DDW 2024 Nutritional Highlights Part 1. Gastrointestinal expert dietitians and access to sufficient foods matter for better IBD outcomes

In May 2024, Nutritional Therapy for IBD attended Digestive Disease Week in Washington, D.C. Find out more about the best practices for integrating a gastrointestinal expert dietitian in IBD care and the impact of access to sufficient foods and malnutrition in IBD (Part 1).

Diet for IBD Prevention

An altered gut microbiome induced by a Western diet has been suggested as a potential trigger of metabolic and immune pathologies, including IBD. New findings in mice by Eugene B. Chang, MD and colleagues from the University of Chicago showed a Western diet also impairs the complete recovery of the gut microbiome after a short course of antibiotics. Also, the longer post-antibiotic dysbiosis, the higher the risk of Salmonella infection accompanied by high levels of cecal inflammation. What is interesting to note is that diet was more effective than microbial re-seeding for robust gut microbiome recovery after antibiotic perturbation.¹ Considering that antibiotic exposure is associated with an increased risk of IBD, these findings suggest diet may contribute to improving the damage of antibiotics in the microbiome that may have contributed to the development of IBD.

Patients with IBD are at increased risk of colorectal cancer compared to the general population. According to Jennifer Wargo, MD from the University of Texas MD Anderson Cancer Center, targeting the gut microbiome by prebiotic food sources could become the next pillar of cancer care. One simple and effective way to target the microbiome to modulate systemic inflammation and improve immunotherapy response may be to achieve 50 g of dietary fiber daily.²

One of the particular foods of the Western diet that has been most researched in IBD is ultra-processed foods (UPFs). Preliminary findings of the FOod Additives on the Mucosal barrier (FOAM) double-blind placebo-controlled randomized controlled trial revealed in healthy young adults no significant increase in fecal calprotectin after consumption of an emulsifier-free diet combined with 3 daily brownies with one of five emulsifiers (native rice starch, carrageenan, carboxymethyl cellulose, polysorbate-80, or soy lecithin) for 4 weeks. However, carrageenan consumption led to an altered intestinal permeability as assessed by increased blood levels of lipopolysaccharide-binding protein.³ While it is unknown if the poor diet quality that includes higher amounts of UPFs or the ultraprocessing itself is associated with health consequences, limiting UPF for IBD prevention seems prudent according to IBD nutrition guidelines.

Not all foods seem to have the same protective effect on reducing IBD risk. Data from 212,458 healthy individuals (Nurses’ Health Study, Nurses’ Healthy Study II, and Health Professionals Follow-Up Study) showed that consuming two or more servings of fruit daily modestly reduced the 20-year risk of Crohn’s disease, with evidence of a dose-response relationship. It is also worth noting that increasing the duration of a healthy diet, lifestyle intervention, and fruit intake were associated with lower CD risk. If we interpret these findings as a glass half full, reaching a minimum intake of two servings is achievable for the healthy adult population and specifically in those at high risk, including first-degree relatives of patients with IBD, and will have protective effects not only for Crohn’s disease but also cardiovascular deaths.⁴

Dairy foods make up a significant part of the Western diet. Although the saturated fats found in milk are pro-inflammatory, data from 197,765 participants without a diagnosis of IBD who were followed up for 26-30 years showed that yogurt intake was associated with a decreased risk of UC. In contrast, total dairy intake or any of the subtypes of dairy products was not associated with the risk of CD.⁵

A Lack of Access to Healthy Foods Impacts Diet Quality in IBD

Nowadays, 1 in 10 Americans struggle to get fresh, nutritious food,⁶ and access to healthy food items in the United States is one of the most important public health issues, followed by homelessness, and transportation.⁷ While COVID-19 was a major disruptor of food availability, access, utilization, and stability, food insecurity is a pervasive problem that affects low-income populations, black, indigenous, and people of color populations, LGBTQ communities, students, children, and those with disabilities to a greater degree than the majority community according to data presented by Joan A. Culpepper-Morgan,MD chief of the Division of Gastroenterology at Harlem Hospital (New York, USA). People with food insecurity may also live in low-income areas (called “food deserts” or “food swamps”) with large amounts of energy-dense foods.⁸ These findings are worrisome because five or more daily servings of ultra-processed foods were associated with an 82% increased risk of IBD.⁹

Food insecurity is also rapidly rising in patients with IBD, with 48% of patients struggling to obtain groceries due to cost in the last 12 months. Poor access to sufficient food is associated with high consumption of UPFs and low intake of unprocessed foods and may lead to serious consequences on the diagnosis, treatment, and health outcomes of IBD. Indeed, 1 in 8 patients with IBD have poor access to healthy food and lack social support, which is associated with financial hardship due to medical bills and not taking their medications as prescribed.¹⁰ Social workers and registered dietitians should work together to help patients with IBD access healthy, unprocessed foods. Low-cost alternatives for less processed and healthier options exist, including canned vegetables, unsweetened breakfast cereals, pure nut butter, or canned fish.

Combating Food Insecurity to Improve Health Outcomes in IBD

One way to combat food insecurity in IBD is by connecting patients to community-based resources that improve access to culturally tailored dishes. Mayra Rojas-Correa, BS and colleagues from the University of Massachusetts Chan Medical School and the University of Puerto Rico Medical Sciences Campus developed a tailored nutritional program for adult patients with mild-to-moderate CD and with ongoing medications living in Puerto Rico. Among up to 60 patients with CD studied, older patients, females, patients living with partners, and patients with high body mass index had worsened quality of life and mental disorders.¹¹

The anti-inflammatory diet followed by participants mixed the principles of the Mediterranean diet and the Specific Carbohydrate Diet and used traditional foods and cuisine styles. Most of the ingredients were low cost, highly available in local supermarkets, and with minimal potential for triggering symptoms (including a variety of foods that contain probiotics and prebiotics and exclude lactose, wheat, and ultra-processed foods). Overall, 211 recipes were created, accompanied by online resources, a cooking manual, and short cooking videos to enable the patients to easily follow the diet (discover the DAIN study here). Recipes in the DAIN study are grouped into three phases according to the patient’s symptoms and manifestations of disease (fistulas and strictures):¹²

The researchers have started testing the efficacy of the diet followed for 10 weeks on symptoms, blood, and fecal parameters. Preliminary findings show good acceptance of traditional dishes prepared and good compliance with counseling sessions with registered dietitians and gastroenterologists.

Edwin K. McDonald, MD and chef from the University of Chicago Medicine, shared tools for fighting food insecurity based on his experience with the program “Good Food is Good Medicine”, consisting of a series of cooking classes focused on nutrition and making better food choices for 6 weeks. This program mainly involves Black and Latinx adults living in low-income Chicago neighborhoods with low food access.

According to McDonald, healthcare professionals are ethically obligated to ask about food insecurity. In doing so, written questionnaires may be more sensitive than verbal approaches. Instead of telling people what to do or not to foster healthy eating patterns, McDonald encouraged creating spaces (teaching kitchens) where individuals come alone or in groups to learn healthy cooking behaviors and healthy recipes with adapted budgets based on their needs and goals. This strategy for tackling poor access to healthy food involves the nutritional environment (food landscape) and economic, cultural, and individual factors.¹³ Preliminary findings showed that it works and may lead to a quick improvement in gut health and gut microbiome that may motivate people to keep eating better.

To connect patients to a food pantry with free food in a nearby area where they live, the University of Chicago also launched the first Feed1st Food Pantry Toolkit that serves as a guide to implementing food pantries from scratch in hospitals, pediatrics offices, and community health centers. Other tools available for healthcare professionals to ensure patients have nutrition access, resources, and education and implement the “Food is Medicine” approach in healthcare include Instacart Health and produce prescription programs such as VeggieRx and Food is Medicine Coalition tailored programs.

Tools for Assessing Malnutrition in IBD

#1 Hunger Vital Sign

Healthcare professionals should be able to identify those at risk of food insecurity and recognize the increased risk when vulnerabilities overlap. The good news is that assessing food insecurity is fast and easy. For instance, USDA validated screening tool “Hunger Vital Sign” helps assess for risk of food insecurity with only two questions:¹⁴

1. Within the past 12 months, did you worry your food would run out?
2.  Within the past 12 months, did the food you bought last or run out?

#2 Global Leadership Initiative on Malnutrition (GLIM) malnutrition diagnostic criteria

The comprehensive Global Leadership Initiative on Malnutrition (GLIM) diagnostic criteria would also assist in assessing malnutrition in patients with IBD at the time of diagnosis and routinely thereafter. The GLIM malnutrition criteria are more comprehensive than the ESPEN malnutrition criteria and include the assessment of:

• Patient observable characteristics: weight loss, low body mass index and reduced muscle mass (sarcopenia)
• Etiologic criteria: reduced oral food intake or assimilation (active nausea, vomiting, reduced appetite, and diarrhea) and presence of inflammation

#3 Novel Malnutrition Screening and Intervention iNourish Program

The effectiveness of a first-of-its-kind program known as iNourish run in the multidisciplinary Malnutrition-IBD Clinic to support individuals with Crohn’s disease and ulcerative colitis was highlighted at DDW. It consists of novel malnutrition screening using an electronic medical record-based tool and counseling approach developed by Stephanie Gold, MD, Assistant Professor of Medicine (Gastroenterology), and clinical dietitian Laura Manning, MPH, RD, CDN and colleagues at Mount Sinai. Established in 2022 and based on data involving 322 adult patients with IBD who had a positive malnutrition screening, the program’s interventions for 3 months were associated with meaningful improvements in both nutritional outcomes (e.g., body mass index) and patient self-confidence in making dietary choices.

Working with a Gastrointestinal Dietitian Matters for the Comprehensive Care of Patients with IBD

Patients with digestive issues commonly associate food with GI symptoms and choose dietary interventions as their preferred treatment option.¹⁵ However, the care of patients with gastrointestinal issues like IBD poses gaps that can be addressed by including a GI expert dietitian as part of the core IBD multidisciplinary team. The most common barriers to using a GI dietitian for digestive care are:^16,17‍

• Nutrition care is personalized, complicated, and requires long-term guidance from an expert
• Doctors routinely spend little time (less than 10 minutes) on nutrition counseling and rarely provide information on menu planning, label reading, and grocery shopping
• Up to 42% of gastroenterologists lack access to a local GI dietitian

 A session at DDW delved into the benefits and best practices for integrating a GI expert dietitian into the IBD multidisciplinary care team from the perspectives of private practice, an independent gastroenterology clinic, and a GI academic center.

 Lauren Cornell, a private practice GI dietitian, highlighted the benefits of working with a private practice dietitian as support for the physicians’ treatment objectives:

• ‍Broadened schedule and increased availability for appointments‍
• More time is allotted to patients, which leads to thorough care, greater opportunities to coordinate care with other members of the medical team, and optimal efficacy of physicians’ treatment protocol‍
• Improves patient’s motivation to change
• Less institutional red tape and workflow flexibility because healthcare practitioners work in different locations and are not under the same electronic medical record as the private practice dietitian 

However, only 30% of gastroenterologists referring their patients to dietitians use GI-specializing dietitians. Cornell also shared tips for identifying a GI dietitian. “Registered dietitians can be a referral source back to the gastroenterologist with the final goal of coordinating a care team that is best for the patient”, said Cornell. The motto of GI dietitians is working with a patient towards the end goal of avoiding over-restriction and achieving maximum diet variety while maintaining symptom control.

Tamara Duker, RDN, and Eric Goldstein, MD, shared their experience of integrating in-house dietitians as part of the team in an independent operating gastroenterology practice clinic. The main benefits of integrating RDs into GI practice are working as a collaborative team (not in silos), enjoying regular on-demand nutrition sessions, and low cost of liability insurance and licensure. Duker shared tips for navigating insurance and reimbursement for nutrition services and highlighted that bringing an RD aboard is a long-term investment and not easily quantifiable financially, with the goal of improving patient adherence and satisfaction with a diet that will lead to better health outcomes.

The unique perspective of a dietitian can complement the gastroenterologist experience, and having both leads to integrated patient-centered care. William D Chey, MD, and Amanda Lynett, MS RDN, shared their experience working with integrated care from a GI academic center at the University of Michigan. While we are now in the multi-disciplinary care of GI patients, the future will consist of integrated care, which is team-based, collaborative, and multidisciplinary care, including a gastroenterologist, a dietitian, a primary care physician, a psychologist, and evidence-based complementary alternative medicine.

Integrated care for IBS-like symptoms, which affects one in three patients with inactive IBD, leads to better symptom improvement in the short term and long term as compared to traditional care involving only a gastroenterologist.^18,19

References:^‍‍

^{1. Kennedy M, Cooper M, St. George M et al. (2024, May 18-21). Dietary interventions are more effective than microbial re-seeding for microbiome recovery after antibiotic perturbation [Guided Poster Session, P1879] Digestive Disease Week® (DDW) 2024, Washington, D.C.}

^{2.Wargo JA. State-of-the-art lecture: Targeting the microbiome to promote health and end cancer. 21 May 2024. Digestive Disease Week® (DDW) 2024, Washington, D.C.}

^{3. Wellens J, Vanderstappen J, Hoekx S, et al. Preliminary analysis of the FOod Additives on the Mucosal barrier study (FOAM): a placebo controlled randomized trial on the effect of five dietary emulsifiers on inflammation, intestinal permeability and the gut microbiome [Guided Poster Session, P1724] Digestive Disease Week® (DDW) 2024, Washington, D.C.}

^{4. Lopes E. Guideline-based healthy diet and lifestyle interventions for the prevention of Crohn’s disease: a target trial emulation. Oral communication within the session “Clinical insights into the role of diet in IBD”. Digestive Disease Week® (DDW) 2024, Washington, D.C.}

^{5. Sasson A. Dairy intake and risk of incident inflammatory bowel disease in US men and women. Oral communication within the session “Clinical insights into the role of diet in IBD”. Digestive Disease Week® (DDW) 2024, Washington, D.C.}

^{6. USDA. “Food Security: Key Statistics & Graphics.” April 22, 2022.}

^{7. Eder M, Henninger M, Durbin S, et al. Screening and interventions for social risk factors: technical brief to support the US preventive services task force. JAMA. 2021; 326(14):1416-1428. doi: 10.1001/jama.2021.12825.}

^{8. Leung CW, Epel ES, Ritchie LD, et al. Food insecurity is inversely associated with diet quality of low-income adults. J Acad Nutr Diet. 2014; 114(12):1943-53.e2. doi: 10.1016/j.jand.2014.06.353.}

^{9. Narula N, Wong ECL, Dehghan M, et al. Association of ultra-processed food intake with risk of inflammatory bowel disease: prospective cohort study. BMJ. 2021; 374:n1554. doi: 10.1136/bmj.n1554.}

^{10. Nguyen NH, Khera R, Ohno-Machado L, et al. Prevalence and effects of food insecurity and social support on financial toxicity in and healthcare use by patients with inflammatory bowel disease. Clin Gastroenterol Hepatol. 2021; 19(7):1377-1386.e5. doi: 10.1016/j.cgh.2020.05.056.}

^{11. Díaz-Díaz L, Rojas Correa M, Estremera L, et al. (2024, May 18-21). Survey on sociodemographic factors and health-related quality of life in Puerto Ricans with Crohn’s disease [Guided Poster Session, P1129] Digestive Disease Week® (DDW) 2024, Washington, D.C.}

^{12. Rojas-Correa M, Estremera L, Yap YR, et al. Dieta Anti-Inflamatoria or DAIN: A Crohn’s disease management strategy tailored for Puerto Ricans. Contemp Clin Trials Commun. 2023; 34:101162. doi: 10.1016/j.conctc.2023.101162.}

^{13. Temelkova S, Lofton S, Lo E, et al. Nourishing conversations: using motivational interviewing in a community teaching kitchen to promote healthy eating via a food as medicine intervention. Nutrients. 2024; 16(7):960. doi: 10.3390/nu16070960.}

^{14. Hager ER, Quigg AM, Black MM, et al. Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics. 2010; 126(1):e26-32. doi: 10.1542/peds.2009-3146.}

^{15. Sturkenboom R, Keszthelyi D, Masclee AAM, et al. Discrete choice experiment reveals strong preference for dietary treatment among patients with irritable bowel syndrome. Clin Gastroenterol Hepatol. 2022; 20(11):2628-2637. doi: 10.1016/j.cgh.2022.02.016.}

^{16. Scarlata K, Eswaran S, Baker JR, et al. Utilization of dietitians in the management of irritable bowel syndrome by members of the American College of Gastroenterology. Am J Gastroenterol. 2022; 117(6):923-926. doi: 10.14309/ajg.0000000000001602.}

^{17. Lenhart A, Ferch C, Shaw M, et al. Use of dietary management in irritable bowel syndrome: results of a survey of over 1500 United States gastroenterologists. J Neurogastroenterol Motil. 2018; 24(3):437-451. doi: 10.5056/jnm17116.}

^{18. Basnayake C, Kamm MA, Stanley A, et al. Standard gastroenterologist versus multidisciplinary treatment for functional gastrointestinal disorders (MANTRA): an open-label, single-centre, randomised controlled trial. Lancet Gastroenterol Hepatol. 2020; 5(10):890-899. doi: 10.1016/S2468-1253(20)30215-6.}

^{19. Basnayake C, Kamm MA, Stanley A, et al. Long-term outcome of multidisciplinary versus standard gastroenterologist care for functional gastrointestinal disorders: a randomized trial. Clin Gastroenterol Hepatol. 2022; 20(9):2102-2111. doi: 10.1016/j.cgh.2021.12.005.}

‍Dr. Andreu Prados is a science and medical writer specializing in making reliable evidence of non-prescription therapeutics for gastrointestinal conditions understandable, engaging and ready for use for healthcare professionals and patients.

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Dr. Natasha Haskey is a clinical scientist and Registered Dietitian with over 20 years of practical experience in nutrition therapy for IBD.  

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 A new article focusing on what is new in nutritional therapies for IBD management, nuances to consider in dietary recommendations for patients with IBD, and why taking care of gut microbiome matters for determining the efficacy of nutritional interventions. Stay tuned for upcoming news!