CONDITIONS & DISORDERS
CROHN’S DISEASE AND ENTERAL NUTRITION This article reports on the use of enteral nutrition (EN) for remission and looks at new research into partial enteral nutrition (PEN) and the Crohn’s Disease Exclusion Diet (CDED). Crohn’s disease is a form of inflammatory bowel disease (IBD), alongside ulcerative colitis. Both are long-term conditions that cause inflammation of the gut. It is unclear what causes IBD, but it is thought to be a combination of genetics and individual immune systems. Crohn’s disease can result in inflammation anywhere in the digestive tract, from the mouth to the anus, but is most commonly seen in the in small intestine or colon.1 Smoking is linked to an increased risk of developing Crohn’s disease.2 Symptoms can be unpleasant and include abdominal pain, loose and frequent bowel movements, fatigue and weight loss as a result of malabsorption. ENTERAL NUTRITION (EN)
Crohn’s disease is increasing in incidence worldwide.3 Dietary intervention is deemed important, as many of the drugs used in treating the condition involve immune suppression and carry associated risks of infections, or, in some cases, malignancy.4 Nevertheless, overall, there is a lack of evidence looking into diets specific to Crohn’s disease, particularly in adults. The use of EN – a liquid-only diet – for the management of Crohn’s disease was first described in the 1970s5 and it is known today, that EN given either orally or via a nasogastric (NG) tube may be used during a flare up. Exclusive EN has been seen to improve the symptoms of Crohn’s disease as it gives the bowel ‘rest’ and allows for mucosal healing. It has also been shown to reduce
Rebecca Gasche Specialist Dietitian, Countess of Chester Hospital NHS Trust
the production of bacterial metabolites within two weeks and reduce the bacterial coating with immunoglobulin.6 EN is usually taken for six to eight weeks and elemental or polymeric oral nutritional supplements or feeds can be used. DIETARY MANAGEMENT
For patients who experience stricturing Crohn’s (narrowing of the bowel), the ESPEN guidelines recommend that a diet with modified texture or EN may be advised.7 The guidelines go on to say that for patients with radiologically identified but asymptomatic stenosis of the intestine, it is common to recommend a diet low in fibre. However, there is no robust data to support this apparently logical approach. When symptoms are present, it may be necessary to adapt the diet to one of soft consistency, perhaps predominantly of nutritious fluids. There is also some evidence for the use of a low residue (low-fibre) diet if there are strictures as a result of Crohn’s disease.7 A literature review by Rhodes and Richman8 reported that indirect evidence for diet and IBD suggests that Crohn’s patients should have a diet that is low in animal fat, avoid foods that are high in insoluble fibre and avoid processed fatty foods. Supplementary vitamin D should be considered and dairy products if tolerated can be consumed to help ensure adequate calcium intakes. There is weak evidence that olive oil might be protective and evidence to suggest that strict
Rebecca has a keen interest and specialises in gastroenterology dietetics. She currently works in the community setting in the Chester area, running clinics and group sessions to manage a wide range of gastroenterology conditions.
REFERENCES Please visit: https://www. nhdmag.com/ references.html
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TAKE A FRESH LOOK AT MANAGING CROHN’S DISEASE
ModuLife is based on a clinically proven solution for the management of Crohn’s Disease (CD) through food and specialist nutrition.1-3 Visit www.mymodulife.com to learn more or ask your Nestlé Health Science representive about enrolling on our free training programme.
THERE’S NO OTHER CD SOLUTION LIKE IT FOR HEALTHCARE PROFESSIONALS ONLY References: 1. Sigall Boneh R, et al. Inflamm Bowel Dis. 2014 Aug;20(8):1353-1360 2. Sigall Boneh R et al. J Crohn’s Colitis. 2017 Oct 1;11(10):1205-1212. 3. Levine A, et al. Gut 2018;67:1726-1738 Modulen IBD is a Food for Special Medical Purposes for the dietary management of Crohn’s disease. For use under Medical Supervision.
Nestlé Health Science UK
CONDITIONS & DISORDERS avoidance of dairy products and/or lactose is not justified. The published guidance provided by professional bodies varies considerably between different sources and is often based on consensus of opinion rather than evidence.8 Further research into this field is needed. The ESPEN guidelines7 report that the use of EN for the treatment of Crohn’s disease in adults is generally weaker than that of paediatric studies, hence most centres will continue to use steroids (or biologicals) as first-line therapy unless these agents are actively contraindicated. However, patient and disease characteristics also contribute to therapeutic management decisions and these may make EN therapy a first-line option in selected cases of adults with a Crohn’s disease flareup. COCHRANE REVIEW
An updated Cochrane review9 (a systematic review of the evidence base) from 2018 looked at whether EN can benefit Crohn’s patients more than corticosteroids. It concluded that there was very low-quality evidence to suggest that corticosteroid therapy may be more effective than EN for induction of clinical remission in adults with active Crohn’s disease. The review also found that there was very low-quality evidence to suggest that EN may be more effective than steroids for induction of remission in children with active Crohn’s disease. When looking at protein composition of feeds for EN, the review found that it does not appear to influence the effectiveness of EN for the treatment of active Crohn’s disease. The review did highlight the fact that many adults and children require NG tube feeding due to the palatability of supplements used and, therefore, EN should be considered in patients who can either comply with NG tube feeding or perceive the nutritional supplements to be palatable, or when steroid side effects are not tolerated, or better avoided. The review advised that more products from industry should be developed to make palatable polymeric formulations, so that they can be delivered without use of a NG, as this may lead to increased patient adherence with this therapy. As highlighted in the Cochrane review,9 the use of EN to achieve remission in children with 16
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Crohn’s is often used as first-line treatment, rather than the use of steroids.3 However, a strict compliance is required and NG tube feeding is often used to overcome this. Besides formulating more palatable nutritional supplements, is there another way to overcome this? A NEW APPROACH?
This year, there has been new research looking into the use of partial enteral nutrition (PEN) and the Crohn’s Disease Exclusion Diet (CDED). The study by Levine et al was published in August 2019, and involved a 12-week trial in children with moderate-mild Crohn’s disease.3 Prior to this study, additional research by Levine et al10 suggested that diet may impact on the pathogenesis of Crohn’s disease, in particular looking at the alteration of microbiome and a breakdown in barrier function with defective bacterial clearance. This particular study from 2018 suggested that a different approach to Crohn’s therapy could be considered, targeting microbiome as this may play a role in the generation of inflammation.10 The changes and westernisation of foods may also play a role in effecting the microbiome, and previous studies looking at PEN with diets of equal part fat, protein and carbohydrate, showed this was not effective in inducing remission.11 The CDED diet had previously shown a promising ability to induce remission and decrease inflammation in case series in both children and adults with CD,12 however, the Levine et al (2019) research was the first study to compare CDED combined with PEN against complete EN.3 This study3 randomly split the groups into either receiving a PEN diet, using Nestle’s product Modulen IBD, alongside a Crohn’s disease exclusion diet (CDED), versus a complete EN diet. The CDED diet is a wholefood diet designed to reduce exposure to the dietary components that are thought to negatively affect the microbiome, intestinal barrier and intestinal immunity. Those on the CDED diet had six weeks of Modulen as PEN and diet making up 50% calories each, followed by 75% diet and 25% PEN in weeks 7-12. Those on complete EN had Modulen IBD as a sole source of nutrition for six weeks, followed by free diet and PEN contributing to 25% calories in weeks 7-12.3
CONDITIONS & DISORDERS The foods allowed in the first six weeks of the CDED diet included protein sources such as egg, chicken, carbohydrates in white rice and certain fruits and vegetables such as one slice of melon, fresh strawberries and carrots. In weeks 6-12 more varieties of fruits, vegetables and higher fibre/fat foods were reintroduced, with foods more likely to trigger symptoms, such as wheat, lactose and artificial sweeteners, being avoided until the full 12 weeks was completed. The results3 showed that both diets were associated with high and comparable rates of clinical remission and both had a significant and similar decrease in inflammation by week 6, and both groups had similar changes in the microbiome induced by diet by week 6. However, the biggest differences were noted in weeks 6-12. The two groups differed from week 6 (as the completely EN group transitioned to PEN with gradual return to free diet), as sustained remission, maintenance of remission and normal CRP (an inflammatory marker) remission at week 12 were significantly better in the CDED/PEN treated group. Faecal calprotectin (a stool sample looking
for inflammation) was actually noted to increase in weeks 6-12 in those on the total EN group, whereas it decreased in those of CDED and PEN. This data suggests that the foods being avoided in the CDED do in fact play a role in remission of Crohn’s disease, and that a structured approach to reintroducing diet should be considered.3 Despite this trial being looked at only in children, the CDED diet is also being recommended in adults, with the hope that it will improve compliance. It is worth noting that Nestlé Health Science funded the above study and have now launched Modulife as a result, a new program ran by Nestlé using the CDED and PEN approach. It provides an online training course for healthcare professionals, as well as support for patients in the form of an app that allows patients to track their diet, contact healthcare professionals, look up recipes, etc. I feel this is a really good resource for patients, as any dietary treatment can be daunting and having support available could be of great benefit.13
Coming in the next issue Dec 2019/Jan 2020 www.NHDmag.com
• Premature infant feeding • Plant-based diets
• Paediatric diabetes
• Nasogastric tube feeding
• ERAS wound care
• Constipation
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