Crohn's and Colitis Congress 2022 Nutritional Highlights

Presentations

Rationale for Diet as Treatment for IBD – Review of the Evidence

Presented by Maitreyi Raman, MD, MSc, FRCPC University of Calgary

Dr. Raman describes the various roles of dietary therapy in the management of IBD where it is used as primary induction therapy, in the treatment of malnutrition and micronutrient deficiency, as well as pre-operatively and as maintenance therapy. She reviews dietary patterns including westernization of diet with processed foods, increased sugar, and emulsifiers that effect the gut lining and are increasingly implicated in the development of IBD.

From her recent research, she describes the modification of the gut microbiome in patients with IBD by dietary intervention, including an interesting relationship of increasing leafy green consumption and lower fecal calprotectin (FC) <100 ug/mg, as well as a more favorable ratio of omega-6 to omega-3 fatty acids of 8:1 and lower CRP <5 mg/L, with additional relationships of food components to regulatory cytokines. Dr. Raman has a newly recruiting CD-Therapeutic Diet Intervention study to evaluate not only the efficacy of the dietary therapy on remission but also the effects on microbiome, metabolome, SCFAs, and many other biochemical patterns which may help determine a precision based approach to dietary therapy.

Precision Microbiome in Inflammatory Bowel Disease

Presented by Randy Longman, MD, PhD Director of Jill Roberts Center for IBD, Weil Cornell

Dr. Longman's work hypothesizes that microbiota regulate mucosal and systemic immunity. He reviews the metabolic function of adherent invasive E. coli (AIEC) and its links to mucosal immunity, FMT in UC (including an ongoing trial of fiber supplementation to improve response to FMT), and the impact of sulfasalazine on the microbiome in peripheral spondyloarthritis (SpA).

Role of the Gut Microbiome in Maintaining Nutrient Balance in the Host

Presented by Suzanne Devkota, PhD, Cedars-Sinai Medical Center, Los Angeles

Dr. Devkota explains the role of diet to influence the composition of the gut microbiota which may in turn further play a role in effecting nutritional status. She describes that host sensing of nutritional status may be dependent on cues from the gut shown by the example of the FGF21 pathway that is altered in germ free mice. In the setting of a low-protein diet, the gut microbiome may further play a role in de novo synthesis of amino acids.

Novel Insights into the Mechanisms of Action of Exclusive Enteral Nutrition in Crohn's Disease: Pre-Clinical Study in a Rodent Model of Crohn's-like Colitis

Presented by Ramasatyaveni Geesala, Postdoctoral Fellow II University of Texas Medical branch at Galveston School of Medicine

It is hypothesized that transmural inflammation causes mechanical stress which induces expression of mechanosensitive genes IL-6 and COX 2 in the gut. Dr. Geesala explains that EEN attenuates inflammation by alleviating the effect of mechanical stress-induced expression of pro-inflammatory genes in Crohn's Disease. The basic foundation of this research is described in this recent publication Targeting Mechano-Transcription Process as Therapeutic Intervention in Gastrointestinal Disorders.

My SCD Protocol – An Online Comprehensive, Remotely-Supervised Protocol for IBD patients to implement an effective dietary intervention

Presented by Ali Arjomand, PhD, Modulla Health

Dr. Arjomand describes a self-guided, step-by-step, on demand dietary intervention in 87 patients with either CD or UC showing marked improvement in symptoms.

Video Presentation
IBD patients using specific carbohydrate diet report symptom improvement (from Healio Gastroenterology)
Patients with IBD Cite Symptom Relief with Online Intervention Tool (from MedPage Today)

Nutrition: Soup to Nuts Session

Defining, Assessing and Identifying Malnutrition in IBD

Presented by Kelly Issokson, MS, RD, CNSC Cedars Sinai Medical Center, Los Angeles.

Kelly Issokson explains that malnutrition is highly prevalent in IBD and influenced by activity, extent, and duration of IBD due to malabsorption, enteric losses, inadequate intake, and/or effects of medical therapy. Malnutrition results in increased risk for VTE (venous thromboembolism), longer hospital stays, reduced response to pharmacotherapy, increasing infection and peri-operative complications, and increased costs.

She describes that malnutrition is not defined by metrics such as low albumin or BMI, but is rather a "state of over or undernutrition with or without inflammatory activity that results in changed body composition and diminished function."

Identifying and Assessing Malnutrition Among Patients with IBD (from Gastroenterology Learning Network)

Malnutrition Assessment and Management in the Context of Surgical Resection

Presented by Amy L. Lightner, MD. Cleveland Clinic

Dr. Lightner reviews three cases to discuss nutritional assessment and management in the peri-operative setting with panelists Kelly Issokson, RD; Neha Shah, RD; Stacey Collins, RD; (and patient perspective), Kate Turner, PsyD, and Tiffany Taft, PsyD. Panelists agree that patients should be assessed early on and offered nutritional therapy. In this setting, patients are willing to do everything to improve their outcomes, including EEN, recognizing that enteral nutrition is still beneficial even if not used exclusively, so patients should be offered all of these enteral nutrition options to decide the best fit for them. Kate Turner, PsyD, describes the importance of discussing with patients the emotional, social, and psychological impact when making decisions utilizing enteral nutrition.

Evaluating Patients for Nutritional Deficiency and Problematic Eating Behavior

Presented by Tiffany Taft, PsyD, Northwestern University,

Dr. Taft describes that patients with IBD are navigating many factors around eating, including nausea, pain, social factors, and aversion to foods. It is important to evaluate if this is an adaptive response to health condition of IBD or a disordered eating pattern like avoidant restrictive food intake disorder (ARFID).

ARFID originated in the pediatric population with sensory and autism spectrum disorders and is now being adapted to IBD. In evaluating patients with the nine-item ARFID scale, 50% of patients with IBD met the criteria for ARFID. Studies using the NIAS scale show lower prevalence of 17%. Restricting food due to fear of GI symptoms was the primary driver of ARFID diagnosis. The Fear of Food Questionnaire (2021) with eighteen questions may be the best assessment tool. In evaluating patients it's important to also remember that eating disorders are highly stigmatized and stereotyped and thus more often attributed to young white women than men or racial or ethnic minorities.

Dr. Taft describes the importance of considering the context of the symptoms. "What clinicians may believe to be an excessive use of food avoidance to prevent IBD symptoms may not align with what our patients believe. We're asking them to eat in spite of feeling nauseated, with abdominal pain and diarrhea. Most of us would NOT eat when feeling this way for a short term infection"

ARFID or Reasonable Food Restriction? The Jury Is Out (from Medscape)

Guild Level Response of Gut Microbiota to Nutrition Intervention/Care and the Health Consequences

Presented by Liping Zhao, Professor, Chair of Applied Microbiology, Rutgers University, Shanghai Jiao Tong University

Dr. Zhao describes ecosystems as complex adaptive systems. Members of wildly different species work together to form a coherent functional group known as a guild. Is it possible that the gut microbiota work together in a guild fashion to improve our health?

Within the same species, there are numerous strains with different ecological functions. The foods we eat feed the microbiome downstream. Dr. Zhao shows a high-fiber diet in Type 2 DM provides strain level response to SCFA production. He further explains that gut bacteria seem to work together as guilds, not as taxa. The foundation of this work is found in this publication: Guild-based Analysis for Understanding Gut Microbiome in Human Health and Diseases.

Metabolism and Bile Acids in IBD

Presented by Dr. Ece Mutlu MD, MS, MBA, Professor of Medicine, Division of Gastroenterology and Hepatology, University of Illinois, Chicago.

Dr. Mutlu explains the metabolome is the sum of all small molecular weight metabolites in a biological sample. There are 65 human metabolomic studies in IBD with consistent themes of metabolomic differences in the IBD vs non-IBD population (Gallagher K et al). Metabolomic features can be altered by diet, as in Dr. Mutlu's research showing the Specific Carbohydrate Diet (SCD) increases butyrate. However, there is more to the story than SCFAs, as tryptophan, tyrosine, sulfur metabolism, lipid metabolism, and B vitamins also play important functional roles. There are metabolomic associations with disease activity, fecal calprotectin, and CRP, as well as associations with treatment and prediction of flare, although Dr. Mutlu explains that these are not ready yet for clinical use.

An IBD metabotype is forming in which bile acid alterations are recognized. Bile acids are synthesized in the liver from cholesterol as primary bile acids, CA and CDCA. They are conjugated and released into the bile duct and into the lumen, where they become deconjugated and reabsorbed. Secondary bile acids are also produced in the lumen via 7 alpha-dehydroxylation. In IBD the amounts of both deconjugated bile acids and secondary bile acids are reduced. Bile acids can affect barrier and immune function pathways and offer future potential avenues of research to advance our knowledge.

Diet as a Risk Factor for IBD

Presented by Ashwin Ananthakrishnan, MD, Massachusetts General Hospital,

Dr. Ananthakrishnan describes that diet is relevant to IBD pathogenesis as we consider the known triad of factors: genetics, microbial disturbances, and immunologic defects with diet impacting the latter two of these. There are four levels of evidence he reviews, beginning with ecological evidence and stepping up through case-control studies, prospective cohorts and finally to human and animal model interventional studies.

Global trends in westernization of diet, with increasing consumption of sugars, fats, and animal proteins, with decreasing consumption of fiber, parallel the increasing incidence of IBD. Prospective cohorts like the Nurses Health Study have shown that increasing fiber, particularly from fruits and vegetables, is associated with reduced risk of developing Crohn's Disease (CD). The EPIC study shows increased intake of omega-3 FA with reduced risk of developing ulcerative colitis (UC). In addition, micronutrient intake such as zinc may also play a protective role. Adherence to a MED has been associated with a decreased risk of developing CD. Dietary patterns high in inflammatory foods were also associated with the development of CD as were high intake of ultra-processed foods.

Ashwin Ananthakrishnan, MD, MPH, on Diet as a Risk Factor in IBD

Clinical Trials of Nutrition Therapy for IBD

Presented by James Lewis, MD, MSCE University of Pennsylvania

Dr. Lewis describes strategies to modify diet, including adding specific foods or supplements, eliminating certain foods and adding more of others, or modifying diet to create a liquid formulation of diet. There is renewed interest in dietary therapy with numerous ongoing clinical trials in therapeutic diets. Remission rates with extensive research in EEN reach 70-80%, with evidence of mucosal healing.

Simple restrictions may not be adequate; for example, the FACES trial did not show reduction in red meat to affect symptomatic relapse. The Crohn's Disease Exclusion Diet (CDED), which includes specific foods, increases fruits and vegetables, and excludes other foods such as grains and dairy, used in combination with PEN, shows similar rates of remission to EEN in pediatric patients and similar 80% remission rates in an open label trial of adults.

In the DINE-CD study comparing Specific Carbohydrate Diet (SCD) to Mediterranean Diet (MED), at the end of 6 weeks, 46% and 43% of patients respectively were in symptomatic remission with 34% to 30% respectively experiencing fecal calprotectin (FC) response with no significant difference between them. In the low-fat diet vs improved standard American diet UC trial, both diets showed improvement in symptoms, with some improvement in inflammation in the low-fat diet group, with a more favorable omega-6 to omega-3 ratio.

Potential guidance for patients: shop the outside aisle, increase fresh fruits and vegetables, choose fresh meats and fish, use olive oil as dominant fat and mixed nuts as an alternative snack to chips, cookies, etc.

High Output Ostomy and Short Bowel Syndrome

Presented by Barbara Bielawska MD, MSc, FRCPC University of Ottawa

High ostomy outputs are > 1.5L/day. They are a frequent cause of hospital readmission after a new ostomy and cause significant complications including dehydration, electrolyte imbalance, kidney stones, chronic kidney disease (25% within 2 years), fatigue, leakages, skin breakdown, social isolation, depression, and poor QOL.

It is important to look for underlying causes of high output ostomy. Potential causes include poor quality of remnant small bowel, sepsis or infection, obstruction, recurrent IBD, medications, and Short Bowel Syndrome.

Patients tend to decrease intake in order to decrease output. Dietitians should instruct patients regarding maintaining oral intake and nutritional status. Medications should be considered to counteract transit time.

Ostomy output levels should be targeted to <1.5L/day and urine >1 L/day. Electrolytes and renal function should be monitored. Patients should be instructed to avoid hypotonic fluids (water) or hypertonic (fruit juices), simple sugars, and standard oral nutritional supplements like Boost or Ensure. Patients are further recommended to separate liquids and solids by 30 minutes, increase complex carbohydrates, and use oral rehydration solutions, 2 cups per day, sipping slowly and working up to 1 L/day while increasing salt intake.

J-Pouch: The Role of Diet

Presented by Elizabeth Wall, MS, RDN-AP, CNSC, University of Chicago,

The relationship of J-Pouch function to meals is recognized by patients, where many are anxious, confused, and frustrated about managing diet with an ileostomy. Dietary recommendations for patients with a J-Pouch include eating multiple small meals; including soluble fibers, and consuming moderate fat and protein while avoiding greasy food, insoluble fiber, caffeine, and alcohol. Additional recommendations include separating consumption of solids and liquids, sipping fluids throughout the day, timing anti-motility medications before meals, and avoiding meals 2-3 hours prior to bedtime to reduce nocturnal BMs.

Patients with a J-Pouch often report trigger foods and may need to further explore food intolerances. Insoluble fibers, caffeine, and alcohol draw water in to the gut lumen and are recognized to increase symptoms. Therapeutic diets like MED or SCD may also be helpful as well as Low FODMAP (temporarily if concurrent symptoms of IBS or small bacterial overgrowth (SIBO) is present). A long term goal for patients may be a plant based MED.

Posters

Diet-Associated inflammation, Physical activity, and Health-Related Outcomes in Ulcerative Colitis

Presented by Kelli Dubois, MS, PhD Candidate, University of South Carolina

Findings from 2052 patients with UC participating in IBD Partners e-cohort suggest an anti-inflammatory diet and physical activity are each complementary to decrease disease activity, anxiety, depression, and fatigue and to improve HR quality of life, sleep, and social satisfaction.

https://ccc.digitellinc.com/ccc/live/18/page/312/1?eventSearchInput=diet+and+IBD (must be registered at the CCC2022 to view)

Effectiveness of Crohn's Disease Exclusion Diet for Induction of Remission in Crohn's Disease Adult Patients

Presented by Martyna Sczcubelek, MD, Department of Internal Medicine and Gastroenterology, Warsaw Poland

Thirty-two adult patients with active CD were treated with CDED plus Modulen in an open label trial. A statistically significant drop in CDAI at 6 weeks and 12 weeks was achieved, with 83% clinical response observed. IBDQ was significantly improved as well as FC levels. Clinical remission was present in 82.1% of patients after 12 weeks from baseline.

Effectiveness of Crohn's Disease Exclusion Diet for Induction of Remission in Crohn's Disease Adult Patients

Long Term Outcomes of Partial Enteral Nutrition Therapy in Children with Crohn's Disease      

Presented by Srisindu Vallanki, MD, Children's Hospital of Philadelphia.

A retrospective chart review of 40 pediatric patients with CD continuing partial enteral nutrition (PEN) up to 1-2 years suggests this can be an effective long-term treatment strategy for mild pediatric CD.