Prevents/reverses osteopenia• Decreases use of steroids• Safe• Improves mucosal healing

1) Gupta et al. 2013

2) Borelli et al. 2006 © 2

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Partial Enteral Nutrition: PEN

• Partial Enteral Nutrition (PEN)o Primary nutrient source is commercial formula

- Provides 50-90% of caloric/nutrient requirements

o Portion of diet is achieved via typical diet for age - Provides 10-50% of caloric requirements- No food restrictions

o Portion of diet is achieved via modified diet- Specific carbohydrate diet (SCD)- Semi-vegetarian diet- Crohn’s disease exclusion diet

EEN/PEN: Polymeric, semi-elemental, elemental

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EEN: Support

• Healthcare teamo Laboratory measurementso Anthropometric and nutrition monitoringo Standardized clinic follow up and disease assessment

- Check-in via phone week 1- Clinic visit week 2, 4, 8 then every 3 months thereafter if in remission

o Financial resources and access to formula- Not covered by insurance- Financial assistance program through institution

• Team approacho Family, physician, dietitian, social worker and/or psychologisto Supportive friends

• Troubleshooting barriers to successo Socialo Flavor fatigue and adequate caloric intakeo Crunch

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Exclusion Diets: Specific Carbohydrate Diet (SCD)

• Backgroundo Nutritionally complete, grain-free diet, low in sugar and lactoseo Developed by Dr. Sidney Haas in the 1920’s to treat Celiac Disease,

common therapyo Elaine Gottschall published “Breaking the Vicious Cycle” 1987

o Anecdotal reports of symptom improvement, limited research inpediatrics and adults

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SCD: Premise

Food additives and processing, microbiome

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SCD: Breaking the Vicious Cycle

Chronic Diarrhea

Small Intestine Mucosal Injury

Water drawn into intestine

Increased bacterial by-products

Bacterial Overgrowth

Carbohydrate Malabsorption

Adapted from Breaking The Vicious Cycle by Elaine Gottschall

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SCD: Fresh, Whole, Unprocessed

Allow

• All fresh meats, fish, shellfish• Most vegetables• Most fruits• Most fats and oils, including

butter• Cheeses aged > 30 days• Homemade yogurt, homemade

nut milks• Whole nuts and seeds• Honey and fruit• Legumes such as lentils and

most beans

Avoid• Packaged, deli, preserved meats• Potatoes, corn, starchy vegetables• Green bananas, plantains, young

coconut• Processed oils such as canola• Soft cheeses (not aged) such as

mozzarella, cottage • Regular milk or commercial yogurts• Flavored/coated with anti-caking

agents• Sweeteners aside from honey• All grains • Soy

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SCD: As Therapy

• Indicationo Primary or adjunct therapy for inflammatory bowel disease (IBD) – CD and

UC

• Brief overviewo Amenable patient and familyo Appropriate therapy for patient based on scope results/discussion with MDo 8-12 weeks strict, then consider food introduction thereaftero Follow up per clinic standard of careo Support

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SCD: Practical Implementation

Presenting to a patient and/or family• At SCH

o RD vs. MD presents after diagnosis confirmedo RD – discuss with MD prior to meeting with family

- Is patient a candidate for nutrition therapy based on disease and his/her goals of care?▪ Does family want to minimize medication exposure?▪ Use diet AND medication?

- Meet with dietitian for detailed educationo MD

- Presents therapy options (medication vs. diet therapy)- If interested in nutrition, refer to RD

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SCD: Education

• With dietitiano ~60 minute educationo Detailed diet history and nutrition assessmento Special considerations

- Vegan/vegetarian- food allergens- Athlete- Age- Selective eating

o Focus on what you can eat vs. restrictions

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SCD: Education

• Educationo Provide resources

- www.nimbal.org- Cookbooks- Favorite recipes- Support group (SCD Families on Facebook)

o Label reading via Google imageo Recipe review and substitutionso Address calorie and nutrient adequacy on SCD - Supplementation may be

indicatedo Address yogurt making and probioticso Educate on transitioning to SCD

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SCD: Transitioning• Stages

o Traditionally- Avoid raw fruits/vegetables until resolution of diarrhea- Ripe/peeled/cooked- Advance to raw once diarrhea resolves

o No current research on stages to prove/disprove efficacy• At SCH

o Start with raw fruits and vegetables, cook if indicatedo Liberalizing diet

- If remission reached by 3 months, gradual introduction of non SCD foods▪ 1 new food x 1 month, consistent intake, then repeat stool calprotectin

- Examples: rice (white or brown), oats, quinoa, organic sweet potatoes, cocoa powder, maple syrup, garbanzo beans

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SCD: Monitoring

SCH IBD

Exit plan Week 8: IBD provider + RD-Clinical improvement: Continue therapy

-Clinical worsening: Change treatment plan

Week 4: IBD provider + RD-Education, nutrition adequacy-Continue therapy if improving-Alternative therapy if worsening/weight loss

Anthropometrics, labs, symptoms

Week 2: IBD provider + RD-Education, troubleshoot barriers, nutrition adequacy -Start maintenance medication if indicated-Alternative therapy if significant worsening/weight loss

Anthropometrics, labs, symptoms

Week 0: IBD provider + IBD RD

Education on SCD Anthropometrics, labs

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SCD: Support

• Healthcare teamo Laboratory measurementso Anthropometric and nutrition monitoringo Standardized clinic follow up and disease assessment

- Check-in via phone week 1- Clinic week 2, 4, 8 then every 3 months thereafter if in remission

• Team approacho Family, physician, dietitian, social worker and/or psychologisto Supportive friends

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SCD: Troubleshooting

• Challenges on the SCDo Increased time cookingo Potential increase in costo Travel and eating outo Sharing food and peer pressure

• Plan ahead for success

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SCD: Tools for Success

• Batch cooko Fully stocked freezero Staples to have on hand

• Creativity and family involvement• Keep meals simple and meal plan• Bring SCD foods to share• Do not be afraid to try substitutions at home and at restaurants • Kitchen Tools

o Yogurt makero Blendero Mixer (hand or stand)o Food processor

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Becoming Proficient in the SCD

• Try the diet yourself!• Online tools

o Webinars- Nuts and bolts of the SCD: https://www.youtube.com/watch?v=iIVO6RMmLcw- Dietary therapy for IBD presented by the gastroenterologists:

https://www.youtube.com/watch?v=rcikdE_pE98

o Cooking blogs- Comfy belly – comfybelly.com- Against All Grain – againstallgrain.com

o Nimbal.org -> PRODUCE -> Download study materials

• Bookso Nutrition In Immune Balance –NiMBALo Breaking the Vicious Cycle - BTVC

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Summary

• EEN and SCD can be and are used as therapy for IBD

• EEN and SCD are different and one may be more appropriate than theother for your patient

• Standardized monitoring and support by a multidisciplinary team is essential

• Set your patient up for success with resources and the support they need

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Thank You!

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Learning Assessment Questions

1) Patient AJ presents to clinic with growth stunting. He dislikes eggs and produce and has an allergy to dairy.Which therapy, if any, would be most appropriate?A. SCDB. EEN with polymeric formulaC. EEN with hydrolyzed formulaD. EEN with elemental formula

2) Both EEN and the SCD are used as primary and adjunct therapy in IBD?A. TrueB. False

3) Polymeric, Hydrolyzed and Elemental formulas are equally effective for treatment with EENA. TrueB. False

4) Circle the following foods that ARE allowed on the SCDA. Most fruits and vegetablesB. Homemade yogurt and aged cheeseC. Most whole grainsD. Honey and turbinado sugar

• Name: Dale Lee, MD, MSCE. Seattle Children’s Hospital, The University of Washington • Presentation Title: Clinical Studies on Dietary Therapy for Inflammatory Bowel Disease • Disclosures: I have no commercial relationships to disclose Presentation Overview/Summary Inflammatory bowel diseases (IBD) are chronic inflammatory conditions affecting the gastrointestinal tract and characterized by a relapsing, remitting course. The two forms of IBD are Crohn’s disease and ulcerative colitis, and they are hypothesized to occur in a susceptible host when an environmental insult initiates an abnormal immune response. Greater consumption of saturated fat, total fat, omega-6-polyunsaturated fatty acids, and meat have been associated with greater risk of developing IBD. Though suppressing the immune system is the general approach, dietary therapies have demonstrated efficacy, especially in children and adolescents. Exclusive enteral nutrition (a formula-based diet) and a variety of food-based exclusion diets have demonstrated efficacy at treating active IBD. In this presentation, the data both supporting and critical of the usage of dietary therapy for IBD will be discussed. Learning Objectives 1) Review the association between diet and the risk of developing IBD 2) Discuss the use of exclusive enteral nutritional therapy in Crohn’s disease 3) Discuss the use of elimination diets in IBD At the conclusion of the presentation, the learner will be able to: 1. Describe the data supporting the use of exclusive enteral nutritional therapy in Crohn’s disease 2. Describe common themes in food-based exclusion diets in IBD 3. Understand that dietary therapy can be used effectively in conjunction with medical therapies Key Takeaways/Fast Facts 1. Data supports the use of dietary therapy for IBD 2. Dietary therapy plus immunosuppressive medications can be used concomitantly Learning Assessment Questions

1. Question 1: Environmental exposures are associated with the risk of developing inflammatory bowel disease.

A. True B. False

2. Question 2: Exclusive enteral nutritional therapy is effective for BOTH Crohn’s disease and ulcerative

colitis. A. True B. False

3. Question 3: The following are exclusion diets that have been studied in IBD:

A. Exclusive enteral nutrition B. The low glycemic index diet C. The specific carbohydrate diet D. The Crohn’s disease exclusion diet

Learning Assessment Answers: 1. Answer = A (true); Environmental exposures associated with the risk of developing inflammatory bowel

disease include food, antibiotics, and geographical location 2. Answer = False; Rationale: Studies have demonstrated that exclusive enteral nutrition is effective for

Crohn’s disease but not ulcerative colitis. 3. Answer = B; Rationale: Exclusive enteral nutrition, the specific carbohydrate diet, and the Crohn’s disease

exclusion diet have all been studied as therapy for IBD. Commonalities in these therapies include the avoidance of wheat/gluten and also the avoidance of “processed foods.” A low glycemic index diet has not been studied for IBD.

References 1. Hou JK, Abraham B, El-Serag H. Dietary intake and risk of developing inflammatory bowel disease: a

systematic review of the literature. American Journal of Gastroenterology 2011;106:563-73. 2. Zachos M, Tondeur M, Griffiths AM. Enteral nutritional therapy for induction of remission in Crohn's

disease. Cochrane Database Syst Rev 2007:CD000542. 3. Lee D, Albenberg L, Compher CW, Baldassano RN, Piccoli DA, Lewis JD, Wu GD. Diet in the Pathogenesis

and Treatment of Inflammatory Bowel Disease. Gastroenterology, 2015 May; 148 (6): 1087-106. 4. Lee D, Baldassano RN, Otley AR, Albenberg L, Griffiths AM, Compher CW, Chen EZ, Li H, Gilroy E, Nessel

L, Grant A, Chehoud C, Bushman FD, Wu GD, Lewis JD. Comparative Effectiveness of Nutrition and Biological Therapy in North American Children with Active Crohn’s Disease. Inflammatory Bowel Diseases, 2015; 21: 1786-1793.

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Clinical Studies on Dietary Therapy

for Inflammatory Bowel Disease

ASPEN 2019 Nutrition Science & Practice Conference

Dale Lee, MD, MSCEAssistant Professor Pediatrics

Director, Clinical NutritionSeattle Children’s Hospital

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Disclosures

I have no commercial relationships to disclose

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Learning Objectives

1. Review the association between diet and the risk of developing inflammatory bowel disease (IBD)

2. Discuss the use of exclusive enteral nutritional therapy in Crohn’s disease

3. Discuss the use of elimination diets in IBD

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Epidemiology: Geography

High

Medium

Low

Lashner. Gastroenterol Clin North Am 1995.

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Is Diet Important?

Dietary exposures are associated with incidence of IBD

Immigration studies implicate environment/diet

Exclusion diets can be effective therapy for IBD (i.e. EEN)

“Western diet”

Risk factor Protective factorSaturated fat FiberTotal PUFA FruitsOmega-6 PUFA VegetablesMeat Omega-3 PUFA

Lee D, et al. Gastroenterol 2015.Hou JK, et al. Am J Gastro 2011. ©

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Risk of Developing IBD

• Incidence of IBD is rising: typically occurring first in more industrialized countries

• Early life exposures are important:o Second-generation immigrants have a higher

risk than first-generationo Children: younger age at immigration

associated with greater IBD risk

Hou JK, et al. Am J Gastro 2011.Benchimol EI, et al. Am J Gastro 2015.

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Targets in IBD Pathogenesis

Diet

Immunesystem

GutMicrobiome-Probiotics, prebiotics-Antibiotics-Fecal transplant

Immunosuppressivemedications

???

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Why Focus on Diet?

• Patient interest and belief• Insufficient efficacy of immunosuppression• Risks with immunosuppression

• Infection• Cancer

• Data supports efficacy of dietary therapy• Primary and adjunctive therapy

Columbel JF, et al. NEJM 2010.

SONIC trial

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Dietary Approaches for Treating IBD

• Exclusive Enteral Nutrition (EEN)

• Exclusion diets: – Specific carbohydrate diet (SCD)– Crohn’s disease exclusion diet– Semi-vegetarian diet– CD-TREAT– “Anti-inflammatory” diet

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What is Exclusive Enteral Nutrition (EEN)?

• Also known as the “defined formula diet”

o Formula provides nearly 100% of nutritional needs

o Exclusion of standard foods

• Formula can be consumed by mouth or via tube

• Does not require a specific formula

• Uses:

o Calories

o Therapy for Crohn’s (~80% efficacy)

Votik AJ. Arch Surg 1973.Day AS, et al. World J Gastro 2015.

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Efficacy of EEN

• Adult data: EEN less effective than corticosteroids

• Pediatric data: EEN as effective as corticosteroids

Narula N, et al. Cochrane Rev 2018. Swaminath A, et al. Alim Pharm Ther 2017.

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Mucosal Healing with EEN

o 37 children with newly diagnosed Crohn’s disease

o 10 week randomized trial: steroids vs. EEN

P < .05

Borrelli O, et al. Clin Gastro Hep 2006.

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EEN: How Exclusive?

PLEASE study (n=90)

• Children with active Crohn’s disease

• 8 week trial:

o Pediatric Crohn’s disease activity index (PCDAI)

o Fecal calprotectin (FCP)

• Three arms:

o Partial Enteral Nutrition (PEN) –50% calories by formula

o Exclusive Enteral Nutrition (EEN)

o Anti-TNF-alpha

Lee D, et al. Inflamm Bowel Dis 2015.

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Nutritional therapy: PEN vs. EEN

EEN

Lee D, et al. Inflamm Bowel Dis 2015.

P=0.04

P=0.03

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Nutritional therapy: EEN vs. Anti-TNF

EEN

Lee D, et al. Inflamm Bowel Dis 2015.

P=0.13

P=0.33

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Quality of Life with Nutritional Therapy

PEN vs. EEN EEN vs. TNFIMPACT total*** -- --

Bowel** -- --Systemic*** EEN --Emotional*** -- --Social** -- --Body -- EENTreatment -- --

Significantly greater improvement highlighted (p<0.05)

***Improvements for all 3 arms**Improvement for both EEN and TNF

Lee D, et al. Inflamm Bowel Dis 2015.

• Comparison of IMPACT III QOL score changes:

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Can EEN be effective in adults?

Conclusion: EEN can be effective in adults, but studies limited by poor compliance

• Poor compliance of EEN in adults with Crohn’s

o Issues: palatability and motivation

• Adults: longer disease duration and prior exposure to meds

• EEN in treatment-naïve adults with Crohn’s

Wall CL, et al. World J Gastro 2013.Okada M, et al. Hepatogastro 1990.O’Morain C, et al. Br Med J 1984. ©

201

9 AS

PEN

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Nut

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Res

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Combo Therapy: Anti-TNF + PEN

• 102 participants on infliximab

• EN group: >900 kcal/d EN

• Non-EN group: <900 kcal/d EN or no EN

• Recurrence = CRP >1.5 mg/dL or shortening IFX interval ≤4 weeks

Hirai F, et al. Dig Dis Sci 2013.

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How do you transition off EEN?

• Medical team needs to have an “exit strategy” in mind when starting EEN

• Options:• Immunosuppressive medications• Continue EEN longer • Whole-food based exclusion diet

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Food-based dietary therapy for IBD

• Specific carbohydrate diet (SCD)• Crohn’s disease exclusion diet

• Semi-vegetarian diet• CD-TREAT• “Anti-inflammatory” diets

• Each of these diets involves the restriction of specific foodso Commonly: bread/gluten, “processed foods”

o Some variance: dairy, sugar, animal fat

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The specific carbohydrate diet (SCD)

• Restricted foods on the SCD:o All grainso Refined sugars

o Cow’s milk products (fully fermented yogurt ok)o “Processed foods”

• Popular following in the community for variety of GI illnesseso Anecdotal evidence plentiful

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Prospective SCD study

• d

Suskind DL, et al. J Clin Gastro 2017.

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Studies on the SCDAuthor Study

designn Summary

Two ongoing multicenter trials: 1) n-of-1 study of SCD and modified SCD (120 participants)2) SCD vs. Mediterranean diet (194 participants)

Suskind DL, J ClinGastro (2018)

Prospective case series

13 Clinical + laboratory improvements; significant microbiome shifts

Braly K, J PedGastro Nut (2017)

Prospective diet eval

9 Nutrient intake comparable to 2012 NHANES reference group for protein, vitamins, minerals

Obih C, Nutrition (2016)

Retrospectivecase series

26 Improved clinical and laboratory parameters for Crohn’s disease and UC

Suskind DL, Dig Dis Sci (2016)

Patient survey 417 Majority of respondents perceive clinical benefit to SCD

Burgis JC, World J Gastro (2016)

Retrospectivecase series

11 Improved labs, growth parameters

Kakodkar S, J AcadNut Diet (2015)

Retrospectivecase series

50 SCD is effective for some adults with IBD; High quality of life reported

Suskind DL, JPGN(2014)

Retrospectivecase series

7 Improvement in clinical + lab parameters (Hct, CRP)

Cohen SA, JPGN (2014)

Prospective case series

16 Clinical and mucosal improvements seen

Patient Perceptions on the SCD

• Online survey with 417 respondents

Suskind DL, et al. Dig Dis Sci 2016.

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Crohn’s Disease Exclusion Diet + PEN

• Prospective study: 37 children and young adults with active Crohn’s

• Diet: Polymeric formula 50% daily kcal

• Excluded foods:o Gluten, Gluten-free baked goodso Dairyo Animal fato Processed meato Emulsifiers o Canned goodso All foods with an “expiration date”

CRP

PCDAI

Week 0 Week 6Sigall-Boneh R, et al. Inflamm Bowel Dis 2014. © 2

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Semi-vegetarian diet

• Prospective 2 year trial in Japan: adults with Crohn’s disease in remission (surgery, medical)o Endpoint--disease relapse

• Evaluating 5-ASA and a “semi-vegetarian diet”

o Allowed: eggs and milk; fish once a week, meat q2 weekso Avoid: sweets, bread, cheese, margarine, fast foods, carbonated

beverages, and juices

• 15/16 subjects on semi-vegetarian diet maintained clinical remission

• 2/6 on ad lib diet maintained remission

Chiba M, et al. World J Gastro 2010

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CD-TREAT: Emulating EEN with food

• Hypothesis: Ordinary food diet based on composition of Modulen formula can achieve similar efficacy as EEN for treatment of Crohn’s

• Diet: o Avoid gluten, lactoseo Match macronut, vitamins, minerals, and fibero Food delivered by catering company

• Results:o 28 Healthy adults: similar effects on

fecal bacteria and metabolites o 5 children with Crohn’s: improved

Svolos V, et al. Gastroenterology 2018.

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Which exclusion diet should I choose?

Exclusion Diets have demonstrated efficacy, and further studies are ongoing to evaluate which dietary components are important

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Conclusion

• There are limitations to the clinical data for dietary therapy in IBD. This should not be a deterrent.

• Exclusive enteral nutrition (EEN) is effective therapy for Crohn’s

• Restriction diets involving regular food have shown promise

• Further studies on dietary therapy needed

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Thank you

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Learning Assessment Questions

Question 1: Environmental exposures are associated with the risk of developing inflammatory bowel disease.

A. TrueB. False

Question 2: Exclusive enteral nutritional therapy is effective for BOTH Crohn’s disease and ulcerative colitis.

A. TrueB. False

Question 3: The following are exclusion diets that have been studied in IBD:A. Exclusive enteral nutritionB. The low glycemic index diet C. The specific carbohydrate dietD. The Crohn’s disease exclusion diet

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References

• Hou JK, Abraham B, El-Serag H. Dietary intake and risk of developing inflammatory bowel disease: a systematic review of the literature. American Journal of Gastroenterology 2011;106:563-73.

• Zachos M, Tondeur M, Griffiths AM. Enteral nutritional therapy for induction of remission in Crohn's disease. Cochrane Database Syst Rev 2007:CD000542.

• Lee D, Albenberg L, Compher CW, Baldassano RN, Piccoli DA, Lewis JD, Wu GD. Diet in the Pathogenesis and Treatment of Inflammatory Bowel Disease. Gastroenterology, 2015 May; 148 (6): 1087-106.

• Lee D, Baldassano RN, Otley AR, Albenberg L, Griffiths AM, Compher CW, Chen EZ, Li H, Gilroy E, Nessel L, Grant A, Chehoud C, Bushman FD, Wu GD, Lewis JD. Comparative Effectiveness of Nutrition and Biological Therapy in North American Children with Active Crohn’s Disease. Inflammatory Bowel Diseases, 2015; 21: 1786-1793.

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Upcoming SCD studies

• Multi-center, led by Dr. David Suskind: SCD n-of-1 studyo 120 participants with active Crohn’s (32 weeks)

o Crossover between SCD and “liberal SCD”

o Endpoints: disease activity, fecal calprotectin

• UPenn, Dr. James Lewis: SCD vs. Mediterranean dieto 194 participants with active Crohn’s disease (6 weeks)

o Randomized 1:1 to the two dietso Intervention: 3 meals and 2 snacks delivered to homeo Endpoints: disease activity and fecal calprotectin change