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Nasser J, Mehravar S, Pimentel M, Lim J, Mathur R, Boustany A, Rezaie A. Elemental Diet as a Therapeutic Modality: A Comprehensive Review. Dig Dis Sci 2024; 69:3344-3360. [PMID: 39001958 PMCID: PMC11415405 DOI: 10.1007/s10620-024-08543-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 06/21/2024] [Indexed: 07/15/2024]
Abstract
Elemental diets have been employed for the management of various diseases for over 50 years, with several mechanisms mediating their beneficial effects. Yet, they are underutilized due to poor palatability, access, cost, and lack of awareness regarding their clinical efficacy. Therefore, in this review, we aimed to systematically search and review the literature to summarize the formulation variability, mechanisms of action, clinical applications, and tolerability of the elemental diets in gastrointestinal diseases. While large prospective trials are lacking, elemental diets appear to exhibit objective and subjective clinical benefit in several diseases, including eosinophilic esophagitis, eosinophilic gastroenteritis, inflammatory bowel diseases, small intestinal bacterial overgrowth, intestinal methanogen overgrowth, chemoradiotherapy-associated mucositis, and celiac disease. Although some data support the long-term use of elemental diets as an add-on supplement for chronic pancreatitis and Crohn's disease, most of the literature on exclusive elemental diets focuses on inducing remission. Therefore, subsequent treatment strategies for maintaining remission need to be adopted in chronic/relapsing diseases. Several mechanistic pathways were identified to mediate the effects of elemental diets, including food additive and allergen-free content, high passive absorption rate, and anti-inflammatory properties. High rates of intolerance up to 40% are seen in the trials where exclusive elemental diets were administered orally due to poor organoleptic acceptability; however, when tolerated, adverse events were rare. Other limitations of elemental diets are cost, access, and lifestyle/social restrictions. Moreover, judicious use is advised in presence of a concomitant restrictive food intake disorders. Elemental diets offer a potentially highly efficacious dietary intervention with minor side effects. Palatability, cost, access, and social restrictions are common barriers of use. Prospective clinical trials are needed to elucidate the role of elemental formulas in the management of individual diseases.
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Affiliation(s)
- Jason Nasser
- Medically Associated Science and Technology (MAST) Program, Cedars-Sinai, 700 N. San Vicente Blvd, Suite G271, West Hollywood, CA, 90069, USA
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai, Los Angeles, CA, USA
| | - Sepideh Mehravar
- Medically Associated Science and Technology (MAST) Program, Cedars-Sinai, 700 N. San Vicente Blvd, Suite G271, West Hollywood, CA, 90069, USA
| | - Mark Pimentel
- Medically Associated Science and Technology (MAST) Program, Cedars-Sinai, 700 N. San Vicente Blvd, Suite G271, West Hollywood, CA, 90069, USA
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai, Los Angeles, CA, USA
| | - Jane Lim
- Medically Associated Science and Technology (MAST) Program, Cedars-Sinai, 700 N. San Vicente Blvd, Suite G271, West Hollywood, CA, 90069, USA
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai, Los Angeles, CA, USA
| | - Ruchi Mathur
- Medically Associated Science and Technology (MAST) Program, Cedars-Sinai, 700 N. San Vicente Blvd, Suite G271, West Hollywood, CA, 90069, USA
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Cedars-Sinai, Los Angeles, CA, USA
| | - Antoine Boustany
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ali Rezaie
- Medically Associated Science and Technology (MAST) Program, Cedars-Sinai, 700 N. San Vicente Blvd, Suite G271, West Hollywood, CA, 90069, USA.
- Karsh Division of Gastroenterology and Hepatology, Department of Medicine, Cedars-Sinai, Los Angeles, CA, USA.
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Deas J, Shah ND, Konijeti GG, Lundin A, Lanser O, Magavi P, Ali S. Dietary therapies for adult and pediatric inflammatory bowel disease. Nutr Clin Pract 2024; 39:530-545. [PMID: 38505875 DOI: 10.1002/ncp.11146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/21/2024] Open
Abstract
Diet is an environmental exposure implicated in the development of inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC). Dietary therapy is also a tool for management of these conditions. Nutrition therapy for IBD has been shown to reduce intestinal inflammation, promote healing, and alleviate symptoms, as well as improve patients' nutrition status. Although the mechanisms of action of most nutrition therapies for IBD are not well understood, the diets are theorized to eliminate triggers for gut dysbiosis and mucosal immune dysfunction associated with the typical Western diet. Exclusive enteral nutrition and the Crohn's disease exclusion diet are increasingly being used as the primary treatment modality for the induction of remission and/or maintenance therapy in children, and in some adults, with CD. Several other diets, such as the Mediterranean diet, anti-inflammatory diet for IBD, and diets excluding gluten, FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), lactose, or other compounds, may be helpful in symptom management in both CD and UC, though evidence for biochemical efficacy is limited. In this review, we discuss the role of diet components in IBD pathogenesis and examine diets currently used in the management of children and adults with IBD. We also address practical, psychosocial, and cultural considerations for dietary therapy across diverse populations.
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Affiliation(s)
- Jessica Deas
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Neha D Shah
- Colitis and Crohn's Disease Center, University of California San Francisco, San Francisco, California, USA
| | - Gauree G Konijeti
- Division of Gastroenterology & Hepatology, Scripps Clinic, La Jolla, California, USA
| | - Abigail Lundin
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Benioff Children Hospitals, University of California San Francisco, San Francisco, California, USA
| | - Olivia Lanser
- Division of Gastroenterology & Hepatology, Scripps Clinic, La Jolla, California, USA
| | - Pooja Magavi
- Division of Gastroenterology & Hepatology, Scripps Clinic, La Jolla, California, USA
| | - Sabina Ali
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Benioff Children Hospitals, University of California San Francisco, San Francisco, California, USA
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Otley A, Day AS, Zachos M. Nutritional Management of Inflammatory Bowel Disease. PEDIATRIC INFLAMMATORY BOWEL DISEASE 2023:355-383. [DOI: 10.1007/978-3-031-14744-9_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Luo J, Xie YM, Wu M, Zhao JG, Hu LL. Global attitudes on and the status of enteral nutrition therapy for pediatric inflammatory bowel disease. Front Med (Lausanne) 2022; 9:1036793. [PMID: 36569124 PMCID: PMC9773139 DOI: 10.3389/fmed.2022.1036793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022] Open
Abstract
Enteral nutrition (EN) is a diet-remission therapy for inflammatory bowel disease (IBD) that plays a more important role in children than adults. EN includes exclusive enteral nutrition (EEN), partial enteral nutrition (PEN), and maintenance enteral nutrition (MEN). However, EEN remains an unstandardized treatment for pediatric IBD. The types and methods of EN differ around the world. The current study reviewed the EN literature on children with IBD. A total of 12 survey studies were identified that analyzed the current state of EN use, including clinical opinions, implementation methods, treatment course, EEN formula, IBD classification, progress, dietary reintroduction, and patient feedback. The findings revealed that EEN has a strong effect on mild to moderate Crohn's disease (CD). The usage rates of this treatment in different sites were ileum/colon (Paris classification L3) > ileum (L1) > upper digestive tract (L4) > colon (L2) > perianal disease (P) > ulcerative colitis (UC) > extraintestinal lesions. The polymeric formula was the most used EN formulation. New EN diets include a CD exclusion diet (CDED), a specific carbohydrate diet (SCD), and a CD treatment-with-eating (CD-TREAT) diet. Children with IBD responded similarly to EEN administered orally or using a feeding tube. Most guidelines recommended 6-8 weeks of EEN treatment to induce remission. Many clinicians preferred to combine drug medications during EEN and recommended that MEN accounts for at least 25-35% of daily caloric intake. EN remains an unstandardized therapy that requires teamwork across disciplines.
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Affiliation(s)
- Juan Luo
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
| | - Yong-Mei Xie
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China,*Correspondence: Yong-Mei Xie,
| | - Mei Wu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
| | - Jin-Gui Zhao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
| | - Liang-Liang Hu
- Department of Pediatrics, Luzhou People’s Hospital, Luzhou, Sichuan, China
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Sohouli MH, Fatahi S, Farahmand F, Alimadadi H, Seraj SS, Rohani P. Meta-analysis: efficacy of exclusive enteral nutrition as induction therapy on disease activity index, inflammation and growth factors in paediatric Crohn's disease. Aliment Pharmacol Ther 2022; 56:384-395. [PMID: 35748390 DOI: 10.1111/apt.17109] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/14/2022] [Accepted: 06/14/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is evidence of inconsistency in sequelae of exclusive enteral nutrition (EEN) as induction therapy in paediatric patients with Crohn's disease (CD). AIM To investigate the potential effects of EEN on paediatric Crohn's disease activity index (PCDAI), inflammation and biochemical parameters in paediatric patients with CD. METHODS We performed a comprehensive systematic search of PubMed/MEDLINE, Web of Science, SCOPUS and Embase until 8 January 2022 regardless of the time of publication or language. Random-effects model was applied to combine the datasets. The main outcomes were analysed through mean difference (MD) and its 95% confidence interval (CI). RESULTS Forty six studies met eligibility criteria and were included in the meta-analysis. Pooled findings indicated that PCDAI score (MD of -27.24; 95% CI -31.84 to -22.64), calprotectin (MD of -842.83 mg/kg; CI -1018.24 to -667.42), CRP (pooled MD of -2.36 mg/dl; CI -2.68 to -2.03), and ESR (MD of -21.09 mm/h; CI -23.79 to -18.38), albumin (MD of 0.65 g/dl; CI 0.58 to 0.72), haemoglobin (MD of 1.12 g/dl; CI 0.87 to 1.37), weight (MD of 4.30 kg; CI 3.39 to 5.22), and height (MD of 0.98 cm; CI 0.35 to 1.62) improved significantly with EEN. CONCLUSIONS Adherence to EEN can have significant, beneficial effects as induction therapy in paediatric patients with CD.
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Affiliation(s)
- Mohammad Hassan Sohouli
- Pediatric Gastroenterology and Hepatology Research Center, Pediatrics Centre of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Student Research Committee, Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Somaye Fatahi
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Farahmand
- Pediatric Gastroenterology and Hepatology Research Center, Pediatrics Centre of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hosein Alimadadi
- Pediatric Gastroenterology and Hepatology Research Center, Pediatrics Centre of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Shaikh Sanjid Seraj
- Department of Surgery, Walsall Manor Hospital, Walsall Healthcare NHS Trust, Walsall, UK
| | - Pejman Rohani
- Pediatric Gastroenterology and Hepatology Research Center, Pediatrics Centre of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
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Yang Q, Tang J, Ding N, Chao K, Li M, Huang Z, Guo H, Chen J, Zhi M, Hu P, Gao X. Twelve-week peptide-based formula therapy may be effective in inducing remission of active Crohn disease among women who are pregnant or preparing for pregnancy. Nutr Clin Pract 2022; 37:366-376. [PMID: 34245474 DOI: 10.1002/ncp.10733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Conventional treatment for Crohn disease (CD) in pregnancy includes mesalamine, thiopurine, and anti-tumor necrosis factor (TNF)-α agents. However, women may abstain because of complications, nonresponse, or potential adverse outcomes. Peptide-based formula therapy, through oral or nasogastric feeding without other food intake, is an effective and safe therapy for active CD. Herein, We confirmed the effectiveness and safety of peptide-based formula therapy for active CD in pregnant women or those preparing for pregnancy. METHOD Outcomes of peptide-based formula therapy to induce CD remission during pregnancy preparation and the conception period were evaluated retrospectively among 14 women. Efficacy was evaluated as the change in serum indices and inflammatory markers after 12-week treatment. Pregnancy outcomes were compared between 14 women treated with nutrition therapy and eight women using conventional CD drugs. RESULTS After 12 weeks, 85.7% (12 of 14) of patients treated with peptide-based formula achieved remission with a significant decrease in the CD activity index (P < .001) and high-sensitivity C-reactive protein level (P = .004). There were no effects of peptide-based formula therapy on pregnancy outcomes compared with conventional CD treatment (P > .05). Among the 12 patients who achieved CD remission with exclusive peptide-based formula therapy, 10 selected to continue total or partial peptide-based formula treatment to maintain CD remission throughout pregnancy. CONCLUSION Peptide-based formula therapy, without other food intake, may provide a safe and effective alternative to conventional CD drugs to induce disease remission among women during conception and pregnancy.
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Affiliation(s)
- Qingfan Yang
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
| | - Jian Tang
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
| | - Ni Ding
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
| | - Kang Chao
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
| | - Miao Li
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
| | - Zicheng Huang
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
| | - Huili Guo
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
| | - Junrong Chen
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
| | - Min Zhi
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
| | - Pinjin Hu
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
| | - Xiang Gao
- Department of Gastroenterology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
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Clinical and Nutritional Impact of a Semi-Elemental Hydrolyzed Whey Protein Diet in Patients with Active Crohn's Disease: A Prospective Observational Study. Nutrients 2021; 13:nu13103623. [PMID: 34684624 PMCID: PMC8538212 DOI: 10.3390/nu13103623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/08/2021] [Accepted: 10/12/2021] [Indexed: 12/30/2022] Open
Abstract
Background: Malnourishment is a common complication in patients with Crohn’s disease. Methods: An observational, prospective study was conducted to assess the nutritional status, disease activity, and stool frequency at baseline and after 12 weeks of treatment with a semi-elemental diet in patients with active Crohn’s disease. Results: A total of 144 patients with Crohn’s disease were included. The nutritional status improved after treatment, resulting in 76.1% of patients at low risk of malnourishment, 20.4% moderately malnourished, and 8.5% severely malnourished after 12 weeks of treatment. Nutritional status improvement was associated with the number of nutritional supplements. Mean albumin levels and body mass index (BMI) improved after 12 weeks of nutritional treatment (from 3.0 g/dL to 3.7 g/dL and from 20.2 kg/m2 to 21.1 kg/m2, respectively). A significant decrease in HBI was found after 12 weeks of nutritional treatment (from 10.2 to 3.7). The mean number of stools per day decreased with the 12 week semi-elemental diet (from 4.6 stools/day to 1.7 stools/day). Conclusion: In this observational study, the semi-elemental diet seemed effective in improving the nutritional status, disease activity, and stool frequency in patients with active Crohn’s disease.
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Ramaswamy PK. Exclusive enteral nutrition with oral polymeric diet helps in inducing clinical and biochemical remission in adults with active Crohn's Disease. JPEN J Parenter Enteral Nutr 2021; 46:423-432. [PMID: 34618355 DOI: 10.1002/jpen.2273] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND AIMS Exclusive enteral nutrition (EEN) is not routinely used as induction therapy for adults with active Crohn's Disease (CD). The aim of this study was to assess the effectiveness of EEN with oral polymeric formula as an adjunct for inducing clinical and biochemical remission in adults with active CD. METHODS We performed a retrospective analysis of data from January 2018 to September 2019 on all patients with active CD who commenced EEN. Primary endpoint was clinical remission (CDAI ≤150) or response (100-point decrease in CDAI) at 8 weeks. Secondary endpoint was achievement of biochemical remission (CRP ≤5 mg/L or faeces calprotectin ≤150 mcg/g) at 8 weeks in those whose baseline values were elevated. We also aimed to identify predictors of response to EEN therapy. RESULTS Sixty-six patients commenced EEN, 53/66 (80.3%) completed the prescribed EEN course. At 8 weeks, 42/66 (63.6%) patients achieved primary endpoint and secondary endpoint was achieved in 30/53 (56.6%) of patients. Patients receiving EEN for ≥ 6 weeks achieved primary (72% vs 47.8%, OR 2.8, p = 0.047, CI 0.97 -8.16) and secondary endpoint (67.6% vs 36.8%, OR 3.58, p = 0.035, CI 1.1- 11.63) more frequently when compared with patients who received EEN for <6 weeks. Nine patients reported adverse effects (4 nausea,3 diarrhoea,1 constipation and 1 abdominal pain), none of whom ceased therapy. CONCLUSION Polymeric EEN is well tolerated, safe and effective in inducing clinical and biochemical remission in adults with active CD. EEN duration of ≥ 6 weeks has better outcomes. This article is protected by copyright. All rights reserved.
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Affiliation(s)
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- Department of Digestive Health, Gold Coast University Hospital.,Department of Nutrition and Food Services, Gold Coast University Hospital.,Faculty of Health Sciences and Medicine, Bond University
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Muscaritoli M, Pradelli L. Medium-Chain Triglyceride (MCT) Content of Adult Enteral Tube Feeding Formulas and Clinical Outcomes. A Systematic Review. Front Nutr 2021; 8:697529. [PMID: 34409063 PMCID: PMC8364971 DOI: 10.3389/fnut.2021.697529] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/06/2021] [Indexed: 01/03/2023] Open
Abstract
Available data on the effect of lipid composition of enteral formulas on clinical outcomes are controversial. The present systematic review was performed in order to verify whether the presence of specific lipidic substrates, namely medium-chain triglycerides (MCT), in enteral tube feeding formulas is associated to measurable clinical benefits in patients receiving enteral nutrition in different clinical settings, including home enteral nutrition (HEN). The results of this systematic review highlight a lack of robust evidence supporting the use of specific types of lipids in standard or disease-specific formulas. Evidence exists, however, that MCT-containing formulas are safe and well-tolerated. Further, well-designed, adequately powered, randomized controlled trials would be needed in order to assess the superiority of MCT- containing enteral formulas over other standard or disease-specific commercially available enteral products.
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Affiliation(s)
- Maurizio Muscaritoli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
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10
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Herrador-López M, Martín-Masot R, Navas-López VM. EEN Yesterday and Today … CDED Today and Tomorrow. Nutrients 2020; 12:nu12123793. [PMID: 33322060 PMCID: PMC7764146 DOI: 10.3390/nu12123793] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 12/11/2022] Open
Abstract
The treatment of Pediatric Crohn’s Disease (CD) requires attention both to achieve mucosal healing and to optimize growth, while also maintaining proper bone health. Exclusive Enteral Nutrition (EEN) is recommended as first-line treatment in luminal CD. The therapeutic mechanisms of EEN are being discovered by advances in the study of the gut microbiota. Although the total exclusion of a normal diet during the time of EEN continues to be of high importance, new modalities of dietary treatment suggest a successful future for the nutritional management of CD. In this sense, Crohn’s Disease Exclusion Diet (CDED) is a long-term strategy, it apparently acts on the mechanisms that influence the appearance of inflammation (reducing dietary exposure to products negatively affecting the microbiota), but does so using specific available whole foods to achieve this goal, increases the time of clinical remission and promotes healthy lifestyle habits. The development of CDED, which partly minimizes the problems of EEN, has enabled a turnaround in the treatment of pediatric CD. This review highlights the role of enteral nutrition in the treatment of Crohn’s disease with special emphasis on newer dietary modalities such as CDED.
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11
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de Laffolie J, Schwerd T, Simon A, Pauli M, Broekaert I, Classen M, Posovszky C, Schmidt-Choudhury A. [Crohn's Disease Exclusion Diet - an alternative to exlusive enteral nutritional therapy in children and adolescents with Crohn's disease? Statement of the GPGE working groups CEDATA and Nutrition/Nutrition Medicine]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2020; 58:890-894. [PMID: 32947634 DOI: 10.1055/a-1199-6751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Epidemiological an clinical observations as well as results from animal studies indicate that nutrition can play a role in the development of inflammatory bowel disease (IBD). Exclusive enteral nutrition therapy represents an example for modulating inflammatory responses solely through diet modification. Therefore, caretakers, patients, families, doctors and nutritionists seek for more dietary options to control IBD. These options include partial enteral nutrition therapy as for example the socalled Crohn's disease exclusion diet. The following statement summarizes existing data and provides recommendations for the current management of enteral nutrition therapy in pediatric Crohn's disease.
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Affiliation(s)
- Jan de Laffolie
- Zentrum für Kinderheilkunde, Justus Liebig Universität Gießen, Germany
| | - Tobias Schwerd
- Kindergastroenterologie, Dr. von Haunersches Kinderspital, Kinderklinik und Kinderpoliklinik der Ludwig-Maximilians-Universität München, München, Germany
| | - Annette Simon
- Zentrum für Kinderheilkunde, Justus Liebig Universität Gießen, Germany
| | | | | | | | | | - Anjona Schmidt-Choudhury
- Klinik für Kinder- und Jugendmedizin der Ruhr-Universität Bochum im St. Josef-Hospital, Katholisches Klinikum Bochum, Germany
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12
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Glassner KL, Abraham BP, Quigley EMM. The microbiome and inflammatory bowel disease. J Allergy Clin Immunol 2020; 145:16-27. [PMID: 31910984 DOI: 10.1016/j.jaci.2019.11.003] [Citation(s) in RCA: 494] [Impact Index Per Article: 98.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 02/06/2023]
Abstract
Inflammatory bowel disease (IBD) is a chronic immune-mediated disease affecting the gastrointestinal tract. IBD consists of 2 subtypes: ulcerative colitis and Crohn disease. IBD is thought to develop as a result of interactions between environmental, microbial, and immune-mediated factors in a genetically susceptible host. Of late, the potential role of the microbiome in the development, progression, and treatment of IBD has been a subject of considerable interest and enquiry. Indeed, studies in human subjects have shown that the gut microbiome is different in patients with IBD compared with that in healthy control subjects. Other evidence in support of a fundamental role for the microbiome in patients with IBD includes identification of mutations in genes involved in microbiome-immune interactions among patients with IBD and epidemiologic observations implicating such microbiota-modulating risk factors as antibiotic use, cigarette smoking, levels of sanitation, and diet in the pathogenesis of IBD. Consequently, there has been much interest in the possible benefits of microbiome-modulating interventions, such as probiotics, prebiotics, antibiotics, fecal microbiota transplantation, and gene manipulation in the treatment of IBD. In this review we will discuss the role of the gut microbiome in patients with IBD; our focus will be on human studies.
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Affiliation(s)
- Kerri L Glassner
- Fondren IBD Program, Lynda K. and David M. Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Tex.
| | - Bincy P Abraham
- Fondren IBD Program, Lynda K. and David M. Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Tex
| | - Eamonn M M Quigley
- Fondren IBD Program, Lynda K. and David M. Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Tex
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13
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Chande N, Costello SP, Limketkai BN, Parker CE, Nguyen TM, Macdonald JK, Feagan BG. Alternative and Complementary Approaches for the Treatment of Inflammatory Bowel Disease: Evidence From Cochrane Reviews. Inflamm Bowel Dis 2020; 26:843-851. [PMID: 31560744 DOI: 10.1093/ibd/izz223] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Indexed: 12/12/2022]
Abstract
The Cochrane IBD Group presented a symposium at Digestive Diseases Week 2018 entitled “Alternative and Complementary Approaches for the Treatment of IBD: Evidence from Cochrane Reviews.” This article summarizes the data presented at this symposium.
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Affiliation(s)
- Nilesh Chande
- Division of Gastroenterology, Department of Medicine, University of Western Ontario, London, Ontario, Canada.,Cochrane IBD Group, University of Western Ontario, London, Ontario, Canada
| | - Samuel P Costello
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Berkeley N Limketkai
- Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, California, USA
| | | | - Tran M Nguyen
- Robarts Clinical Trials Inc. London, Ontario, Canada
| | - John K Macdonald
- Division of Gastroenterology, Department of Medicine, University of Western Ontario, London, Ontario, Canada.,Cochrane IBD Group, University of Western Ontario, London, Ontario, Canada
| | - Brian G Feagan
- Division of Gastroenterology, Department of Medicine, University of Western Ontario, London, Ontario, Canada.,Cochrane IBD Group, University of Western Ontario, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
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14
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Comeche JM, Caballero P, Gutierrez-Hervas A, García-Sanjuan S, Comino I, Altavilla C, Tuells J. Enteral Nutrition in Patients with Inflammatory Bowel Disease. Systematic Review, Meta-Analysis, and Meta-Regression. Nutrients 2019; 11:nu11112657. [PMID: 31689999 PMCID: PMC6893586 DOI: 10.3390/nu11112657] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/23/2019] [Accepted: 10/25/2019] [Indexed: 02/07/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic disease mediated by the immune system and is characterized by inflammation of the gastrointestinal tract. One of the possible treatments for this pathology is a change in the type of diet, of which enteral nutrition (EN) is one. This study is to understand how the use of EN can affect the adult population diagnosed with IBD. We conducted a systematic review, meta-analysis, and a meta-regression. On the different databases (MEDLINE, Scopus, Cochrane, LILACS, CINAHL, WOS), we found 363 registers with an accuracy of 12% (44 registers). After a full-text review, only 30 research studies were selected for qualitative synthesis and 11 for meta-analysis and meta-regression. The variables used were Crohn's disease activity index (CDAI), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). EN has been shown to have efficacy for the treatment of Crohn's disease and is compatible with other medicines. As for the CDAI or rates of remission, there were no differences between enteral and parenteral nutrition. Polymeric formulas have shown better results with respect to the CRP. The long-term treatment could dilute the good CDAI results that are obtained at the start of the EN treatment.
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Affiliation(s)
- Jose M Comeche
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Pablo Caballero
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Ana Gutierrez-Hervas
- Department of Nursing (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Sofia García-Sanjuan
- Department of Nursing (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Iris Comino
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Cesare Altavilla
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Jose Tuells
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
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15
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Mańkowska-Wierzbicka D, Karczewski J, Swora-Cwynar E, Dobrowolska A, Stelmach-Mardas M. The Clinical Importance of 21-Day Combined Parenteral and Enteral Nutrition in Active Inflammatory Bowel Disease Patients. Nutrients 2019; 11:E2246. [PMID: 31540473 PMCID: PMC6770879 DOI: 10.3390/nu11092246] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 12/13/2022] Open
Abstract
The aim of the study was to show the clinical magnitude of short-term feeding: enteral nutrition (EN) combined with parenteral nutrition (PN) in active Crohn's disease and ulcerative colitis patients. Among 122 eligible inflammatory bowel disease (IBD) patients, 65 met the inclusion criteria. Combined EN and PN was administered for 21 days, wherein over the first 3-5 days of treatment, trophic enteral nutrition (300 kcal/day) was used with an energy increase of up to 1500 kcal. An EN was administered using a nasogastric tube or, in case of intolerance, using a naso-jejunal tube. For PN, the "All in One" system was used according to individually prepared admixtures (ESPEN Guidelines). In addition to routine blood measurement (i.e., ALAT, ASPAT, GGTP, creatinine, lipid profile), the following parameters were assessed: adiponectin, leptin, (hs)TNF-α, hsIL-6 and hsIL-10, TSH, NT-proBNP, serum vitamin B12 concentration, and tHcy. The results showed a considerable improvement in all clinically significant parameters (p < 0.05), showing the benefits and importance of short-term well-balanced EN combined with PN for nutritional and clinical status in IBD patients with active disease. The daily work at hospitals with active IBD patients demonstrates the potential of continued administration of home-based nutrition by patients.
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Affiliation(s)
- Dorota Mańkowska-Wierzbicka
- Department of Gastroenterology, Metabolic Diseases, Internal Medicine and Dietetics, Poznan University of Medical Sciences, Poznan 60-355, Poland.
| | - Jacek Karczewski
- Department of Gastroenterology, Metabolic Diseases, Internal Medicine and Dietetics, Poznan University of Medical Sciences, Poznan 60-355, Poland.
- Department of Environmental Medicine, Poznan University of Medical Sciences, Poznan 60-806, Poland.
| | - Ewelina Swora-Cwynar
- Department of Gastroenterology, Metabolic Diseases, Internal Medicine and Dietetics, Poznan University of Medical Sciences, Poznan 60-355, Poland.
| | - Agnieszka Dobrowolska
- Department of Gastroenterology, Metabolic Diseases, Internal Medicine and Dietetics, Poznan University of Medical Sciences, Poznan 60-355, Poland.
| | - Marta Stelmach-Mardas
- Department of Biophysics, Poznan University of Medical Sciences, Poznan 60-780, Poland.
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Di Caro S, Fragkos KC, Keetarut K, Koo HF, Sebepos-Rogers G, Saravanapavan H, Barragry J, Rogers J, Mehta SJ, Rahman F. Enteral Nutrition in Adult Crohn's Disease: Toward a Paradigm Shift. Nutrients 2019; 11:E2222. [PMID: 31540038 PMCID: PMC6770416 DOI: 10.3390/nu11092222] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/05/2019] [Accepted: 09/08/2019] [Indexed: 02/06/2023] Open
Abstract
Medical and surgical treatments for Crohn's disease are associated with toxic effects. Medical therapy aims for mucosal healing and is achievable with biologics, immunosuppressive therapy, and specialised enteral nutrition, but not with corticosteroids. Sustained remission remains a therapeutic challenge. Enteral nutrition, containing macro- and micro-nutrients, is nutritionally complete, and is provided in powder or liquid form. Enteral nutrition is a low-risk and minimally invasive therapy. It is well-established and recommended as first line induction therapy in paediatric Crohn's disease with remission rates of up to 80%. Other than in Japan, enteral nutrition is not routinely used in the adult population among Western countries, mainly due to unpalatable formulations which lead to poor compliance. This study aims to offer a comprehensive review of available enteral nutrition formulations and the literature supporting the use and mechanisms of action of enteral nutrition in adult Crohn's disease patients, in order to support clinicians in real world decision-making when offering/accepting treatment. The mechanisms of actions of enteral feed, including their impact on the gut microbiome, were explored. Barriers to the use of enteral nutrition, such as compliance and the route of administration, were considered. All available enteral preparations have been comprehensively described as a practical guide for clinical use. Likewise, guidelines are reported and discussed.
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Affiliation(s)
- Simona Di Caro
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Konstantinos C Fragkos
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Katie Keetarut
- Department of Dietetics, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Hui Fen Koo
- UCL Medical School, 74 Huntley Street, Bloomsbury, London WC1E 6DE, UK.
| | - Gregory Sebepos-Rogers
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Hajeena Saravanapavan
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - John Barragry
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Jennifer Rogers
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Shameer J Mehta
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Farooq Rahman
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
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Catt H, Hughes D, Kirkham JJ, Bodger K. Systematic review: outcomes and adverse events from randomised trials in Crohn's disease. Aliment Pharmacol Ther 2019; 49:978-996. [PMID: 30828852 PMCID: PMC6492112 DOI: 10.1111/apt.15174] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/03/2018] [Accepted: 01/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The suitability of disease activity indices has been challenged, with growing interest in objective measures of inflammation. AIM To undertake a systematic review of efficacy and safety outcomes in placebo-controlled randomised controlled trials (RCTs) of patients with Crohn's disease. METHODS MEDLINE, EMBASE, CINAHL and Cochrane Library were searched until November 2015, for RCTs of adult Crohn's disease patients treated with medical or surgical therapies. Data on efficacy and safety outcomes, end-point definitions, and measurement instruments were extracted and stratified by publication date (pre-2009 and 2009 onwards). RESULTS One hundred and eighty-one RCTs (110 induction and 71 maintenance) were identified, including 23 850 patients. About 92.3% reported clinical efficacy endpoints. The Crohn's Disease Activity Index (CDAI) dominated, defining clinical response or remission in 63.5% of trials (35 definitions of response or remission). CDAI < 150 was the commonest endpoint, but reporting reduced between periods (46.4%-41.1%), whilst use of CDAI100 increased (16.8%-30.4%). Fistula studies most commonly reported fistula closure (9, 90.0%). Reporting of biomarker, endoscopy and histology endpoints increased overall (33.3%-40.6%, 14.4%-30.4% and 3.2%-12.5%, respectively), but were heterogeneous and rarely reported in fistula trials. Patient-reported outcome measures were reported in 41.4% of trials and safety endpoints in 35.4%. Many of the common adverse events relate to disease exacerbation or treatment failure. CONCLUSIONS Trial endpoints vary across studies, over time and are distinct in fistula studies. Despite growth in reporting of objective measures of inflammation and in patient-reported outcome measures, there is a lack of standardisation. This confirms the need for a core outcome set for comparative effectiveness research in Crohn's disease.
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Affiliation(s)
- Heather Catt
- Department of BiostatisticsUniversity of LiverpoolLiverpoolUK
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines EvaluationBangor UniversityBangorUK
| | | | - Keith Bodger
- Department of BiostatisticsUniversity of LiverpoolLiverpoolUK,Digestive Diseases CentreAintree University Hospital NHS TrustLiverpoolUK
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Stoner PL, Kamel A, Ayoub F, Tan S, Iqbal A, Glover SC, Zimmermann EM. Perioperative Care of Patients with Inflammatory Bowel Disease: Focus on Nutritional Support. Gastroenterol Res Pract 2018; 2018:7890161. [PMID: 30344603 PMCID: PMC6174741 DOI: 10.1155/2018/7890161] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/28/2018] [Indexed: 12/16/2022] Open
Abstract
Patients with inflammatory bowel disease (IBD) commonly require surgery despite the availability of an increasingly large repertoire of powerful immunosuppressive medications for the treatment of IBD. Optimizing patients' care preoperatively is crucial to obtaining good surgical outcomes. This review discusses preoperative assessment and management principles including assessing disease location and activity with cross-sectional or endoscopic imaging, addressing modifiable risk factors (i.e., stopping smoking, weaning steroids, and correcting anemia), and properly managing medications. The major focus of our literature review is the evaluation for malnutrition, a common finding that affects up to 70% of patients with IBD and a well-known, independent risk factor for adverse postoperative outcomes. Our review confirms that whenever feasible, oral or enteral nutrition (EN) is the preferred method of nutritional support; parenteral nutrition (PN) should be reserved for nutritionally deficient IBD patients unable to tolerate EN. In selected patients, recent data demonstrated that the use of preoperative PN resulted in improved nutritional status, fewer postoperative complications, and reduced disease severity. Our review highlights the need for well-designed, prospective trials investigating perioperative nutritional support in patients with IBD. Future studies should perform modern nutritional assessment, standardize for diet, and include patients with UC since this subset of patients is underrepresented in existing studies. In addition, relevant outcome of interest specific to Crohn's disease (CD) patients such as length of small bowel resected, number of anastomoses, and need for an ostomy should be included as these patients may require repeated small bowel resections.
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Affiliation(s)
- Patrick L. Stoner
- Department of Medicine, Division of Gastroenterology, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Amir Kamel
- Department of Pharmacotherapy, College of Pharmacy, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Fares Ayoub
- Department of Medicine, Division of Gastroenterology, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Sanda Tan
- Department of Surgery, Division of Colorectal Surgery, College of Medicine, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Atif Iqbal
- Department of Surgery, Division of Colorectal Surgery, College of Medicine, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Sarah C. Glover
- Department of Medicine, Division of Gastroenterology, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
| | - Ellen M. Zimmermann
- Department of Medicine, Division of Gastroenterology, University of Florida, 2000 SW Archer Rd, Gainesville, FL 32610, USA
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19
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Nutrition in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto Inflammatory Bowel Disease Group of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 66:687-708. [PMID: 29570147 DOI: 10.1097/mpg.0000000000001896] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS A growing body of evidence supports the need for detailed attention to nutrition and diet in children with inflammatory bowel disease (IBD). We aimed to define the steps in instituting dietary or nutritional management in light of the current evidence and to offer a useful and practical guide to physicians and dieticians involved in the care of pediatric IBD patients. METHODS A group of 20 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to Nutrition Committee of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition Porto, IBD Interest, and Nutrition Committee. A list of 41 predefined questions was addressed by working subgroups based on a systematic review of the literature. RESULTS A total of 53 formal recommendations and 47 practice points were endorsed with a consensus rate of at least 80% on the following topics: nutritional assessment; macronutrients needs; trace elements, minerals, and vitamins; nutrition as a primary therapy of pediatric IBD; probiotics and prebiotics; specific dietary restrictions; and dietary compounds and the risk of IBD. CONCLUSIONS This position paper represents a useful guide to help the clinicians in the management of nutrition issues in children with IBD.
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20
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Narula N, Dhillon A, Zhang D, Sherlock ME, Tondeur M, Zachos M. Enteral nutritional therapy for induction of remission in Crohn's disease. Cochrane Database Syst Rev 2018; 4:CD000542. [PMID: 29607496 PMCID: PMC6494406 DOI: 10.1002/14651858.cd000542.pub3] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Corticosteroids are often preferred over enteral nutrition (EN) as induction therapy for Crohn's disease (CD). Prior meta-analyses suggest that corticosteroids are superior to EN for induction of remission in CD. Treatment failures in EN trials are often due to poor compliance, with dropouts frequently due to poor acceptance of a nasogastric tube and unpalatable formulations. This systematic review is an update of a previously published Cochrane review. OBJECTIVES To evaluate the effectiveness and safety of exclusive EN as primary therapy to induce remission in CD and to examine the importance of formula composition on effectiveness. SEARCH METHODS We searched MEDLINE, Embase and CENTRAL from inception to 5 July 2017. We also searched references of retrieved articles and conference abstracts. SELECTION CRITERIA Randomized controlled trials involving patients with active CD were considered for inclusion. Studies comparing one type of EN to another type of EN or conventional corticosteroids were selected for review. DATA COLLECTION AND ANALYSIS Data were extracted independently by at least two authors. The primary outcome was clinical remission. Secondary outcomes included adverse events, serious adverse events and withdrawal due to adverse events. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (CI). A random-effects model was used to pool data. We performed intention-to-treat and per-protocol analyses for the primary outcome. Heterogeneity was explored using the Chi2 and I2 statistics. The studies were separated into two comparisons: one EN formulation compared to another EN formulation and EN compared to corticosteroids. Subgroup analyses were based on formula composition and age. Sensitivity analyses included abstract publications and poor quality studies. We used the Cochrane risk of bias tool to assess study quality. We used the GRADE criteria to assess the overall quality of the evidence supporting the primary outcome and selected secondary outcomes. MAIN RESULTS Twenty-seven studies (1,011 participants) were included. Three studies were rated as low risk of bias. Seven studies were rated as high risk of bias and 17 were rated as unclear risk of bias due to insufficient information. Seventeen trials compared different formulations of EN, 13 studies compared one or more elemental formulas to a non-elemental formula, three studies compared EN diets of similar protein composition but different fat composition, and one study compared non-elemental diets differing in glutamine enrichment. Meta-analysis of 11 trials (378 participants) demonstrated no difference in remission rates. Sixty-four per cent (134/210) of patients in the elemental group achieved remission compared to 62% (105/168) of patients in the non-elemental group (RR 1.02, 95% CI 0.88 to 1.18; GRADE very low quality). A per-protocol analysis (346 participants) produced similar results (RR 1.04, 95% CI 0.91 to 1.18). Subgroup analyses performed to evaluate the different types of elemental and non-elemental diets (elemental, semi-elemental and polymeric) showed no differences in remission rates. An analysis of 7 trials including 209 patients treated with EN formulas of differing fat content (low fat: < 20 g/1000 kCal versus high fat: > 20 g/1000 kCal) demonstrated no difference in remission rates (RR 1.03; 95% CI 0.85 to 1.26). Very low fat content (< 3 g/1000 kCal) and very low long chain triglycerides demonstrated higher remission rates than higher content EN formulas. There was no difference between elemental and non-elemental diets in adverse event rates (RR 1.00, 95% CI 0.63 to 1.60; GRADE very low quality), or withdrawals due to adverse events (RR 1.29, 95% CI 0.80 to 2.09; GRADE very low quality). Common adverse events included nausea, vomiting, diarrhea and bloating.Ten trials compared EN to steroid therapy. Meta-analysis of eight trials (223 participants) demonstrated no difference in remission rates between EN and steroids. Fifty per cent (111/223) of patients in the EN group achieved remission compared to 72% (133/186) of patients in the steroid group (RR 0.77, 95% CI 0.58 to 1.03; GRADE very low quality). Subgroup analysis by age showed a difference in remission rates for adults but not for children. In adults 45% (87/194) of EN patients achieved remission compared to 73% (116/158) of steroid patients (RR 0.65, 95% CI 0.52 to 0.82; GRADE very low quality). In children, 83% (24/29) of EN patients achieved remission compared to 61% (17/28) of steroid patients (RR 1.35, 95% CI 0.92 to 1.97; GRADE very low quality). A per-protocol analysis produced similar results (RR 0.93, 95% CI 0.75 to 1.14). The per-protocol subgroup analysis showed a difference in remission rates for both adults (RR 0.82, 95% CI 0.70 to 0.95) and children (RR 1.43, 95% CI 1.03 to 1.97). There was no difference in adverse event rates (RR 1.39, 95% CI 0.62 to 3.11; GRADE very low quality). However, patients on EN were more likely to withdraw due to adverse events than those on steroid therapy (RR 2.95, 95% CI 1.02 to 8.48; GRADE very low quality). Common adverse events reported in the EN group included heartburn, flatulence, diarrhea and vomiting, and for steroid therapy acne, moon facies, hyperglycemia, muscle weakness and hypoglycemia. The most common reason for withdrawal was inability to tolerate the EN diet. AUTHORS' CONCLUSIONS Very low quality evidence suggests that corticosteroid therapy may be more effective than EN for induction of clinical remission in adults with active CD. Very low quality evidence also suggests that EN may be more effective than steroids for induction of remission in children with active CD. Protein composition does not appear to influence the effectiveness of EN for the treatment of active CD. EN should be considered in pediatric CD patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient adherence with this therapy.
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Affiliation(s)
- Neeraj Narula
- McMaster UniversityDivision of Gastroenterology1280 Main Street WestHamiltonONCanadaL8S 4K1
| | - Amit Dhillon
- Northern Ontario School of MedicineDepartment of Internal MedicineSudburyONCanada
| | - Dongni Zhang
- University of Western OntarioSchulich School of Medicine & DentistryLondonONCanada
| | - Mary E Sherlock
- McMaster Children's HospitalDivision of Gastroenterology & NutritionHamilton Health Sciences1280 Main Street WestHamiltonONCanada
| | - Melody Tondeur
- The Hospital for Sick ChildrenCentre for Global Child Health525 University AveTorontoONCanadaM5G 2L3
| | - Mary Zachos
- McMaster Children’s HospitalDivision of Gastroenterology & Nutrition1280 Main St. WestHamiltonONCanadaL8S 4K1
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21
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Ajabnoor SM, Forbes A. Effect of fat composition in enteral nutrition for Crohn's disease in adults: A systematic review. Clin Nutr 2017; 38:90-99. [PMID: 29310893 DOI: 10.1016/j.clnu.2017.12.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 11/10/2017] [Accepted: 12/20/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND & AIMS The role of enteral nutrition (EN) fat composition in regulating inflammation in Crohn's disease (CD) is not clear. There is, moreover, insufficient evidence to guide the choice of EN in CD with any confidence. We have reanalysed the findings of previous studies in a systematic review focussing on the relationship between EN fat content and remission rates (RR). METHODS A systematic search with no language restriction was undertaken in Medline and Embase databases supplemented by a manual search in the reference lists of identified studies. The selection criteria were: clinical trial, exclusive EN, adults and CD. Data on the type of EN, its fat composition, achieved RR, and study design were extracted. An established assessment tool was used to assess the quality of the studies. RESULTS A total of 29 clinical trials are included in this review. The quality of the studies was highly variable. No fewer than 27 formulations of enteral feed were identified including 4 elemental and 23 non-elemental preparations. There was a positive correlation between the total n-6 fatty acid content and response rates, which was significant when expressed as the ratio between n-6 and n-3 fatty acids (r = 0.378, p = 0.018). A non-significant positive trend was founded (r = 0.072; p = 0.643) between medium chain triglycerides (MCT) delivery as a percentage of the total energy provision and RR. While a non-significant negative trend was reported for the delivery of monounsaturated fatty acids (MUFA) (r = -0.23, p = 0.13). A qualitative advantage to regimens based on safflower oil suggest that optimised therapeutic approaches are within reach.
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Affiliation(s)
- Sarah M Ajabnoor
- Norwich Medical School, University of East Anglia, Norwich Research Park, UK; Clinical Nutrition Department, Faculty of Applied Medical Sciences, King Abdulaziz University, Saudi Arabia
| | - Alastair Forbes
- Norwich Medical School, University of East Anglia, Norwich Research Park, UK.
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22
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Vora R, Puntis JW. Dietary Treatment for Crohn’s Disease—Old Therapy, New Insights. EXPLORATORY RESEARCH AND HYPOTHESIS IN MEDICINE 2017; 2:1-8. [DOI: 10.14218/erhm.2017.00026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Otley AR, Day AS, Zachos M. Nutritional Management of Inflammatory Bowel Disease. PEDIATRIC INFLAMMATORY BOWEL DISEASE 2017:333-356. [DOI: 10.1007/978-3-319-49215-5_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Forbes A, Escher J, Hébuterne X, Kłęk S, Krznaric Z, Schneider S, Shamir R, Stardelova K, Wierdsma N, Wiskin AE, Bischoff SC. ESPEN guideline: Clinical nutrition in inflammatory bowel disease. Clin Nutr 2016; 36:321-347. [PMID: 28131521 DOI: 10.1016/j.clnu.2016.12.027] [Citation(s) in RCA: 414] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 12/28/2016] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The ESPEN guideline presents a multidisciplinary focus on clinical nutrition in inflammatory bowel disease (IBD). METHODOLOGY The guideline is based on extensive systematic review of the literature, but relies on expert opinion when objective data were lacking or inconclusive. The conclusions and 64 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required. RESULTS IBD is increasingly common and potential dietary factors in its aetiology are briefly reviewed. Malnutrition is highly prevalent in IBD - especially in Crohn's disease. Increased energy and protein requirements are observed in some patients. The management of malnutrition in IBD is considered within the general context of support for malnourished patients. Treatment of iron deficiency (parenterally if necessary) is strongly recommended. Routine provision of a special diet in IBD is not however supported. Parenteral nutrition is indicated only when enteral nutrition has failed or is impossible. The recommended perioperative management of patients with IBD undergoing surgery accords with general ESPEN guidance for patients having abdominal surgery. Probiotics may be helpful in UC but not Crohn's disease. Primary therapy using nutrition to treat IBD is not supported in ulcerative colitis, but is moderately well supported in Crohn's disease, especially in children where the adverse consequences of steroid therapy are proportionally greater. However, exclusion diets are generally not recommended and there is little evidence to support any particular formula feed when nutritional regimens are constructed. CONCLUSIONS Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 64 recommendations, of which 9 are very strong recommendations (grade A), 22 are strong recommendations (grade B) and 12 are based only on sparse evidence (grade 0); 21 recommendations are good practice points (GPP).
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Affiliation(s)
- Alastair Forbes
- Norwich Medical School, University of East Anglia, Bob Champion Building, James Watson Road, Norwich, NR4 7UQ, United Kingdom.
| | - Johanna Escher
- Erasmus Medical Center - Sophia Children's Hospital, Office Sp-3460, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands.
| | - Xavier Hébuterne
- Gastroentérologie et Nutrition Clinique, CHU de Nice, Université Côte d'Azur, Nice, France.
| | - Stanisław Kłęk
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, 15 Tyniecka Street, 32-050, Skawina, Krakau, Poland.
| | - Zeljko Krznaric
- Clinical Hospital Centre Zagreb, University of Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia.
| | - Stéphane Schneider
- Gastroentérologie et Nutrition Clinique, CHU de Nice, Université Côte d'Azur, Nice, France.
| | - Raanan Shamir
- Tel-Aviv University, Schneider Children's Medical Center of Israel, 14 Kaplan St., Petach-Tikva, 49202, Israel.
| | - Kalina Stardelova
- University Clinic for Gastroenterohepatology, Clinical Centre "Mother Therese", Mother Therese Str No 18, Skopje, Republic of Macedonia.
| | - Nicolette Wierdsma
- VU University Medical Center, Department of Nutrition and Dietetics, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Anthony E Wiskin
- Paediatric Gastroenterology & Nutrition Unit, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8BJ, United Kingdom.
| | - Stephan C Bischoff
- Institut für Ernährungsmedizin (180) Universität Hohenheim, Fruwirthstr. 12, 70593 Stuttgart, Germany.
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Guo Z, Gong J, Li Y, Gu L, Cao L, Wang Z, Zhu W, Li J. Mucosal MicroRNAs Expression Profiles before and after Exclusive Enteral Nutrition Therapy in Adult Patients with Crohn's Disease. Nutrients 2016; 8:519. [PMID: 27556489 PMCID: PMC4997431 DOI: 10.3390/nu8080519] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 08/07/2016] [Accepted: 08/15/2016] [Indexed: 12/12/2022] Open
Abstract
MicroRNAs (miRNAs) have been shown to be important for the pathogenesis of Crohn's disease (CD). Exclusive enteral nutrition (EEN) is an effective therapy for inducing remission in CD. We aimed to investigate the alteration of miRNAs expression profile in the terminal ileal mucosa of CD patients before and after EEN. Twenty-five patients and ten healthy individuals were included. MiRNAs expression profile was firstly assessed using microarray technology and then validation was performed by qRT-PCR. The correlations between miRNAs and CD activity index (CDAI) score and serum C-reactive protein (CRP) level were also evaluated. Microarray analysis showed that mucosal miRNAs expression profile after EEN therapy was significantly changed compared with inflamed mucosa before treatment, and was most similar to the healthy one among all CD groups. Altered expressions of hsa-miR-192-5p, hsa-miR-423-3p, hsa-miR-99a-5p, hsa-miR-124-3p, hsa-miR-301a-5p, hsa-miR-495-5p, and hsa-let-7b-5p were confirmed by qRT-PCR. hsa-let-7b-5p was significantly correlated with serum CRP levels before and after EEN treatment (r = -0.518, p = 0.008, and r = -0.569, p = 0.003). Our study showed EEN induction therapy was associated with a trend for normalizing of the mucosal miRNAs expression profile, and expression of mucosal hsa-let-7b-5p was correlated with serum CRP level in patients with CD.
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Affiliation(s)
- Zhen Guo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing 210002, China.
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing 210002, China.
| | - Yi Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing 210002, China.
| | - Lili Gu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing 210002, China.
| | - Lei Cao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing 210002, China.
| | - Zhiming Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing 210002, China.
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing 210002, China.
| | - Jieshou Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing 210002, China.
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Medium chain triglycerides (MCT) formulas in paediatric and allergological practice. GASTROENTEROLOGY REVIEW 2016; 11:226-231. [PMID: 28053676 PMCID: PMC5209465 DOI: 10.5114/pg.2016.61374] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 07/10/2015] [Indexed: 11/17/2022]
Abstract
Fats constitute the most significant nutritional source of energy. Their proper use by the body conditions a number of complex mechanisms of digestion, absorption, distribution, and metabolism. These mechanisms are facilitated by fats made of medium chain fatty acids; therefore, they are an easy and quick source of energy. Thus, an increased supply of medium chain triglycerides (MCT) is particularly important in patients with disturbances of digestion and absorption such as disturbed bile secretion, classic coeliac disease, short bowel syndrome, inflammatory diseases of the intestines, disturbed outflow of lymph, some metabolic disease, and severe food allergies, as well as in prematurely born neonates. Use of preparations containing an additive of MCT is limited, especially if they are to be used for a longer period of time. With a large quantity of MCT in a diet, there is a risk of deficiency of necessary unsaturated fatty acids and some fat-soluble vitamins. The caloricity of MTC compared to long-chain triglycerides is lower, and formulas with MCT are characterised by higher osmolality. Medium chain triglycerides is not recommended as an additive to standard formulas for healthy children. The use of MCT should be limited to strictly specified medical indications.
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Alexander DD, Bylsma LC, Elkayam L, Nguyen DL. Nutritional and health benefits of semi-elemental diets: A comprehensive summary of the literature. World J Gastrointest Pharmacol Ther 2016; 7:306-319. [PMID: 27158547 PMCID: PMC4848254 DOI: 10.4292/wjgpt.v7.i2.306] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 10/10/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To critically review and summarize the literature on nutritional and health outcomes of semi-elemental formulations on various nutritionally vulnerable patient populations who are unable to achieve adequate nutrition from standard oral diets.
METHODS: We conducted a comprehensive literature search of Pubmed and Embase databases. We manually screened articles that examined nutritional and health outcomes (e.g., growth, disease activity, gastrointestinal impairment, mortality, and economic impact) among various patient groups receiving semi-elemental diets. This review focused on full-text articles of randomized controlled clinical trials and other intervention studies, but pertinent abstracts and case studies were also included. Results pertaining primarily to tolerance, digestion, and absorption were summarized for each patient population in this systematic review.
RESULTS: Results pertaining primarily to tolerance, digestion, and absorption were summarized for each patient population. The efficacy of semi-elemental whey hydrolyzed protein (WHP) diet have been reported in various nutritionally high risk patient populations including - Crohn’s disease, short bowel syndrome, acute and chronic pancreatitis, cerebral palsy, cystic fibrosis, cerebrovascular accidents, human immunodeficiency virus, critically ill, and geriatrics. Collectively, the evidence from the medical literature indicates that feeding with a semi-elemental diet performs as well or better than parenteral or amino acid based diets in terms of tolerance, digestion, and nutrient assimilation measures across various disease conditions.
CONCLUSION: Based on this comprehensive review of the literature, patient populations who have difficulty digesting or absorbing standard diets may be able to achieve improved health and nutritional outcomes through the use of semi-elemental WHP diets.
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Shah ND, Parian AM, Mullin GE, Limketkai BN. Oral Diets and Nutrition Support for Inflammatory Bowel Disease: What Is the Evidence? Nutr Clin Pract 2015; 30:462-73. [PMID: 26084506 DOI: 10.1177/0884533615591059] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Inflammatory bowel disease (IBD), which primarily includes Crohn's disease and ulcerative colitis, involves chronic inflammation of the gastrointestinal tract. The mechanisms of IBD pathogenesis are not well understood at this time, but likely involve an interaction between genetic, gut microbial, immune, and environmental factors. Emerging epidemiologic studies have suggested a relationship between specific dietary nutrients as an environmental factor and IBD risk. Clinical trials have also shown oral diets to have variable efficacy in affecting clinical outcomes for IBD. This review discusses the key studies that evaluated the use of various oral diets as well as nutrition support in the management of IBD.
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Affiliation(s)
- Neha D Shah
- Digestive Health Center, Stanford Health Care, Palo Alto, California Division of Gastroenterology & Hepatology, Stanford University School of Medicine, Stanford, California
| | - Alyssa M Parian
- Division of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gerard E Mullin
- Division of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Berkeley N Limketkai
- Digestive Health Center, Stanford Health Care, Palo Alto, California Division of Gastroenterology & Hepatology, Stanford University School of Medicine, Stanford, California Division of Gastroenterology & Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Lev‐Tzion R, Griffiths AM, Ledder O, Turner D. Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn's disease. Cochrane Database Syst Rev 2014; 2014:CD006320. [PMID: 24585498 PMCID: PMC8988157 DOI: 10.1002/14651858.cd006320.pub4] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The anti-inflammatory effects of n-3 (omega-3 fatty acids, fish oil) have been suggested to be beneficial in chronic inflammatory disorders such as inflammatory bowel disease. This review is an update of a previously published Cochrane review. OBJECTIVES To systematically review the efficacy and safety of n-3 for maintenance of remission in Crohn's disease (CD). SEARCH METHODS The following databases were searched from inception to November 2013 without language restriction: CENTRAL, MEDLINE, EMBASE, HealthSTAR, PubMed, and ACP journal club. SELECTION CRITERIA Randomized placebo-controlled trials (RCT) of n-3 for maintenance of remission in CD were included. Studies must have enrolled patients of any age group, who were in remission at the time of recruitment, and were followed for at least six months. The intervention must have been fish oil or n-3 given in pre-defined dosage. Co-interventions were allowed only if they were balanced between the study groups. DATA COLLECTION AND ANALYSIS The primary outcome was the relapse rate and secondary outcomes included change in disease activity scores, time to first relapse and adverse events. Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality using the Cochrane risk of bias tool. The overall quality of the evidence supporting the primary and selected secondary outcomes was reassessed for the current update using the GRADE system. We used the RevMan software for analyses. We calculated the risk ratio (RR) and corresponding 95% confidence interval (CI) for dichotomous outcomes and the hazard ratio and 95% CI for time-to-event outcomes. Random-effects or fixed-effect models were used according to degree of heterogeneity and sensitivity analyses were performed in an attempt to explore possible sources of heterogeneity. MAIN RESULTS Six studies with a total of 1039 patients were eligible for inclusion. The two largest studies were rated as low risk of bias for all assessed items. Four studies were rated as unclear risk of bias for randomization and allocation concealment. Two studies were rated as high risk of bias for incomplete outcome data and selective reporting. There was a marginal significant benefit of n-3 therapy for maintenance of remission. Thirty-nine per cent of patients in the n-3 group relapsed at 12 months compared to 47% of placebo patients (6 studies, 1039 patients; RR 0.77, 95% CI 0.61 to 0.98). A GRADE analysis rated the overall quality of the evidence for the primary outcome (i.e. relapse) as very low due to unexplained heterogeneity (I2 = 58%), publication bias, and a high or unknown risk of bias in four studies in the pooled analysis. When two large studies at low risk of bias were considered the benefit was no longer statistically significant. Thirty-seven per cent of patients in the n-3 group relapsed at 12 months compared to 42% of placebo patients (2 studies, 738 patients; RR 0.88, 95% CI 0.74 to 1.05). No significant heterogeneity was identified for this pooled analysis ( I2 = 0%). A GRADE analysis indicated that the overall quality of the evidence supporting this outcome was moderate due to sparse data (294 events). No serious adverse events were recorded in any of the studies but in a pooled analyses there was a significantly higher rate of diarrhea (4 studies, 862 patients; RR 1.36 95% CI 1.01 to 1.84) and upper gastrointestinal tract symptoms (5 studies, 999 patients; RR 1.65, 95% CI 1.25 to 2.18) in the n-3 treatment group. AUTHORS' CONCLUSIONS Evidence from two large high quality studies suggests that omega 3 fatty acids are probably ineffective for maintenance of remission in CD. Omega 3 fatty acids appear to be safe although they may cause diarrhea and upper gastrointestinal tract symptoms.
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Affiliation(s)
- Raffi Lev‐Tzion
- Shaare Zedek Medical CenterPediatric Gastroenterology UnitJerusalemIsrael
| | - Anne Marie Griffiths
- The Hospital for Sick ChildrenDivision of Gastroenterology, Hepatology & Nutrition555 University Ave.TorontoONCanadaM5G 1X8
| | - Oren Ledder
- Shaare Zedek Medical CenterPediatric Gastroenterology UnitJerusalemIsrael
| | - Dan Turner
- Shaare Zedek Medical CenterPediatric Gastroenterology UnitJerusalemIsrael
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Lee J, Allen R, Ashley S, Becker S, Cummins P, Gbadamosi A, Gooding O, Huston J, Le Couteur J, O'Sullivan D, Wilson S, Lomer MCE. British Dietetic Association evidence-based guidelines for the dietary management of Crohn's disease in adults. J Hum Nutr Diet 2013; 27:207-18. [PMID: 24313460 DOI: 10.1111/jhn.12176] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Crohn's disease is a debilitating chronic inflammatory bowel disease. Appropriate use of diet and nutritional therapy is integral to the overall management strategy of Crohn's disease. The aim was to develop evidence-based guidelines on the dietary management of Crohn's disease in adults. METHODS Questions relating to the dietary management of Crohn's disease were developed. These included the roles of enteral nutrition to induce remission, food re-introduction diets to structure food re-introduction and maintain remission, and dietary management of stricturing disease, as well as whether probiotics or prebiotics induce or maintain remission. A comprehensive literature search was conducted and relevant studies from January 1985 to November 2009 were identified using the electronic database search engines CINAHL, Cochrane Library, EMBASE, MEDLINE, Scopus and Web of Science. Evidence statements, recommendations, practical considerations and research recommendations were developed. RESULTS Fifteen research papers were critically appraised and the evidence formed the basis of these guidelines. Although corticosteroids appear to be more effective, enteral nutrition (elemental or non-elemental) can be offered as an alternative option to induce disease remission. After a course of enteral nutrition, food re-introduction diets may be useful to structure food re-introduction and help maintain disease remission. Dietary fibre is contraindicated in the presence of strictures as a result of the risk of mechanical obstruction. The use of probiotics and prebiotics is not currently supported. CONCLUSIONS As an alternative to corticosteroids, evidence supports enteral nutrition to induce disease remission. Food re-introduction diets provide structure to food re-introduction and help maintain disease remission. These guidelines aim to reduce variation in clinical practice.
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Affiliation(s)
- J Lee
- Department of Nutrition and Dietetics, Addenbrookes, Cambridge, UK
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Wall CL, Day AS, Gearry RB. Use of exclusive enteral nutrition in adults with Crohn’s disease: A review. World J Gastroenterol 2013; 19:7652-7660. [PMID: 24282355 PMCID: PMC3837264 DOI: 10.3748/wjg.v19.i43.7652] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 08/08/2013] [Accepted: 09/17/2013] [Indexed: 02/06/2023] Open
Abstract
Exclusive enteral nutrition (EEN) is well-established as a first line therapy instead of corticosteroid (CS) therapy to treat active Crohn’s disease (CD) in children. It also has been shown to have benefits over and above induction of disease remission in paediatric populations. However, other than in Japanese populations, this intervention is not routinely utilised in adults. To investigate potential reasons for variation in response between adult studies of EEN and CS therapy. The Ovid database was searched over a 6-mo period. Articles directly comparing EEN and CS therapy in adults were included. Eleven articles were identified. EEN therapy remission rates varied considerably. Poor compliance with EEN therapy due to unpalatable formula was an issue in half of the studies. Remission rates of studies that only included patients with previously untreated/new CD were higher than studies including patients with both existing and new disease. There was limited evidence to determine if disease location, duration of disease or age of diagnosis affected EEN therapy outcomes. There is some evidence to support the use of EEN as a treatment option for a select group of adults, namely those motivated to adhere to an EEN regimen and possibly those newly diagnosed with CD. In addition, the use of more palatable formulas could improve treatment compliance.
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Abstract
PURPOSE OF REVIEW Diet is known to have a major role in the expression of inflammatory bowel disease (IBD). The role of dietary interventions and enteral nutrition in the management of IBD remains unelucidated. This study was to review the current evidence for dietary risk factors for the development of IBD and the efficacies of dietary and enteral interventions. RECENT FINDINGS High dietary intakes of total fats, polyunsaturated fatty acids, omega-6 fatty acids, and meat are associated with an increased risk of Crohn's disease and ulcerative colitis. Further prospective studies are required to confirm these observations. Among various dietary interventions, none has shown striking efficacy. Meta-analyses have shown enteral nutrition to be inferior to corticosteroids in adults with active Crohn's disease. However, in children, a meta-analysis has shown no significant difference in the remission rates between enteral nutrition and corticosteroid therapy. Although the evidence level is not striking, enteral nutrition may be useful for maintaining remission in patients with quiescent Crohn's disease. SUMMARY Dietary risk factors for IBD and the therapeutic benefit of dietary and enteral interventions need to be confirmed by further well designed studies in large cohorts of patients.
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Ueno F, Matsui T, Matsumoto T, Matsuoka K, Watanabe M, Hibi T. Evidence-based clinical practice guidelines for Crohn's disease, integrated with formal consensus of experts in Japan. J Gastroenterol 2013; 48:31-72. [PMID: 23090001 PMCID: PMC3541931 DOI: 10.1007/s00535-012-0673-1] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 08/16/2012] [Indexed: 02/04/2023]
Abstract
Crohn's disease is a disorder of unknown etiology and complicated pathogenesis. A substantial amount of evidence has accumulated recently and has been applied to clinical practice. The present guidelines were developed based on recent evidence and the formal consensus of experts relevant to this disease. Here we provide an overview of these guidelines, as follows. Target disease: Crohn's disease Users: Clinical practitioners in internal medicine, surgery, gastroenterology, and general practice Purpose: To provide appropriate clinical indicators to practitioners Scope of clinical indicators: Concept of Crohn's disease, epidemiology, classifications, diagnosis, treatment, follow up, and special situations Intervention: Diagnosis (interview, physical examination, clinical laboratory tests, imaging, and pathology) and treatment (lifestyle guidance, drug therapy, nutritional therapy, surgery, etc.) Outcome assessment: Attenuation of symptoms, induction and maintenance of remission, imaging findings, quality of life (QOL), prevention of complications and harm of therapy Methods for developing these guidelines: Described in the text Basis of recommendations: Integration of evidence level and consensus of experts Cost-benefit analysis: Not implemented Evaluation of effectiveness: Yet to be confirmed Status of guidelines: Updated version of the first Guidelines published in 2010 Publication sources: Printed publication available and electronic information in preparation Patient information: Not available Date of publication: October 2011 These guidelines were intended primarily to be used by practitioners in Japan, and the goal of these guidelines is to improve the outcomes of patients with Crohn's disease.
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Affiliation(s)
| | - Toshiyuki Matsui
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Takayuki Matsumoto
- Division of Lower Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Katsuyoshi Matsuoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinano-machi Shinjuku, Tokyo, 160-8582 Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshifumi Hibi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinano-machi Shinjuku, Tokyo, 160-8582 Japan
| | - On Behalf of the Guidelines Project Group of the Research Group of Intractable Inflammatory Bowel Disease subsidized by the Ministry of Health, Labour and Welfare of Japan and the Guidelines Committee of the Japanese Society of Gastroenterology
- Ofuna Chuo Hospital, Kanagawa, Japan
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
- Division of Lower Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinano-machi Shinjuku, Tokyo, 160-8582 Japan
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
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Cabré E, Domènech E. Impact of environmental and dietary factors on the course of inflammatory bowel disease. World J Gastroenterol 2012; 18:3814-22. [PMID: 22876032 PMCID: PMC3413052 DOI: 10.3748/wjg.v18.i29.3814] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 03/26/2012] [Accepted: 03/29/2012] [Indexed: 02/06/2023] Open
Abstract
Besides their possible effects on the development of inflammatory bowel disease (IBD), some environmental factors can modulate the clinical course of both ulcerative colitis (UC) and Crohn’s disease (CD). This review is mainly devoted to describing the current knowledge of the impact of some of these factors on the outcome of IBD, with special emphasis on smoking and diet. Although the impact of smoking on the susceptibility to develop CD and UC is firmly established, its influence on the clinical course of both diseases is still debatable. In CD, active smoking is a risk factor for postoperative recurrence. Beyond this clinical setting, smoking cessation seems to be advantageous in those CD patients who were smokers at disease diagnosis, while smoking resumption may be of benefit in ex-smokers with resistant UC. The role of dietary habits on the development of IBD is far from being well established. Also, food intolerances are very frequent, but usually inconsistent among IBD patients, and therefore no general dietary recommendations can be made in these patients. In general, IBD patients should eat a diet as varied as possible. Regarding the possible therapeutic role of some dietary components in IBD, lessons should be drawn from the investigation of the primary therapeutic effect of enteral nutrition in CD. Low-fat diets seem to be particularly useful. Also, some lipid sources, such as olive oil, medium-chain triglycerides, and perhaps omega-3 fatty acids, might have a therapeutic effect. Fermentable fiber may have a role in preventing relapses in inactive UC.
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Alhagamhmad MH, Day AS, Lemberg DA, Leach ST. An update of the role of nutritional therapy in the management of Crohn's disease. J Gastroenterol 2012; 47:872-82. [PMID: 22699323 DOI: 10.1007/s00535-012-0617-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 05/14/2012] [Indexed: 02/04/2023]
Abstract
Crohn's disease is an increasingly global health concern. Currently without a cure, it significantly alters the quality of life of Crohn's disease sufferers and places a heavy financial burden on the community. Recent reports show that the rising prevalence of Crohn's disease is no longer confined to Western countries, with considerable increases seen particularly in Asia. Nutritional problems are often associated with Crohn's disease, most notably in the paediatric population, with underweight and stunting commonly seen at presentation. In addition, linear growth retardation and pubertal delay can also manifest in these younger patients. Therefore, exclusive enteral nutrition has been used as a therapeutic option to treat Crohn's disease, in part to address the nutritional complications of the disease. Exclusive enteral nutrition can improve nutrition as well as induce remission at a rate equivalent to corticosteroids. It is safe particularly with long-term use and can induce mucosal healing, considered the gold standard for therapy, at a rate superior to corticosteroids. Exclusive enteral nutrition has thus become the preferred therapeutic option in many centres for the treatment of paediatric Crohn's disease. This review discusses the role of exclusive enteral nutrition as a therapeutic option for the treatment of Crohn's disease, as well as the latest findings into its mechanisms of action.
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Affiliation(s)
- Moftah H Alhagamhmad
- School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
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Nutritional therapy versus 6-mercaptopurine as maintenance therapy in patients with Crohn's disease. Dig Liver Dis 2012; 44:649-54. [PMID: 22542605 DOI: 10.1016/j.dld.2012.03.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 03/01/2012] [Accepted: 03/04/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND 6-Mercaptopurine is often used as maintenance therapy in patients with Crohn's disease. However, toxicities like myelosuppression limit its clinical benefit. AIMS To evaluate the efficacy of elemental diet versus 6-mercaptopurine as maintenance therapy in Crohn's disease. METHODS Ninety-five eligible patients with Crohn's disease activity index ≤150 were randomly assigned to: 6-mercaptopurine (0.5-1.5mg/kg/day, n=30); Elental as an elemental diet (≥900 kcal/day, n=32); none (control, n=33). In the three groups, patients were and remained on 5-aminosalicylic acid (2250-3000 mg/day). Patients were observed for 2 years and the rate of relapse (Crohn's disease activity index ≥200) was monitored. RESULTS At 24 months, the fractions of patients who had maintained remission were 60%, 46.9% and 27.2% for 6-mercaptopurine, Elental and the control groups, respectively. Log-rank test showed better efficacy for 6-mercaptopurine (P=0.0041) and Elental (P=0.0348) versus control. No significant difference was found between 6-mercaptopurine and Elental. Further, in the 6-mercaptopurine group, 2 patients experienced liver injury and one developed alopecia. CONCLUSIONS This 24 months comparison study showed that Elental as maintenance therapy in Crohn's disease patients was as effective as 6-mercaptopurine. Elental should be useful for long-term maintenance therapy in Crohn's disease. This is the first comparison study evaluating nutritional therapy versus 6-mercaptopurine.
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Abstract
BACKGROUND & AIM Despite their well known anti-inflammatory actions, the clinical usefulness of omega-3 PUFA in inflammatory bowel disease is controversial. We aimed to systematically review the available data on the performance of omega-3 PUFA as therapeutic agents in these patients. METHODS Electronic databases were systematically searched for RCT of fish oil or omega-3 PUFA therapy in both active and inactive ulcerative colitis or Crohn's disease, without limitation on either the length of therapy or the form it was given, including nutritional supplements and enteral formula diets. Eligible articles were assessed for methodological quality on the basis of the adequacy of the randomisation process, concealment of allocation, blinding of intervention and outcome, possible biases, and completeness of follow-up. The five-point Oxford quality score was calculated. RESULTS A total of 19 RCT were finally selected for this review. Overall, available data do not allow to support the use of omega-3 PUFA supplementation for the treatment of both active and inactive inflammatory bowel disease. Negative results are quite consistent in trials assessing the use of omega-3 PUFA to maintain disease remission, particularly ulcerative colitis, and to a lesser extent Crohn's disease. Trials on their use in active disease do not allow to draw firm conclusions mainly because the heterogeneity of design (ulcerative colitis) or their short number (Crohn's disease). In most trials, the appropriateness of the selected placebo is questionable. CONCLUSION The present systematic review does not allow to make firm recommendations about the usefulness of omega-3 PUFA in inflammatory bowel disease.
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Galland L. Inflammatory Bowel Disease. Integr Med (Encinitas) 2012. [DOI: 10.1016/b978-1-4377-1793-8.00102-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Brown AC, Rampertab SD, Mullin GE. Existing dietary guidelines for Crohn's disease and ulcerative colitis. Expert Rev Gastroenterol Hepatol 2011; 5:411-25. [PMID: 21651358 DOI: 10.1586/egh.11.29] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Patients with inflammatory bowel disease (IBD) often question their doctors about diet. The objectives of this article are to provide clinicians with existing dietary advice by presenting the dietary information proposed by medical societies in the form of clinical practice guidelines as it relates to IBD; listing dietary guidelines from patient-centered IBD-related organizations; and creating a new 'global practice guideline' that attempts to consolidate the existing information regarding diet and IBD. The dietary suggestions derived from sources found in this article include nutritional deficiency screening, avoiding foods that worsen symptoms, eating smaller meals at more frequent intervals, drinking adequate fluids, avoiding caffeine and alcohol, taking vitamin/mineral supplementation, eliminating dairy if lactose intolerant, limiting excess fat, reducing carbohydrates and reducing high-fiber foods during flares. Mixed advice exists regarding probiotics. Enteral nutrition is recommended for Crohn's disease patients in Japan, which differs from practices in the USA.
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Affiliation(s)
- Amy C Brown
- Department of Complementary & Alternative Medicine, John A Burns School of Medicine, University of Hawaii at Manoa, 651 Ilalo Street, MEB 223, Honolulu, HI 96813, USA.
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Turner D, Shah PS, Steinhart AH, Zlotkin S, Griffiths AM. Maintenance of remission in inflammatory bowel disease using omega-3 fatty acids (fish oil): a systematic review and meta-analyses. Inflamm Bowel Dis 2011; 17:336-45. [PMID: 20564531 DOI: 10.1002/ibd.21374] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The objective was to systematically review the efficacy and safety of n-3 (omega-3 fatty acids, fish oil) for maintaining remission in Crohn's disease (CD) and ulcerative colitis (UC). Electronic databases were searched systematically for randomized controlled trials of n-3 for maintenance of remission in inflammatory bowel disease (IBD). Studies of patients of any age group who were in remission at the time of recruitment and were followed for at least 6 months were included. The primary outcome was relapse rate at the end of the follow-up period. Nine studies were eligible for inclusion; six studies of CD (n = 1039) and three of UC (n = 138). There was a statistically significant benefit for n-3 in CD (relative risk [RR] 0.77; 95% confidence interval [CI] 0.61-0.98); however, the studies were heterogeneous (I(2) = 58%). The absolute risk reduction was -0.14 (95% CI: -0.25 to -0.02). Opinions may vary on whether this is a clinically significant effect. Two well-done studies with a larger sample size reported no benefit. A sensitivity analysis excluding a small pediatric study resulted in the pooled RR being no longer statistically significant. A funnel plot analysis suggested publication bias for the smaller studies. For UC, there was no difference in the relapse rate between the n-3 and control groups (RR 1.02; 95% CI: 0.51-2.03). The pooled analysis showed a higher rate of diarrhea (RR 1.36; 95% CI: 1.01-1.84) and symptoms of the upper gastrointestinal tract (RR 1.96; 95% CI: 1.37-2.80) in the n-3 treatment group. There are insufficient data to recommend the use of omega 3 fatty acids for maintenance of remission in CD and UC.
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Affiliation(s)
- Dan Turner
- Pediatric Gastroenterology Unit, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Israel.
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Enteral diets enriched with medium-chain triglycerides and N-3 fatty acids prevent chemically induced experimental colitis in rats. Transl Res 2010; 156:282-91. [PMID: 20970751 DOI: 10.1016/j.trsl.2010.07.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Revised: 07/21/2010] [Accepted: 07/22/2010] [Indexed: 02/07/2023]
Abstract
The specific purpose of this study was to evaluate the significant effects of medium-chain triglycerides (MCTs) and N-3 fatty acids on chemically induced experimental colitis induced by 2,4,6-trinitrobenzene sulphonic acid (TNBS) in rats. Male Wistar rats were fed liquid diets enriched with N-6 fatty acid (control diets), N-3 fatty acid (MCT- diets), and N-3 fatty acid and MCT (MCT+ diets) for 2 weeks and then were given an intracolonic injection of TNBS. Serum and tissue samples were collected 5 days after ethanol or TNBS enema. The severity of colitis was evaluated pathologically, and tissue myeloperoxidase activity was measured in colonic tissues. Furthermore, protein levels for inflammatory cytokines and a chemokine were assessed by an enzyme-linked immunosorbent assay in colonic tissues. Induction of proinflammatory cytokines tumor necrosis factor-α and interleukin-1β in the colon by TNBS enema was markedly attenuated by the MCT+ diet among the 3 diets studied. Furthermore, the induction of chemokines macrophage inflammatory protein-2 and monocyte chemotactic protein-1 also was blunted significantly in animals fed the MCT+ diets. As a result, MPO activities in the colonic tissue also were blunted significantly in animals fed the MCT+ diets compared with those fed the control diets or the MCT- diets. Furthermore, the MCT+ diet improved chemically induced colitis significantly among the 3 diets studied. Diets enriched with both MCTs and N-3 fatty acids may be effective for the therapy of inflammatory bowel disease as antiinflammatory immunomodulating nutrients.
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Brown AC, Roy M. Does evidence exist to include dietary therapy in the treatment of Crohn's disease? Expert Rev Gastroenterol Hepatol 2010; 4:191-215. [PMID: 20350266 DOI: 10.1586/egh.10.11] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Prescription drugs and surgery are two common medical therapies for Crohn's disease (CD), an inflammatory bowel disease that affects the GI tract. Unfortunately, certain drugs can cause serious side effects, and surgeries must often be repeated. No diet has been established to alleviate the pain and suffering of CD patients. This is curious given the fact that a higher prevalence of food sensitivities exist in this population of patients, and enteral nutrition is not only the first-line of therapy in Japan, but a known research method used to place the majority of CD patients into remission. Although not all patients respond equally to diet, many simply remove symptom-provoking foods, such as dairy, wheat, corn and certain fruits and vegetables. We suggest assisting these patients in their self-assessment of irritating and symptom-provoking foods by educating them in the use of a food-symptom diary followed by a customized elimination diet trialed for 2-4 weeks to determine if there is any benefit to the individual patient.
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Affiliation(s)
- Amy C Brown
- Department of Complementary and Alternative Medicine, John A Burns School of Medicine, University of Hawaii, 651 Ilalo Street, MEB 223, Honolulu, HI 96813, USA.
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Kono H, Fujii H, Ishii K, Hosomura N, Ogiku M. Dietary medium-chain triglycerides prevent chemically induced experimental colitis in rats. Transl Res 2010; 155:131-41. [PMID: 20171598 DOI: 10.1016/j.trsl.2009.08.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Revised: 08/21/2009] [Accepted: 08/25/2009] [Indexed: 01/25/2023]
Abstract
The effects of dietary medium-chain triglycerides (MCTs) on experimental colitis induced by 2,4,6-trinitrobenzene sulphonic acid (TNBS) were investigated in rats. Male Wistar rats were given an intracolonic injection of TNBS and were then fed liquid diets containing MCTs or corn oil (AIN93) as controls. Serum and tissue samples were collected 1 week after TNBS enema. The severity of colitis was evaluated pathologically, and tissue myeloperoxidase (MPO) activity was measured. Furthermore, messenger RNA (mRNA) and protein levels for inflammatory cytokines and a chemokine were assessed by reverse-transcription polymerase chain reaction and enzyme-linked immunosorbent assay, respectively. In another set of experiments, the protein expression of Toll-like receptor (TLR)-4 in the colon was measured 1 week after feeding of liquid diets. To investigate the effects of MCTs on macrophages, RAW246.7 macrophages were incubated with media containing albumin conjugated with MCT or linoleic acid, which is the major component of corn oil. Then, the production of tumor necrosis factor-alpha (TNF-alpha) was measured. Dietary MCTs blunted significantly the protein levels of TLR-4 in the colon. Furthermore, the expression of TLR-4 was significantly blunted in RAW264.7 cells incubated with MCTs compared with cells incubated with linoleic acid. Induction of interleukin 1beta (IL-1beta), TNF-alpha, and macrophage inflammatory protein-2 (MIP-2) in the colon was attenuated by dietary MCT. Furthermore, MPO activities in the colonic tissue were significantly blunted in animals fed the MCT diets compared with those fed the control diets. As a result, dietary MCTs improved chemically induced colitis significantly. MCTs most likely are useful for the therapy of inflammatory bowel disease as an anti-inflammatory immunomodulating nutrient.
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Affiliation(s)
- Hiroshi Kono
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan.
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Yamamoto T, Nakahigashi M, Saniabadi AR. Review article: diet and inflammatory bowel disease--epidemiology and treatment. Aliment Pharmacol Ther 2009; 30:99-112. [PMID: 19438426 DOI: 10.1111/j.1365-2036.2009.04035.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Diet is thought to have an important role in the immunopathogenesis and treatment of inflammatory bowel disease (IBD). AIM To identify dietary constituents as risk factors for development of IBD and the therapeutic efficacy of dietary modifications or enteral nutrition in IBD. METHODS The Medline and the Cochrane Library were searched for clinical trials and meta-analyses in the scope of diet and nutrition in IBD. RESULTS There are many studies in small cohorts of patients that claim that intake of certain diet constituents like fat, refined sugar, fruits, vegetables and fibre affect the expression of IBD. These are often compromised by insufficient data or methodological limitations and do not provide unequivocal evidence to incriminate any particular dietary factor. Among various dietary interventions, none has shown striking efficacy with the possible exception of complete enteral nutrition. Enteral nutrition appears effective in both active and quiescent Crohn's disease (CD), but independent meta-analyses have shown enteral nutrition to be inferior to corticosteroids in the management of active CD, when assessed on an intention-to-treat basis. CONCLUSIONS The current levels of knowledge concerning dietary risk factors for IBD, and the therapeutic efficacy of dietary and nutritional interventions need to be supported by well-designed trials in large cohorts of patients.
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Affiliation(s)
- T Yamamoto
- Inflammatory Bowel Disease Centre, Yokkaichi Social Insurance Hospital, 10-8 Hazuyamacho, Yokkaichi, Mie 510-0016, Japan.
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Mañé J, Pedrosa E, Lorén V, Ojanguren I, Fluvià L, Cabré E, Rogler G, Gassull MA. Partial replacement of dietary (n-6) fatty acids with medium-chain triglycerides decreases the incidence of spontaneous colitis in interleukin-10-deficient mice. J Nutr 2009; 139:603-10. [PMID: 19126671 DOI: 10.3945/jn.108.101170] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Enteral nutrition has a primary therapeutic effect in active Crohn's disease. It is unknown which nutrient(s) account for this action, but a role for both the amount and type of dietary fat has been postulated. Some clinical and experimental data suggest that medium-chain triglycerides (MCT) may reduce intestinal inflammation. We aimed to assess the effect of replacing part of the dietary fat with MCT on the incidence and severity of colitis in interleukin (IL)-10(-/-) mice under specific pathogen-free conditions. Twenty-four IL-10(-/-) 4-wk-old mice were randomized to receive a control diet based on sunflower oil [(n-6) fatty acids (FA)] and an experimental isocaloric, isonitrogenous diet with 50% sunflower and 50% coconut oil (MCT diet). When the mice were 12 wk old, they were killed and the colon was examined for the presence of colitis, lymphocyte subpopulations and apoptosis, ex vivo cytokine production in supernatant of colon explants, toll-like receptor (TLR)-2 and TLR-9 mRNA, and FA profile in colonic tissue homogenates. Colitis incidence was lower in the IL-10(-/-) mice fed the MCT diet (1/12) than in the mice fed the control diet (8/12; P = 0.03). The histological damage score was also lower in the former (P < 0.0005). Feeding the MCT diet resulted in fewer total and apoptotic intraepithelial CD3+ and lamina propria CD3+CD4+ lymphocytes, as well as downregulated production of IL-6 and interferon-gamma, and reduced TLR-9 mRNA. We conclude that partial replacement of dietary (n-6) FA with MCT decreases the incidence of colitis in a model of spontaneous intestinal inflammation and provide experimental arguments for a possible primary therapeutic effect of MCT in human Crohn's disease.
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Affiliation(s)
- Josep Mañé
- Health Sciences Research Institute, University Hospital Germans Trias i Pujol, 08916 Badalona, Spain
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Turner D, Zlotkin SH, Shah PS, Griffiths AM. Omega 3 fatty acids (fish oil) for maintenance of remission in Crohn's disease. Cochrane Database Syst Rev 2009:CD006320. [PMID: 19160277 DOI: 10.1002/14651858.cd006320.pub3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The anti-inflammatory effects of n-3 (omega-3 fatty acids, fish oil) have been suggested to be beneficial in chronic inflammatory disorders such as inflammatory bowel disease. OBJECTIVES To systematically review the efficacy and safety of n-3 for maintenance of remission in Crohn's disease (CD). SEARCH STRATEGY The following databases were searched from their inception without language restriction: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Healthstar, PubMed, and ACP journal club. Experts were contacted for unpublished data. SELECTION CRITERIA Randomized placebo-controlled trials (RCT) of n-3 for maintenance of remission in CD were included. Studies must have enrolled patients of any age group, who were in remission at the time of recruitment, and were followed for at least six months. The intervention must have been fish oil or n-3 given in pre-defined dosage. Co-interventions were allowed only if they were balanced between the study groups. The primary outcome was the relapse rate and secondary outcomes included change in disease activity scores, time to first relapse and adverse events. DATA COLLECTION AND ANALYSIS Two independent investigators reviewed studies for eligibility, extracted the data and assessed study quality using Jadad's criteria. Meta-analyses were performed using RevMan 4.2 software weighted by the Mantel-Haenszel method. Random or fixed effect models were used according to degree of heterogeneity and subgroup analyses were performed in an attempt to explore possible sources of heterogeneity. MAIN RESULTS Six studies were eligible for inclusion. There was a marginal significant benefit of n-3 therapy for maintaining remission (RR 0.77 0.; 95%CI 0.61 to 0.98; P = 0.03). However, the studies were both clinically and statistically heterogeneous (P = 0.03, I(2) = 58%). Two large studies showed negative results. When considering the estimated rather than the observed 1-year relapse rate of these two studies, the benefit was no longer statistically significant (RR 0.59; 95% CI 0.34 to 1.03; P=0.06). A funnel plot suggested publication bias. No serious adverse events were recorded in any of the studies but in a pooled analyses there was a significantly higher rate of diarrhea (RR 1.36 95% CI 1.01 to 1.84) and symptoms of the upper gastrointestinal tract (RR 1.98 95% CI 1.38 to 2.85) in the n-3 treatment group. AUTHORS' CONCLUSIONS Omega 3 fatty acids are safe but probably ineffective for maintenance of remission in CD. The existing data do not support routine maintenance treatment of Crohn's disease with omega 3 fatty acids.
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Affiliation(s)
- Dan Turner
- Pediatric Gastroenterology Unit, Shaare Zedek Medical Center, P.O.B 3235, Jerusalem, Israel, 91031.
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Dupont B, Dupont C, Justum AM, Piquet MA, Reimund JM. Enteral nutrition in adult Crohn's disease: Present status and perspectives. Mol Nutr Food Res 2008; 52:875-84. [DOI: 10.1002/mnfr.200800093] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Issa M, Binion DG. Bowel Rest and Nutrition Therapy in the Management of Active Crohn's Disease. Nutr Clin Pract 2008; 23:299-308. [DOI: 10.1177/0884533608318675] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Mazen Issa
- From the Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - David G. Binion
- From the Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee
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