Clinical challenges: integrating diet into the management of Crohn’s disease

Incorporating nutrition into treatment regimens for Crohn’s disease has some support, with a shift toward a whole food approach for symptom relief and healing.

Although far from definitively established, inflammation is a potential mechanism through which diet may modulate the onset of Crohn’s disease.

“There is some evidence that certain dietary components may increase the risk of developing celiac disease, but it is less clear whether diet has any impact on flare-ups of existing diseases,” says Linda A. Feagins, MD, of Dell University Medical School of Texas. Austin. “The studies on nutrition are mainly retrospective, so we have to take the data with a grain of salt.”

Although no specific dietary or environmental factor is known to directly trigger inflammatory bowel disease or trigger flare-ups, a review of three large prospective cohorts of health professionals found that people who had a diet high in inflammation potential had an increased risk of developing Crohn’s disease.

Specifically, compared with participants in the lowest quartile of the cumulative mean empirical dietary inflammatory diet score (EDIP), those in the highest quartile had a 51% higher risk of celiac disease (HR 1.51, 95% CI 1.10-2 .07, P=0.01 for trends). Compared to participants with persistently low EDIP scores, those who switched from a low- to a high-inflammatory diet or persistently followed a pro-inflammatory diet had a greater risk of Crohn’s disease (HR 2.05, 95% CI 1 ,10-3.79 and HR 1.77). , 95% CI 1.10-2.84).

Components in typical Western diets have mainly been proposed as triggers for Crohn’s disease, where dietary antigens cause changes in the gut microbiome leading to flora dysbiosis, altered host homeostasis and dysregulated T cell immune response.

These potentially harmful aspects of the Western diet include higher intake of red and processed meats, ultra-processed convenience foods, sugar and refined grains. Other features include greater consumption of unhealthy fats, such as saturated and trans fats and omega-6 polyunsaturated fatty acids, as well as exposure to commercial food additives and emulsifiers such as carrageenan and additive-associated inorganic microparticles.

“The data on food additives comes mainly from animal studies, although there is some small human data that suggests they may play a role,” Feagins said.

In contrast, a reduced risk has been associated with the Mediterranean diet’s higher intake of fiber and the polyunsaturated omega-3 fats found in fish, nuts, seeds and avocados. Individuals can easily make beneficial changes by eating a fiber-rich Mediterranean diet, told Ashwin Ananthakrishnan, MD, MBBS, MPH, of Massachusetts General Hospital and Harvard Medical School in Boston. MedPage Today.

Although most doctors agree that maintaining good nutrition is essential in Crohn’s disease, it is less clear what the best way to do it is. In terms of maintenance, high quality data on diet is limited, with studies investigating the causes of dietary relapse showing mixed results. Nutritional therapies remain underutilized by many gastroenterologists, and randomized controlled trials are lacking for most popular diets.

Furthermore, integrating nutrition into management is clinically challenging, Ananthakrishnan said. “Dietary strategies require a lot of patient involvement and motivation for sustained adherence, and partial adherence is less effective than full adherence.”

Additionally, relying on fresh, high-quality, home-made food is expensive and time-consuming. “This may not be possible for everyone,” he added. “Children, adolescents and young adults attending college have limited control over the quality of their food and preparation methods. This makes dieting a challenge without adequate support from the entire family.”

Other regimes

Apart from whole food diets, dietary interventions whose benefits have been tested in randomized controlled trials include exclusive enteral nutrition or the CD exclusion diet, Ananthakrishnan said.

For example, an Israeli-Canadian study of 74 children found that combining a celiac disease exclusion diet with 50% of calories from enteral nutrition induced sustained remission in a significantly greater proportion of patients than exclusive enteral nutrition. It also caused remission-associated changes in the fecal microbiome. At week 12, after return to 25% enteral nutrition with the CD exclusion diet or a free diet, remission rates without corticosteroids were 75.6% and 45.1%, respectively (OR 3.77).

“A number of other exclusion diets, including the specific carbohydrate diet, have also shown benefits in reducing Parkinson’s disease,” Ananthakrishnan said. “But ensuring adequate soluble fiber from fruits and vegetables, minimizing processed foods and red meat intake, and reducing sugar-sweetened beverages appear to be beneficial. In general, it is important to combine nutritional therapy with pharmacological therapy to ensure maximum benefit to the celiac patient.”

But do gastroenterologists routinely recommend this approach? “There is no published data on physicians’ practices, but my perception is that more physicians, especially in academic centers, are at least beginning to recognize that nutrition plays a role,” Feagins said. “But there is still a group of doctors and an older dogma that says diet plays no role.”

The challenge in recommending any diet is that people’s disease and eating preferences are both heterogeneous, she added. “And doctors rarely have the information to recommend which diet to which patients.”

Ananthakrishnan agreed: “Historically, gastroenterologists and even nutritionists have not received sufficient training in the role of nutrition in Crohn’s disease. But this is changing as there is increasing data and training programs to address this.”

In the current clinical setting, if a patient has active disease and is starting a new therapy, Feagins often encourages synergistic treatment with a Mediterranean diet. “And if CD is under control and the patient is on optimal medications without active disease but begins to experience symptoms of irritable bowel syndrome [IBS] on top of CD I will look at the IBS spectrum and perhaps recommend a trial of low-FODMAP [fermentable oligo-, di-, and monosaccharides and polyols] diet,” she said.

As for potentially anti-inflammatory supplements like fish oil and turmeric, “I don’t recommend these routinely, but I have no problem if a patient wants to take them,” Feagins said. ‘And there are indications that turmeric helps with this [ulcerative colitis].”

Given the danger of macro- and micronutrient deficiencies with specialized diets, gastroenterologists should consider engaging registered dietitians to optimize nutrition in the inpatient and outpatient setting. All CD patients should be screened for malnutrition, Feagins said. “This is something we do at my clinic at least annually, if not more often. There is a very simple screener that has two questions to do this. This helps me decide who should see the dietitian sooner rather than later.”