ESPEN launches an updated guideline on nutrition in IBD

By Andreu Prados, PhD, BPharm, RDN, and Catherine WallPhD, NZRD

Inflammatory bowel disease (IBD) can impact the body’s digestion and absorption of nutrients resulting in an impaired nutritional status. Identifying and treating nutrient deficiencies is central to improving quality of life and preventing further complications in patients with IBD.

To help physicians, doctors of different specializations, registered dietitians, pharmacists, nurses, and other professionals involved in the care of patients with IBD, the European Society for Clinical Nutrition and Metabolism (ESPEN) has updated its guideline on clinical nutrition in IBD published first in 2017.

Find below the main ESPEN guideline’s take-home messages on the role of nutritional therapy in the prevention and treatment of IBD and IBD and treatments of malnutrition for patients in the hospital and home settings:

1. Role of nutrition in the prevention of IBD:

• A diet containing adequate fiber intake (more than 25-30 g per day) and omega-3 fatty acids, and low in omega-6 and artificial trans fatty acids protect against IBD: this means including at least 5 handfuls of different coloured fruit and vegetables daily, eating daily foods that contain omega-3 fatty acids (e.g., nuts and seeds, fish, seafood and canola oil) and eat less foods that are high in omega-6 fatty acids (e.g., sunflower, safflower, corn, vegetable oils, commercial mayonnaise) and commercially prepared long shelf life products that contain hydrogenated fats that are high in trans fatty acids. 
• Ultra-processed food and dietary emulsifiers (i.e., carboxymethylcellulose) could be associated with an increased risk of IBD
• Breastfeeding reduces the risk of IBD. If you can breastfeed, breastfeeding for longer is more protective.

2. IBD and malnutrition:

• Malnutrition is a common IBD complication and patients with IBD should be screened for malnutrition regularly and treated appropriately
• While overall energy requirements for patients with IBD are similar to those of healthy people (30-35 kcal/kg/day), particular disease states (e.g., acute inflammation during flares) may increase energy demands, especially in ulcerative colitis
• Protein requirements are increased in active IBD (in adults protein intake should be increased to 1.2-1.5 g/kg/day), while they are not elevated in remission IBD. Daily protein intake for an adult in remission includes 2 protein servings. One serving equals 65 grams of cooked lean meat, 100 grams of cooked fish, one cup of cooked/canned legumes, 2 large eggs, 170 grams of tofu or 30 grams of nuts/seeds.
• Patients with IBD should be checked for micronutrient deficiencies at least once per year, both in the active and remission phase
• Iron, zinc, and vitamin D deficiencies are common in IBD and require specific replacement approaches
• Oral iron to correct anemia is preferred compared to intravenous iron as first-line treatment in patients with iron deficiency or mild anemia, those with inactive disease, and those who have not been previously intolerant to oral iron
• Dietitians and nurses are central to improving nutritional therapy of patients with IBD and avoiding malnutrition 

3. Role of nutrition in active IBD:

• Crohn’s Disease Exclusion Diet (CDED) plus enteral nutrition should be considered versus exclusive enteral nutrition in pediatric patients with mild to moderate CD to achieve remission
• CDED can be considered (with or without enteral nutrition) in adults with mild to moderate active CD
• Patients with intestinal strictures may need a diet with adapted texture or exclusive enteral nutrition
• Children and adults with active disease, under treatment with corticosteroids, or with suspected hypovitaminosis D should be monitored for vitamin D status and treated with calcium/vitamin D appropriately
• Fat malabsorption is common in patients with IBD and should be assessed by looking for the cause and treating it
• Other nutritional interventions if oral feeding is not sufficient include oral nutritional supplements, enteral nutrition, and, lastly, parenteral nutrition, which should be recommended in a personalized manner

See here available science-based dietary options for nutritional therapy for IBD.

4. Nutritional therapy before and after surgery in IBD:

• Nutritional status should be checked before surgery and treated accordingly with diet in patients with malnutrition
• Normal food intake, oral nutritional supplements, or enteral nutrition are affordable for most patients with IBD after surgery. If oral diet cannot be recommended after surgery, enteral nutrition and/or parenteral nutrition should be indicated

5. Gut microbiome-targeted interventions in IBD:

• Probiotics should not be recommended for the treatment of Crohn’s disease, while selected probiotics can help some patients with ulcerative colitis when 5-aminosalicylic acid is not tolerated
• Prebiotics should not be recommended for the treatment in Crohn’s disease or ulcerative colitis
• No recommendation can be made for or against fecal microbiota transplantation in IBD

6. Role of nutrition in remission IBD:

• In the remission phase of IBD, patients should be advised to follow a healthy diet and avoid individual food triggers
• Neither enteral nutrition nor parenteral nutrition are first-line treatments for maintaining remission in IBD. If nutritional therapy with normal foods is not sufficient to manage malnutrition, oral nutritional supplements or enteral nutrition can be recommended
• Vitamin B12 supplementation is needed in patients with the resection of the ileocecal valve or with documented deficiency
• Folic Acid supplementation is needed in patients treated with sulphasalazine and methotrexate
• Iron and folate levels should be monitored regularly in pregnant women, and deficiencies should be treated accordingly
• Breastfeeding women should also check their nutritional status to identify deficiencies

The updated ESPEN guideline is available as an app version for download for iOS and Android and a web-based version will become available soon.

References

‍^{Bischoff SC, Bager P, Escher J, et al. ESPEN guideline on clinical nutrition in inflammatory bowel disease. Clin Nutr. 2023; 42(3):352-379. doi: 10.1016/j.clnu.2022.12.004.}

^‍‍About the writers:

‍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. He holds bachelor’s degrees in Pharmacy and Human Nutrition and Dietetics and a PhD in nutrition communication.

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Dr. Catherine Wall has an undergraduate degree in Human Nutrition and a postgraduate diploma in dietetics. Her PhD research focused on nutritional therapy for adults with active Crohn's disease. Thereafter, she completed a postdoctoral fellowship in nutrition screening and dietary management of inflammatory bowel disease at King's College London, United Kingdom.

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