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Existing dietary guidelines for Crohn’s disease and ulcerative colitis

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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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411
Review
www.expert-reviews.com ISSN 1747-4124
© 2011 Expert Reviews Ltd
10.1586/EGH.11.29
Amy C Brown†1,
S Devi Rampertab2 and
Gerard E Mullin3
1Department of Compleme ntary &
Alternative Medicine, John A Burns
School of Medicine, University of
Hawaii at Manoa, 651 Ilalo Street,
MEB 223, Honolulu, HI 96813, USA
2Division of Gastroenterology,
Penn State Hershey Medical Center,
PA, USA
3Johns Hopkins School of Medicine,
The Johns Hopkins Hospital, MD, USA
Author for correspondence:
Tel.: +1 808 692 0907
amybrown @hawaii.edu
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.
Keywor ds: Crohn’s disease • diet • dietar y supplements • enteral nutrition • inammatory bowel disease
• nutrition • parenteral nutrition • ulcerative colitis
Existing dietary guidelines
for Crohns disease and
ulcerative colitis
Expert Rev. Gastroenterol. Hepatol. 5(3), 411–425 (2011)
• Create a new ‘global practice guideline’ that
incorporates the current clinical practice
guidelines and informal dietary recommenda-
tions into one consolidated set of guidelines;
• Comment on existing nutrition guidelines for
IBD and recommend future research.
Clinical practice guidelines
The current recommendations of the American
Dietetic Association (ADA), clinical practice
guidelines from selected medical organizations
and a few informal dietary recommendations are
now briefly summarized.
The American Dietetic Association
The ADA [101] is the world’s largest organization of
food and nutrition professionals, and their online
Nutrition Care Manual (available by subscription)
lists the majority of diets recommended for various
medical conditions [102]. Only general guidelines
are provided for IBD listed in Box 1, with an accom- with an accom-
panying table of recommended foods (TaBle 1) and
foods that are not recommended (TaBle 2).
The American College of Gastroenterology
The American Journal of Gastroenterology pub-
lished the American College of Gastroenterology
Although physicians are not always taught infor-
mation about diet and inflammatory bowel
disease (IBD) in their training or through their
professional associations, registered dietitians may
also not be adequately prepared to present dietary
information to patients with IBD. Based on our
previous review of the literature on diet and
Crohn’s disease (CD), it appears that a large gap
exists in translating research-based dietary knowl-
edge to clinical practice for the IBD population [1].
Creating evidence-based dietary recommenda-
tions for people with IBD is an un addressed need.
These patients need up-to-date dietary clinical
practice guidelines that will, if possible, best serve
to reduce the risk of nutritional deficiency and
possibly reduce their symptoms.
The current state of the art is that various clini-
cal practice guidelines for IBD patients exist, but
many are sparse on dietary recommendations,
and vary by origin.
The objectives of this article are to:
• Collectively present the dietary information
relating to IBD in the form of clinical practice
guidelines proposed by medical societies;
• List the ‘informal dietary guidelines’ suggested
by patient-centered IBD-related associations;
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Expert Rev. Gastroen terol . Hepatol. 5(3), (2011)
412
Review
(ACG) Practice Guidelines for CD [2] and ulcerative colitis
(UC) [3].
Crohn’s disease
The only mention of nutrition for patients with CD is “no pla-
cebo-controlled trials of nutritional therapy for active CD have
been performed.” They report that corticosteroids are more
effective than enteral nutrition to induce remission in active
CD patients, but that more than 50% of corticosteroid acute
users become ‘steroid dependent’ or ‘steroid resistant’. It is also
mentioned that no difference in efficacy exists between elemental
and polymeric diets, and the only appropriate use of enteral diets
is as an adjunctive therapy to support a patient’s nutrition [2].
Ulcerative colitis
The dietary information for patients with UC is more sparse. It
states, with the exception of patients with significant nutrition
depletion, total parenteral nutrition showed no benefit, and may
even deprive colonic enterocytes of short-chain fatty acids [3].
The online ACG consumer guide information sheets [103]
provide more information on diet and suggest:
• Lactose-intolerant individuals should avoid milk or milk prod-
ucts or use those to which lactase enzyme has been added;
• A low-roughage diet is recommended for those experiencing
diarrhea after meals;
• Patients can often eat a reasonably unrestricted diet.
World Gastroenterology Organization practice guidelines
Compared with other clinical practice guidelines, those from
the World Gastroenterology Organization (WGO) provide the
most comprehensive dietary advice to IBD patients [4]. Diet
and lifestyle considerations are part of the WGO global guide-
lines [4]. Although they state that the impact of diet is poorly
understood, they add that dietary changes may help reduce
symptoms in CD and UC.” Their guidelines, provided in Box 2,
Box 1. General inflammatory bowel disease
guidelines from the American Dietetic Association.
Eat small meals or snacks every 3 or 4 h
Use low-fiber foods when you have symptoms (recommended
foods chart: Ta Ble 1). You can slowly reintroduce small amounts
of whole-grain foods and higher-fiber fruits and vegetables one
at a time when symptoms improve
Drink enough fluids (at least eight cups each day) to avoid
dehydration
Eat foods with added probiotics and prebiotics
Use a multivitamin
During periods when you don’t have symptoms, include whole
grains and a variety of fruits and vegetables in your eating plan.
Start new foods one at a time, in small amounts
© 2010 American Dietetic Association. Reprinted with permission from [101].
Table 1. American Dietetic Association ‘recommended’ foods for inflammatory bowel disease.
Food group Recommended foods Notes
Milk and dairy
products
Buttermilk
Evaporated, skimmed, powdered or low-fat milk
Yogurt
Cheeses (low-fat)
Ice cream (low-fat)
Sherbet
Choose lactose-free products if you have lactose intolerance. Lactose
intolerance causes symptoms after drinking regular milk or eating
foods from milk. Symptoms include diarrhea, nausea, stomach pain
and bloating
Choose yogurt with live, active cultures (see food label)
Meats and other
protein foods
Tender, well-cooked meats, poultry, fish, eggs
and soy prepared without added fat
Smooth nut butter
Grains Bread, bagels, rolls, crackers, cereals and pasta
made from white or refined flour
Choose grain foods with less than 2 g of fiber per serving (see
food label)
Vegetables Most well-cooked vegetables without seeds
Potatoes without skin
Lettuce
Strained vegetable juice
See TaBl e 2 for vegetables to avoid if you have diarrhea or
abdominal pain
Fruits Fruit juice without pulp (except prune juice)
Ripe banana or melons
Most canned, soft fruits
Peeled apple
Choose canned fruit in juice or light syrup. Heavy syrup has lots of
sugar, which may make diarrhea worse.
See TaBl e 2 for foods to avoid if you have diarrhea or abdominal pain
Fats and oils Limit fats and oils to less than eight teaspoons per day
Beverages Water
Decaffeinated coffee
Caffeine-free tea
Soft drinks without caffeine
Rehydration beverages
Drinking beverages with sugar or corn syrup may make
diarrhea worse. Very sweet juices may also have this effect
© 2010 American Dietetic Association. Reprinted with permission from [101].
Brown, Rampertab & Mullin
www.expert-reviews.com 413
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focus on the reduction of symptoms (CD
and UC), reduction of inflammation (CD),
probiotics and supplements.
The American Society for Parenteral
& Enteral Nutrition
The American Society for Parenteral and
Enteral Nutrition (ASPEN) guidelines,
divided by adult and pediatric patients in
Box 3, suggest that all IBD patients should
receive nutrition screening to determine
which patients require formal nutrition
intervention [5].
The European Society for Clinical
Nutrition & Metabolism
In 2006, the Europe a n Society for
Parenteral and Enteral Nutrition (ESPEN)
published enteral nutrition guidelines for
IBD patients [6] . Van Gossum et al. stated
that malnutrition occurs in 20–85% of
CD patients, and the highest risk group
is patients with the disease in their small
intestines [7]. Selected dietary guidelines for
enteral and parenteral nutrition from both
publications are highlighted in Box 4.
The Japanese Society for Pediatric
Gastroenterology, Hepatology
& Nutrition
The authors of ‘Guidelines for the treat-
ment of CD in children,’ published in
Pediatrics International, the official journal
of the Japan Pediatric Society, provide their
guidelines in Box 5 [8].
Informal dietary recommendation
Several informal sources of dietary information for patients with
IBD exist through the Crohn’s & Colitis Foundation of America,
The National Digestive Diseases Information Clearinghouse and
Medline Plus. These public recommendations are now briefly
provided in the following sections.
Crohn’s & Colitis Foundation of America
The leading IBD nonprofit association in the USA suggests on their
website that “there is no single diet for everyone with IBD,and that
“dietary recommendations must be individualized” [104]. However,
they add that, “what you eat may go a long way toward reducing
symptoms and promoting healing.” The Specific Carbohydrate
Diet, popularized in Elaine Gottschall’s lay book, Breaking the
Vicious Cycle’, is mentioned as being only supported by patient
testimonials, but “bottom line, it may be worth a try.” Patients are
recommended to limit their salt intake during corticosteroid treat-
ment because salt worsens fluid retention. If there is a stricture, Box 6
provides suggestions to avoid cramping or contractions.
The National Digestive Diseases
Information Clearinghouse
The National Digestive Diseases Information Clearinghouse, a
service of the National Institute of Diabetes and Digestive and
Kidney Diseases (NIH) lists no recommendations concerning
diet for UC, but Box 7 lists suggestions for those with CD [105].
Medline Plus
The website providing information from the National Library of
Medicine, the NIH and other government agencies and health-
related organizations provides more detailed information for IBD
patients (Box 8 ) [106,107].
Global IBD dietary clinical practice guideline
Many of the aforementioned dietary recommendations have
identical or similar content, with some degree of variation. In
order to consolidate the information into a concise summary,
TaBle 3 was created by the authors to provide a summary of existing
guidelines. This is an educated summary of existing guidelines
Table 2. American Dietetic Association ‘foods to avoid’ for
inflammatory bowel disease.
Food group Foods to avoid
Milk and dairy
products
Whole milk, half-and-half, cream, sour cream
Yogurt with berries, orange or lemon rind, or nuts
Ice cream (unless low-fat or nonfat)
Meats and other
protein foods
Fried meats, including sausage and bacon
Luncheon meats, such as bologna or salami
Hot dogs
Tough or chewy cuts of meat
Fried eggs
All dried beans, peas and nuts
Chunky nut butters
Grains Whole-wheat or whole-grain breads, rolls, crackers or pasta
Brown rice and wild rice
Cereals made from whole grain
Any grain foods made with seeds or nuts
Vegetables Beets, broccoli, Brussels sprouts, cabbage, sauerkraut, cauliflower,
corn, greens (spinach, mustard, turnip and collards), lima beans,
mushrooms, okra, onions, parsnips, peppers, potato skins and
winter squash
Fruits All raw fruits except peeled apples, ripe bananas and melon
Canned berries, canned cherries
Dried fruits, including raisins
Prune juice
Fats and oils Do not have more than eight teaspoons a day
Beverages Beverages with caffeine, such as coffee, tea, cola and some
sport drinks
Alcoholic drinks
Avoid sweet fruit juices and soft drinks or other beverages made with
sugar or corn syrup if they make diarrhea worse
Other Sugar alcohols (sorbitol, mannitol and xylitol) cause diarrhea in some
people. These ingredients are often found in sugarless gums and
candies, and some medications
© 2010 American Dietetic Association. Reprinted with permission from [101].
Existing dietary guidelines for Crohn’s disease & ulcerative colitis
Expert Rev. Gastroen terol . Hepatol. 5(3), (2011)
414
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and no attempt has been made to explore the scientific basis for
these recommendations.
Commentary on existing IBD dietary guidelines
Overall, the subject of diet and IBD embodies both nutrient
deficiencies, as well as the role diet may play in reducing IBD
symptoms. The former has more concrete data, whereas the latter
has not been well investigated.
The literature becomes difficult to decipher at times because
‘nutritional therapy’, a broad term covering all types of nutrition,
is often used in the medical literature to define enteral and/or
parenteral nutrition in relationship to IBD, and rarely describes
an actual oral diet. The topics of nutritional deficiency screening,
diet and enteral and/or parenteral nutrition are now briefly dis-
cussed in light of the aforementioned existing dietary guidelines
for patients with IBD.
Nutritional deficiency screening
Nutritional deficiency for patients with IBD is well described in the
literature, but only the ESPEN has recommended nutritional defi-
ciency screening in this patient population [7]. A diseased GI tract
can potentially compromise nutrient status, especially with regards
to nutrient absorption, healing and/or growth in children. Primary
problems related to CD include mal absorption, malnutrition,
Box 3. American Society for Parenteral and Enteral Nutrition clinical practice guidelines for inflammatory
bowel disease concerning diet.
Adult practice guidelines for IBD from ASPEN include [8] :
Enteral nutrition should be used in CD patients requiring specialized nutrition support
Parenteral nutrition should be reserved for those patients with IBD in whom enteral nutrition is not tolerated
Fistula-associated CD – a brief course of bowel rest and parenteral nutrition is recommended
Perioperative specialized nutrition support is indicated for those who are severely malnourished and for those in whom surgery can be
safely postponed
Specialized nutrition support and bowel rest should not be used as primary therapies for either UC or CD
Pediatric practice guidelines for IBD patients provided by ASPEN include :
Enteral nutrition should be given to children with growth retardation to help induce a growth spurt
Enteral nutrition should be used as an adjunct to medical therapy in those who are unable to maintain their nutrition status through
oral intake
Parenteral nutrition should be used in children who are unable to maintain normal growth and development on enteral nutrition or a
standard diet
ASPEN : Americ an Societ y for Parenteral and Enteral Nutrition; CD : Crohn’s disease; IBD: Inflammator y bowel disease; UC: Ulcerative colitis.
Adapted from [5].
Box 2. World Gastroenterology Organization clinical practice guidelines for inflammatory bowel disease
concerning diet.
During disease activity, decrease the amount of fiber
Dairy products can be maintained unless not tolerated
A high-residue diet may be indicated in cases of ulcerative proctitis (disease limited to rectum where constipation is more of a problem)
Limited data suggest that reducing dietary fermentable oligosaccharides, disaccharides and monosaccharides, and polyols may reduce
symptoms of IBD
Diet and lifestyle considerations may reduce inflammation in CD, specifically:
A liquid diet, predigested formula or nothing by mouth may reduce obstructive symptoms
An exclusive enteral diet can settle inflammatory disease, especially in children
Probiotics:
IBD may be caused or aggravated by alterations in gut flora
There is no evidence that probiotics are effective in either UC or CD; however:
– Escherichia coli Nissle 1917 is not inferior to 5-aminosalicylic acid
– VSL#3 (combination of eight bacterial strains) reduced flares of pouchitis (a post-ileoanal pouch procedure for UC)
Supplements:
Nutritional supplementation for those with malnutrition or during periods of reduced oral intake
Vitamin/mineral supplementation for all
Vitamin B12 and vitamin D for those that who are deficient
Steroid users should receive calcium and vitamin D supplementation
Chronic iron-deficiency anemia should be treated with parenteral iron if oral iron is not tolerated
CD: Crohn’s disease ; IBD: Inflammator y bowel disease; UC: Ulcerative colitis.
Adapted from [4].
Brown, Rampertab & Mullin
www.expert-reviews.com 415
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reduced dietary intake, weight loss, increased resting energy expend-
iture during flares, growth retardation in children, and the need for
adequate bowel rest, hydration and food sensitivity screening [1].
In support of ESPEN’s practice guidelines, these potential prob-
lems indicate that it is in the patient’s best interest to be screened
for primary nutritional problems, with referral to a registered
dietitian to arrange a treatment plan and follow-up. TaB le 4 pro-
vides a general checklist of these nutrition-related problems that
may exist in CD patients [9–16]. Patients with UC are also prone to
nutritional deficiency, especially since iron-deficient anemia due
to blood loss occurs in up to 80% of these patients.
Dietary supplements
Many of the dietary guidelines indirectly addressed nutritional defi-
ciency by suggesting a daily vitamin/mineral supplement with phy-
sician guidance. Special consideration should be given for vitamin D
and the the other fat soluble vitamins A, E
and K, as well as other nutrients, such as vita-
min C, vitamin B12, folate, calcium, mag-
nesium, iron, zinc and copper. IBD patients
who are prescribed corticosteroid medica-
tions should be informed of the increased
risk for osteoporosis and should receive
calcium and vitamin D supplementation.
Diet for IBD
No diet currently exists for patients with
IBD. This is problematic because when
125 pediatric IBD patients were questioned about diet, 90% of
the CD patients and 71% of the UC patients revealed that they
had altered their diets since diagnosis [17]. Approximately 73%
of these reported that their dietary changes alleviated symptoms
of abdominal pain, diarrhea and flatulence.
Unfortunately, IBD patients often ask questions about diet
without receiving instruction or referral to a registered dietitian.
For example, when CD patients were asked if diet altered their
symptoms, 78% (n = 21 out of 27), replied ‘yes’ [18]. However, only
15% of these patients (n = 4 out of 27) received a dietary referral.
Currently, many IBD patients continue to receive minimal dietary
instruction, despite clinical practice guidelines and emerging
research suggesting that dietary changes may ameliorate symptoms.
In terms of existing guidelines for dietary modifications, three
suggested limiting dairy if lactose intolerant, two suggested lim-
iting excess fat, one indicated decreasing excess carbohydrates,
Box 4. The European Society for Clinical Nutrition and Metabolism clinical practice guidelines for
inflammatory bowel disease concerning diet.
Crohn’s disease:
Enteral nutrition is indicated for the prevention and treatment of undernutrition, improving grow th in children, quality-of-life
improvements, acute-phase therapy, perioperative nutrition and maintenance of remission in chronic active disease
Enteral nutrition is the sole therapy in adults during the acute phase when corticosteroid treatment is not feasible
For enteral therapy, use oral supplements up to 600 kcal /day with food intake, and then tube feeding if higher intakes are necessary.
Continuous tube feeding is better than bolus, owing to a lower complication rate
Whole proteins are preferred as free amino acid- or peptide-based formulas are not recommended
Parenteral nutrition is usually combined with oral /enteral food unless there is continuing intra-abdominal sepsis or perforation
Undernourished CD patients may benefit from parenteral nutrition
Despite encouraging experimental data, insufficient data exist to recommend glutamine, n-3 fatty acids or other pharmaconutrients
Vitamin B12 deficiencies are well documented, especially if the distal ileum is affected by CD or resectioned. In these patients,
serum B12and folate should be measured annually
Correct nutrient deficiencies with vitamin/mineral supplementation
Ulcerative colitis:
Unlike CD, both enteral and parenteral nutrition do not serve as primary therapies in UC, where nutritional deficiencies are not as
common compared with CD. Enteral nutrition is only for patients with undernutrition or inadequate intake
Parenteral nutrition should only be used in those with UC who are malnourished or at risk of becoming malnourished before or after
surgery because they cannot tolerate food or an enteral feed
Bowel rest should not be provided through the use of parenteral nutrition during acute inflammatory periods
Parenteral and enteral nutrition are not recommended for the maintenance of remission
Iron-deficient anemia due to blood loss occurs in 80% of UC patients
Correct nutrient deficiencies with vitamin/mineral supplementation
CD: Crohn’s disease; UC: Ulcerative colitis.
Adapted from [6].
Box 5. Japanese Society for Pediatric Gastroenterology, Hepatology
and Nutrition clinical practice guidelines for inflammatory bowel
disease concerning diet.
Total enteral nutrition (elemental formula) and oral mesalazine are used together as the
primary therapy during the onset and active stage of the disease
Total parenteral nutrition with oral mesalazine is reserved for children having
serious illnesses
Corticosteroids should not be used until at least 1 week after starting total parenteral
nutrition, and then additional amounts used if the child does not respond to total
parenteral nutrition
Adapted from [8].
Existing dietary guidelines for Crohn’s disease & ulcerative colitis
Expert Rev. Gastroen terol . Hepatol. 5(3), (2011)
416
Review
and five suggested avoiding high-fiber foods, especially during
flares. The question of whether or not to use probiotics continues
to be debated.
Reducing dairy
The prevalence of lactose malabsorption is significantly greater in
patients with CD involving the small bowel than it is in patients
with CD involving the colon or UC [19]. Symptoms of IBD and
lactose intolerance often overlap, so it seems prudent to avoid
lactose-containing foods if there is an intolerance.
Reducing fat
Some patients with IBD react to excess dietary fat and perhaps
this is where the recommendation is derived. Few research stud-
ies are available to support or refute such a recommendation.
The topic needs further investigation because patients with mal-
absorption may be at risk of not obtaining their necessary essential
fatty acids. Perhaps saturated fats should be limited, with more of
an emphasis on more healthy fat intakes.
Reducing carbohydrates
Only the WGO mentioned “limited evidence suggests reduc-
ing carbohydrates” [4] . The Crohn’s and Colitis Foundation
of America mentions the Specific Carbohydrate Diet as only
being supported by testimonials, but that it might be worth
a try. However, this is apart from their
dietary suggestions provided for patients
experiencing bowel strictures.
The malabsorption and compromise of
digestive enzymes on an inflamed GI tract
may contribute to the small number of
studies in the literature suggesting some
success of the Specific Carbohydrate Diet.
This popular dietary regimen described
in Elaine Gottschall ’s book,Breaking
the Vicious Cycle’, is largely supported
by testimonials.
The diet was originally created by a
renowned pediatrician to treat celiac disease and needs to be clini-
cally tested in people with IBD. It is essentially an elimination
diet in disguise that limits dairy, gluten and processed foods. It
is unique in also limiting saccharides, except the easily absorbed
monosaccharides, which are allowed. The purpose of removing
dietary disaccharides and polysaccharides (starches) is to inhibit
the growth of microorganisms in the intestines, their resulting
overgrowth and therefore the possible side effects of gas, bloating
and abdominal pain.
Another possibility we suggest is that an inflamed intestinal
wall in the duodenal region would compromise the digestive
enzymes of not only lactose, but also other disaccharides, and
perhaps even the enzymes for proteins and fats.
Elimination diet
Although not mentioned in any of the dietary guidelines, the
use of an elimination diet in patients with CD has some weak
support in the literature. Brown and Roy’s previous review of
diet and CD revealed a higher rate of food allergies in patients
with IBD [1]. For example, a survey by Ballegaard et al. observed
that more than half of their IBD subjects were affected by food
sensitivities. They reported food intolerances occurring in 14%
(n = 70) of their healthy controls, compared with 66% (n = 53)
of CD subjects and 64% (n = 77) of those with UC (n = 75).
The most commonly reported symptoms in this study were
Box 6. Crohn’s & Colitis Foundation of America dietary suggestions
for inflammatory bowel disease patients with strictures of
the bowel.
Low-fiber diet or special liquid diet may be beneficial
Restrict intake of certain high-fiber foods, such as nuts, seeds, corn, popcorn and
various Chinese vegetables
Minimize ‘scrappy’ foods, such as raw fruits, vegetables, seeds, nuts and corn hulls
Eat smaller meals at more frequent intervals
Reduce the amount of greasy or fried foods
Limit consumption of milk or milk products if you are lactose intolerant
Adapted from [106].
Box 7. The National Digestive Diseases Information Clearinghouse dietary suggestions for people with
Crohn’s disease (none exist for ulcerative colitis).
Crohn’s disease:
Decreased appetite can affect nutrition needed for good health and healing
Diarrhea and poor absorption of necessary nutrients may occur
No special diet has been proven effective for preventing or treating CD, but it is very important that people who have CD follow a
nutritious diet and avoid any foods that seem to worsen symptoms
There are no consistent dietary rules to follow that will improve a person’s symptoms
People should only take vitamin supplements based on their doctor’s advice
Foods such as bulky grains, hot spices, alcohol and milk products may increase diarrhea and cramping
The doctor may recommend nutritional supplements, especially for children whose growth has been slowed. Special high-calorie liquid
formulas are sometimes used for this purpose
A small number of patients may need to be briefly fed intravenously (through a small tube inserted into the vein of the arm)
CD: Crohn’s disease.
Adapted from [105].
Brown, Rampertab & Mullin
www.expert-reviews.com 417
Review
abdominal pain, meteorism (drum-like
distention of the abdomen caused by gas in
the abdomen or intestines), diarrhea and
flatulence. The most frequently symptom-
provoking foods were vegetables (40 %),
fruit (28% apple, strawberries and cit-
rus fruits), milk (27%), bread (23%), meat
(25% – beef and smoked meat) and others
(38%) [20].
Not all IBD patients are afflicted with
food allergies. The majority do react to
foods so perhaps they should be tested for
food allergies and food intolerances. This
may also apply more for patients with CD
in the duodenum, rather those afflicted in
the colon or patients with UC. Allergy tests
are not always reliable, so perhaps a 2-week
trial elimination diet would determine if
symptoms improve. This dietary method is
cost-effective and such regimens have been
provided to animals [21].
Reduced fiber during flares (active disease
states, fistulas or strictures)
Reducing high-fiber foods during symp-
toms appears to have generated the most
support in the dietary guidelines. It may be
important to communicate to IBD patients
that high-fiber foods are not recommended,
especially for those with CD, during flares
or in the presence of active disease states,
fistulas or strictures. There appears to be a
tendency among the dietary guidelines to
restrict foods such as raw fruits, raw veg-
etables, beans, bran, popcorn, seeds, nuts,
corn hulls, whole grains, brown rice and
wild rice. Although not mentioned, raw salads would also fall
into this category.
Even lower in fiber and easier to absorb are enteral feedings,
which may be considered during periods of exacerbation, mal-
absorption or inadequate nutrient intake. These enteral feed-
ings are preferred over parenteral with the exception of some
cases of extreme malabsorption or complications, such as s-
tulas. Patients with CD may benefit from learning that their
symptoms may be temporarily alleviated during these times if
placed on an enteral diet, and that in some cases they may even
avoid surger y.
Enteral nutrition for CD
It appears that the majority of research supporting ‘nutrition’
and IBD has previously focused on enteral nutrition, sometimes
inaccurately referred to as diet’. Enteral nutrition (polymeric,
semi-elementa l and elemental) are liquid diets consisting of
nutrients broken down into their smaller units. Polymeric diets
contain intact nutrients that are more palatable and cheaper than
semi-elemental diets, which consist of partially hydrolyzed nutri-
ents, or elemental diets containing completely hydrolyzed nutri-
ents broken down into their smallest units of digestion, such as
amino acids, monosaccharides, fatty acids, vitamins and miner-
als [22]. The nutrients are fed into the body through either the gut
(enteral) or vein (parenteral). There appears to be no difference
in efficacy between elemental diets (n = 188) and nonelemental
diets (semi-elemental or polymeric diet; n = 146) for CD patients,
according to researchers conducting a Cochrane meta-ana lysis of
ten trials [23].
Enteral nutrition is considered to be arst-line therapy for
adults with CD in Japan because it places patients in remission,
after which they start the ‘slide method in which a low-fat
diet slowly replaces the elemental diet [24] . The ‘half-elemental
diet therapy is fed during the night through a nasogastric
tube while the patient is at home and consuming a low-fat diet
(20 30 g) during the day [9] . Insurance plans of ten dictate
whether or not a particula r treatment plan is pursued, and
Japan’s national health insurance plan covers enteral nutrition
for CD [24] .
Box 8. Medline Plus dietary suggestions for people with Crohn’s
disease and ulcerative colitis.
Crohn’s disease [106]:
No specific diet has been demonstrated to improve or worsen the bowel inflammation
in CD. However, eating a healthy amount of calories, vitamins and protein is important
to avoid malnutrition and weight loss. Specific food problems may vary from person
to person
Certain types of foods may worsen diarrhea and gas symptoms, especially during times
of active disease. Suggestions for diet during periods when symptoms are
present include:
– Eat small amounts of food throughout the day
– Drink lots of water (frequent consumption of small amounts throughout the day)
– Avoid high-fiber foods (bran, beans, nuts, seeds and popcorn)
– Avoid fatty, greasy or fried foods and sauces (butter, margarine and heavy cream)
– If your body does not digest dairy foods well, limit dair y products
– Avoid or limit alcohol and caffeine consumption
People who have a blockage of the intestines may need to avoid raw fruits and
vegetables. Those who have difficulty digesting milk sugar (lactose) may need to avoid
milk products
Ask your doctor about extra vitamins and minerals you may need:
– Iron supplements (if you are anemic)
– Calcium and vitamin D supplements to help keep your bones strong
– Vitamin B12 to prevent anemia
Ulcerative colitis [107]:
Certain types of foods may worsen diarrhea and gas symptoms, especially during times of
active disease. Dietary suggestions include:
Eat small amounts throughout the day
Drink lots of water (frequent consumption of small amounts throughout the day)
Avoid high-fiber foods (bran, beans, nuts, seeds and popcorn)
Avoid fatty, greasy or fried foods and sauces (butter, margarine and heavy cream)
Limit milk products if you are lactose intolerant. Dairy products are a good source of
protein and calcium
Avoid or limit alcohol and caffeine consumption
CD: Crohn’s disease.
Existing dietary guidelines for Crohn’s disease & ulcerative colitis
Expert Rev. Gastroen terol . Hepatol. 5(3), (2011)
418
Review
Table 3. A ‘global’ clinical practice guideline summarizing dietary advice for inflammatory bowel disease
patients created by combining current clinical practice guidelines and informal dietary suggestions into
one (not all suggestions are in agreement or based on evidence-based research).
General diet
IBD No special diet has been proven to be effective for preventing or treating CD symptoms or inflammation, but it is very important
that people who have CD follow a nutritious diet, and avoid malnutrition, weight loss and any foods that seem to worsen
symptoms. Specific food problems may vary from person to person‡‡,§§
Decreased appetite can affect nutrition needed for good health and healing
Eat smaller meals at more frequent intervals†,††,§§
CD Certain types of foods may worsen diarrhea and gas symptoms, especially during times of active disease§§
Fiber or grains
IBD Decrease fiber consumption during disease activity, especially whole-grain products, bran, beans, brown rice, wild rice, nuts,
corn, corn hulls, popcorn, seeds, raw fruits and certain vegetables†,‡,††,‡‡
A special liquid diet may be beneficial††
During periods of no symptoms, slowly reintroduce high-fiber foods one at a time in small amounts
Those with blocked intestines may need to avoid raw fruits and vegetables‡‡
Vegetables & fruits
IBD During diarrhea and abdominal pain:
Recommended Avoid
Well-cooked vegetables Potatoes with skins or potato skins
Strained vegetable or fruit juices Vegetables or fruits with seeds
Canned or soft fruits Corn and corn products
Peeled apple, ripe banana or melon Raw greens, beets, broccoli, Brussels sprouts, cabbage, sauerkraut,
cauliflower, lima beans, mushrooms, okra, onions, parsnips, peppers and
winter squash
Most raw and dried fruits (see exceptions on left)
Canned berries or cherries
Prune juice
Dairy
IBD Dairy products can be maintained unless not tolerated
Limit intake of milk and milk products if you do not digest dairy foods well, or are lactose intolerant†,††,‡‡,§§
If tolerated, fermented foods, such as yogurt (choose live cultures) and certain low-fat cheeses, may be allowed
If tolerated, nonfat, skimmed or low-fat milk products over higher fat versions
Fat
IBD Avoid fatty, greasy or fried foods and sauces (butter, margarine and heavy cream)††,§§
During diarrhea or abdominal pain, keep fat intake below eight teaspoons per day
CD: Crohn’s disease ; IBD: Inflammator y bowel disease; UC: Ulcerative colitis.
© 2011 Amy Brown.
Adapted from :
Clinical practice guidelines:
American Dietetic As sociation (ADA).
World Gastro enterolog y Organization (WGO ).
§American Society for Parenteral and Enteral Nutrition (ASPEN).
European Society for Clinic al Nutrition and Metabolism (ESPEN).
#Japanese Society for Pediatric Gastroenterology, Hepatology and N utrition.
Informal diet ary suggestions :
††Crohn’s & Colitis Foundation of America.
‡‡National Digestive Diseases Information Clearinghous e.
§§Medline Plus.
Brown, Rampertab & Mullin
www.expert-reviews.com 419
Review
Table 3. A ‘global’ clinical practice guideline summarizing dietary advice for inflammatory bowel disease
patients created by combining current clinical practice guidelines and informal dietary suggestions into
one (not all suggestions are in agreement or based on evidence-based research) (cont.).
Carbohydrates
IBD Limited evidence suggests reducing carbohydrates – dietary fermentable oligosaccharides, disaccharides and monosaccharides,
and sugar alcohols (erythritol, sorbitol, xylitol and so on, as used in sugarless products)
Meats or protein foods
IBD Well-cooked meats without added fat
Avoid high-fat meats – fried, processed (hot dogs and luncheon meats), bacon or sausage
Avoid dried beans and peas
Avoid nuts. Choose smooth over chunky nut butters
Beverages
IBD During diarrhea and abdominal pain:
Recommended Avoid
Drink lots of water (frequent consumption of small
amounts throughout the day)†,§§
High sugar drinks
Sweet juices
Caffeine†,§§
Alcohol§§ ,‡‡
Sugar alcohols (erythritol, sorbitol and so on)
Probiotics
IBD IBD may be caused or aggravated by alterations in gut flora
Eat foods with added probiotics and prebiotics. Ask for advice
There is no evidence that probiotics are effective in either UC or CD; however, Escherichia coli Nissle 1917 is not inferior to
5-aminosalicylic acid, and VSL#3 (combination of bacterial strains ) reduced flares of pouchitis (a post-ileoanal pouch procedure
for UC)
Dietary supplements
IBD Vitamin/mineral supplementation for all†,‡ or at least in those with malnutrition or during periods of reduced oral intake‡,¶. Ask for
physician’s advice‡‡,§§
Vitamin B12 (to prevent anemia) and vitamin D (for bones) for those that who are deficient
Steroid users should receive calcium and vitamin D supplementation
Iron supplements if you are anemic. Chronic iron-deficiency anemia should be treated with parenteral iron if oral iron is
not tolerated
CD Diarrhea and poor absorption of necessary nutrients may occur‡‡
UC Iron-deficient anemia due to blood loss occurs in 80% of UC patients
Liquid meals (enteral nutrition) for adults
IBD A liquid diet, predigested formula or nothing by mouth may reduce obstructive symptoms
CD: Crohn’s disease ; IBD: Inflammator y bowel disease; UC: Ulcerative colitis.
© 2011 Amy Brown.
Adapted from :
Clinical practice guidelines:
American Dietetic As sociation (ADA).
World Gastro enterolog y Organization (WGO ).
§American Society for Parenteral and Enteral Nutrition (ASPEN).
European Society for Clinic al Nutrition and Metabolism (ESPEN).
#Japanese Society for Pediatric Gastroenterology, Hepatology and N utrition.
Informal diet ary suggestions :
††Crohn’s & Colitis Foundation of America.
‡‡National Digestive Diseases Information Clearinghous e.
§§Medline Plus.
Existing dietary guidelines for Crohn’s disease & ulcerative colitis
Expert Rev. Gastroen terol . Hepatol. 5(3), (2011)
420
Review
Table 3. A ‘global’ clinical practice guideline summarizing dietary advice for inflammatory bowel disease
patients created by combining current clinical practice guidelines and informal dietary suggestions into
one (not all suggestions are in agreement or based on evidence-based research) (cont.).
Liquid meals (enteral nutrition) for adults (cont.)
CD Enteral nutrition is the sole therapy in adults during the acute phase when corticosteroid treatment is not feasible
For enteral therapy, use oral supplements up to 600 kcal/day with food intake, and then tube feeding if higher intakes are
necessary. Continuous tube feeding is better than bolus, owing to a lower complication rate
Whole proteins are preferred as free amino acid- or peptide-based formulas are not recommended
Enteral nutrition for adult CD patients requiring specialized nutrition support§
Liquid meals (enteral nutrition) for children
IBD An exclusive enteral diet can settle inflammatory disease, especially in children
Enteral nutrition should be given to children with growth retardation to help induce a growth spurt§ ,‡‡
Enteral nutrition should be used as an adjunct to medical therapy in those who are unable to maintain their nutrition status
through oral intake§
Total enteral nutrition (elemental formula) and oral mesalazine is used together as the primary therapy during the onset and
active stage of the disease #
CD Enteral nutrition is indicated for the prevention and treatment of undernutrition, improving growth in children, quality-of-life
improvements, acute phase therapy, perioperative nutrition and maintenance of remission in chronic active disease
Vein feeding (parenteral nutrition)
IBD Parenteral nutrition should be reserved for those patients with IBD in whom enteral nutrition is not tolerated§
Parenteral nutrition should be used in children who are unable to maintain normal growth and development on enteral nutrition
or a standard diet§
Total parenteral nutrition with oral mesalazine is reserved for children who have serious illnesses#
Corticosteroids should not be used until at least 1 week after starting total parenteral nutrition, and then additional amounts
used if the child does not respond to total parenteral nutrition#
CD Parenteral nutrition is usually combined with oral/enteral food unless there is continuing intra-abdominal sepsis or perforation
Undernourished CD patients may benefit from parenteral nutrition ,‡‡
Despite encouraging experimental data, insufficient data exist to recommend glutamine, n-3 fatty acids or
other pharmaconutrients
Vitamin B12 deficiencies are well documented, especially if the distal ileum is affected by CD or resectioned. In these patients,
serum B12 and folate should be measured annually
Correct nutrient deficiencies with vitamin/mineral supplementation
Fistula in CD – a brief course of bowel rest and parenteral nutrition is recommended§
UC Unlike CD, both enteral and parenteral nutrition do not serve as primary therapies in UC, where nutritional deficiencies are not as
common compared with CD. Enteral nutrition is only for patients with undernutrition or inadequate intake
Parenteral nutrition should only be used in those with UC who are malnourished or at risk of becoming malnourished before or
after surgery because they cannot tolerate food or an enteral feed
Bowel rest should not be provided through the use of parenteral nutrition during acute inflammator y periods
Parenteral and enteral nutrition are not recommended for maintenance of remission
CD: Crohn’s disease ; IBD: Inflammator y bowel disease; UC: Ulcerative colitis.
© 2011 Amy Brown.
Adapted from :
Clinical practice guidelines:
American Dietetic As sociation (ADA).
World Gastro enterolog y Organization (WGO ).
§American Society for Parenteral and Enteral Nutrition (ASPEN).
European Society for Clinic al Nutrition and Metabolism (ESPEN).
#Japanese Society for Pediatric Gastroenterology, Hepatology and N utrition.
Informal diet ary suggestions :
††Crohn’s & Colitis Foundation of America.
‡‡National Digestive Diseases Information Clearinghous e.
§§Medline Plus.
Brown, Rampertab & Mullin
www.expert-reviews.com 421
Review
In the USA, clinical practice guidelines do not appear uniform
in their recommendations for enteral therapy. The ACG states,
“corticosteroids are more effective than enteral nutrition to induce
remission in active CD patients,” while the WGO indicates, “An
exclusive enteral diet can settle inflammatory disease, especially
in children.”
The difference between the USA and Japan in the use of enteral
therapy appears to be based on a meta-analysis of six trials (15 eli-
gible trials were found) by Zachos et al., stating that corticosteroids
are more effective than enteral nutrition [23]. In terms of pediatric
patients, Dziechciarz et al.’s. meta-ana lysis of seven out of 11 ran-
domized clinical trials demonstrated similar efficacy for enteral
nutrition compared with corticosteroids [25]. In Japan, Matsui
et al. concluded from their review that enteral nutrition used as
a primary therapy results in maintaining remissions with lower
adverse reactions, fewer complications and surgeries, and lower
mortality rates than patients not receiving enteral nutrition [26].
The corticosteroid over enteral nutrition conclusion appears
controversial. Smith mentioned that the exclusion of two large
trials due to concomitant use of other medications in the steroid
arm resulted in both enteral nutrition and steroids having equal
efficacy [24] . In addition, only a few meta-analyses averaging ten
trials or less, exist in the literature. However, our informal litera-
ture search found approximately 36 clinical trials investigating
the use of enteral nutrition in CD patients [1]. Taken alone and
without comparison to corticosteroids, the majority (86% [30
out of 35]) of these studies resulted in beneficial effects of enteral
nutrition to CD patients [27–56], while the remaining 14% (five
out of 35) had mixed results [57–61].
Despite the inconsistent recommendations of enteral nutrition
use mentioned in clinical practice guidelines, the serious side
effects of corticosteroids (especially stunted growth in pediatric
patients) make enteral therapy the recommended treatment in the
USA for children with active CD. It is also recommended for adults
suffering from malnutrition or corticosteroid complications [9].
There are also positive indications that enteral therapy may be a
viable option for some CD patients, at least temporarily. Possible
benefits exist in the form of improved remission and relapse rates,
mucosal healing, hospitalization rates, biochemical values and
nutritional status.
Remission & relapse rates
Researchers sometimes use 3–5 weeks of enteral therapy to place
approximately 85% of their CD subjects into remission prior to
being treated by an experimental drug or diet [62,63]. CD patients
(aged 7–71 years) requiring hospitalization were placed on an
elemental diet (Vivonex®) for 4 weeks and achieved a 92% (22
out of 24) remission rate [64] . Despite a Cochrane review stating
that there was no difference between elemental diet types [23],
75% (12 out of 16) of CD patients on an elemental diet (Vivonex)
went into remission compared with only 36% (5 out of 14) on a
polymeric diet (Fortison™). Corticosteroid-resistant IBD cases
Table 4. Primary nutritional problems related to Crohn’s disease.
Potential nutritional
problems
Description
Malabsorption Inflammation, ulceration or surger y can compromise digestion and absorption
Malnutrition Affects 65 –75% of CD patients [9] and may include protein-losing enteropathy, iron-deficient anemia,
calcium, folic acid, iron, zinc, vitamin D, vitamin K and vitamin B12 [10]. Diarrhea may affect zinc, potassium
and magnesium. Steatorrhea compromises absorption of calcium, zinc, magnesium and copper [11].
Dietary supplements are warranted, coupled with yearly routine evaluation of serum B12 and
vitamin D levels
Reduced dietary intake Fear of abdominal pain from consuming food, anorexia, strictures and fistulas can all contribute to
malnutrition [12]
Weight loss Anorexia and malnutrition contributes to weight loss in 65–75% of patients [9,13]
Increased resting energy
expenditure
Caloric requirements can increase during flares [14]
Reduced growth Decreased linear grow th that may be expressed in adulthood, and delayed puberty occur in 40 –50% of
children [15]
Osteopenia 40–50% [12]
Osteoporosis 5–36% [12]
Lack of bowel rest Interferes with the ability of the bowel to heal itself
Dehydration Due to chronic diarrhea. Lack of hydration can lead to kidney stones
Possible food sensitivities due
to allergens and intolerances
May trigger inflammation, contribute to symptoms and exacerbate any intestinal damage
Anemia may be due to iron, vitamin B12 and iron deficiencies. Iron deficiency is the main caus e of anemia occurring in up to 80 % of UC patients [16].
Osteopenia may be due to protein, calcium and vitamin D de ficiencie s.
CD: Crohn’s disease.
© 2011 Amy Brown.
Existing dietary guidelines for Crohn’s disease & ulcerative colitis
Expert Rev. Gastroen terol . Hepatol. 5(3), (2011)
422
Review
may respond to elemental therapy. Axelsson and Jarnum gave
31 subjects on high-dose prednisone therapy for 1–4 weeks an
elemental diet, resulting in 44% (15 out of 31) remission [62].
Remission maintenance rates were measured among 61 patients
induced into remission with drugs [50]. After 1, 2 and 4 years,
remission rates were 94, 63 and 63% in the group receiving home
elemental enteral hyperalimentation (HEEH), 75, 66 and 66%
in the group receiving HEEH and drugs, 63, 42 and 0% in the
group receiving drugs, and 50, 33 and 0% in the group receiving
no maintenance therapy, respectively. These researchers concluded
that “elemental diet therapy was effective not only for the induction
of remission, but also for the maintenance of remission in CD” [50].
Mucosal healing
Enteral therapy may contribute to mucosal healing, which is one
of the latest therapeutic goals in the management of IBD. Several
studies have demonstrated that enteral nutrition allows the GI
tract to heal [27,65–68]. Elemental diets have been reported to sig-
nificantly improve lactulose/l-rhamnose permeability ratios [69]
and cytokine production [70], suggesting mucosal healing. An
oral polymeric diet (CT3211; Nestle, Vevey, Switzerland) fed to
29 pediatric patients with CD for 8 weeks resulted in complete
clinical remission in 79% of the participants [39]. The clinical
response to the oral polymeric diet was associated with muco-
sal healing and a downregulation of mucosal pro inflammatory
cytokine mRNA in both the terminal ileum and colon [39]. The
healing of gut inflammatory lesions occurred in 74% (14 out
of 19) of CD pediatric patients receiving an oral polymeric for-
mula compared with 33% (six out of 18) of subjects on cortico-
steroids [68]. Berni Canani also noted that 65% (26 out of 37) of
their pediatric CD patients had improvement in mucosal inflam-
mation compared with 40% (four out of ten) in the corticosteroid
group [67]. In addition, complete mucosal healing was observed
in 19% (seven out of 37) subjects in the enteral group, compared
with none of those receiving corticosteroids.
Enteral therapy may contribute to mucosal healing owing to
decreased fecal bacterial concentrations [71] and/or decreased
antigen uptake reducing the risk of an inflammatory response.
Hospitalization rates
Enteral nutrition was also recently reported to decrease hospital-
ization rates [72].
Biochemical values
A total of 28 malnourished CD patients provided with oral nutri-
tion experienced significantly increased serum proteins, creatinine
height index and circulating T lymphocyte numbers, while serum
orosomucoid levels dropped significantly, suggesting that disease
activity was reduced [73]. Sedimentation rate and renal urea excre-
tion decreased in certain IBD patients consuming an elemental
diet [62]. In 17 pediatric patients with CD in their small intes-
tines, linear growth (assessed from height velocity over 6 months)
was significantly greater in the children receiving an elemental
diet [74].
Nutritional status
Enteral formulas are available to address the insufficient nutrient
intake and growth failure related to IBD in pediatric patients [75].
Malnutrition is common in IBD due to decreased food intake, mal-
absorption, increased nutrient loss, increased energy requirements
and drug–nutrient interactions [76]. In pediatric patients, weight
loss occurs in up to 85% of those with CD and 65% of those with
UC. Approximately 15–40% of IBD pediatric patients experience
growth failure, which is more common in CD than UC.
It may be inaccurate to suggest that ‘nutritional therapies
(enteral nutrition) do not workbased on the aforementioned
data. They may work as well as pharmaceutical intervention with-
out the side effects. The major problems of enteral nutrition are
patient compliance, their limited duration of use and the 60%
relapse rate that occurs after discontinuation. Other problems
to consider are that elemental diets are liquid, so possible side
effects of this treatment are osmolarity diarrhea, abdominal dis-
tension, colic, cholelithiasis and pneumonia (due to pulmonary
aspiration) [77].
Perhaps the decision of whether or not to use enteral therapy
should involve the patient with CD. Such patients should at
least be made aware that enteral therapy is an option available to
them, especially during manageable flares or when considering
certain surgeries. Makola provides a list and cost comparison of
28 elemental, semi-elemental and polymeric formulations [78].
Expert commentary
More research is needed to elucidate the evidence-based,
dietary-related clinical practice guidelines for patients with IBD.
Suggested research topics include, but are not limited to:
Key issues
Based on the above review of the current existing dietary guidelines for inflammatory bowel disease ( IBD), we suggest the following
regarding nutrient deficiencies, as well as the role diet may play in reducing IBD symptoms.
Screen all IBD patients for nutritional deficiencies, especially children, and make the appropriate nutrition counseling referrals. Consider
suggesting a vitamin/mineral supplement and or specific nutrient supplementation based on individual patient history.
Overall dietary suggestions may include to eat smaller, more frequent meals, consume sufficient liquids (especially water), decrease
excess saturated fat, decrease excess sugars (especially disaccharides and polysaccharides) and decrease high-fiber foods during flares.
Educate IBD patients about possible food sensitivities, and suggest that a 2-week, trial elimination diet may aid in their detection.
Inform Crohn’s disease patients that dietary surveys often list casein and gluten as the top two food offenders.
Educate Crohn’s disease patients about enteral or oral elemental supplementation options that may alleviate flares, reduce
hospitalization rates and increase the possibility of remission.
Brown, Rampertab & Mullin
www.expert-reviews.com 423
Review
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dietary suggestions in Ta Ble 3 to patients inquiring about diet.
The relatively unexplored area of diet and IBD will remain a work
in progress that will continue to be revised as new research and
clinical practice experiences emerge.
Financial & competing interests disclosure
This research was made possible by a grant from the Broad Medical Research
Program of The Broad Foundation. Amy Brown is CEO of Natural Remedy
Labs, LLC. The authors have no other relevant affiliations or financial
involvement with any organization or entity with a financial interest in or
financial conflict with the subject matter or materials discussed in the
manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.
• Researching the benefit of utilizing enteral nutrition during
flares on reducing hospitalization, medication and surgical rates;
• Quantifying rates of lactose intolerance and other disaccharide,
lipase, pancreatic elastase and protease deficiencies in IBD
patients through stool and hydrogen breath testing;
• Clinically testing elimination diets for effectiveness, if any, in
reducing symptoms of CD, UC and irritable bowel syndrome.
Five-year view
We suggest that there is sufficient information to date to incor-
porate nutritional screening for all IBD patients, act proactively
against nutrient and growth deficiencies, and to provide the
Existing dietary guidelines for Crohn’s disease & ulcerative colitis
Expert Rev. Gastroen terol . Hepatol. 5(3), (2011)
424
Review
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Inflamm. Bowel Dis. 13(12), 1493–1501
(2007).
• Evidenceofmucosalhealingfromtheuse
ofenteralnutrition.
78 Makola D. Elemental and semi-elemental
formulas: are they superior to polymeric
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•• Table1listsalmost30differententeral
formulasandtheircostcomparison.
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Existing dietary guidelines for Crohn’s disease & ulcerative colitis
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... A case-control study of 354 individuals conducted in China showed a protective effect of light alcoholic beverages consumption against the development of UC [60]. However, due to the obvious link between alcohol and chronic heart or liver disorders, according to the current guidelines for dietary management in IBD, alcohol, generally, should be avoided [61]. ...
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Background/objectives: Immune-mediated inflammatory diseases (IMIDs) are prevalent diseases. There is, however, a lack of understanding of the link between diet and IMIDs, how much dietary patterns vary between them and if there are food groups associated with a worsening of the disease. Subjects/methods: To answer these questions we analyzed a nation-wide cohort of n = 11,308 patients from six prevalent IMIDs and 2050 healthy controls. We compared their weekly intake of the major food categories, and used a Mendelian randomization approach to determine which dietary changes are caused by disease. Within each IMID, we analyzed the association between food frequency and disease severity. Results: After quality control, n = 11,230 recruited individuals were used in this study. We found that diet is profoundly altered in all IMIDs: at least three food categories are significantly altered in each disease (P < 0.05). Inflammatory bowel diseases showed the largest differences compared to controls (n ≥ 8 categories, P < 0.05). Mendelian randomization analysis supported that some of these dietary changes, like vegetable reduction in Crohn's Disease (P = 2.5 × 10-10, OR(95% CI) = 0.73(0.65, 0.80)), are caused by the disease. Except for Psoriatic Arthritis and Systemic Lupus Erythematosus, we have found ≥2 food groups significantly associated with disease severity in the other IMIDs (P < 0.05). Conclusions: This cross-disease study demonstrates that prevalent IMIDs are associated to a significant change in the normal dietary patterns. This variation is highly disease-specific and, in some cases, it is caused by the disease itself. Severity in IMIDs is also associated with specific food groups. The results of this study underscore the importance of studying diet in IMIDs.
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This study compared the effect of enteral nutrition as the sole therapy of active Crohn's disease with drug treatment. Patients with active Crohn's disease (Crohn's Disease Activity Index > 200) were randomized to receive either enteral nutrition with a liquid oligopeptide diet (n = 55) or a combination of 6-methylprednisolone, 48 mg daily, subsequently tapered, and sulfasalazine, 3 g daily (n = 52). The two groups were not different with respect to age, sex, body weight, location of disease, or treatment before the study. The severity of disease was similar at the beginning of the study in both groups [Crohn's Disease Activity Index ( ± SEM), 323 ± 12 vs. 316 ± 11]. Remission was defined as a decrease of the initial Crohn's Disease Activity Index by 40% or at least 100 points. Twenty-nine patients in the diet group and 41 patients in the drug group reached remission within 6 weeks of therapy (χ2 test, P < 0.01). The median elapsed time to remission was 30.7 days in the diet group compared with 8.2 days in the drug group (Mantel Cox, P < 0.01). To determine whether one of these treatments was more beneficial for a subgroup of patients, the effectiveness of both treatments was analyzed separately in patients with very severe disease (initial Crohn's Disease Activity Index > 300) and less severe disease (initial Crohn's Disease Activity Index < 300), and in patients with different disease location. However, no influence of initial disease activity or disease location on the effect of either treatment could be shown. These data show that enteral nutrition is less effective than a combination of 6-methylprednisolone and sulfasalazine in treating active Crohn's disease.
Nutritional support, utilizing enteral nutrition formulas, is an integral part of the primary and/or adjunctive management of gastrointestinal and other disorders with nutritional consequences. Four major types of enteral nutrition formulas exist including: elemental and semi-elemental, standard or polymeric, disease-specific and immune-enhancing. Although they are much more expensive, elemental and semi-elemental formulas are purported to be superior to polymeric or standard formulas in certain patient populations. The aim of this article is to evaluate whether this claim is supported by the literature and to ultimately show that except for a very few indications, polymeric formulas are just as effective as elemental formulas in the majority of patients with gastrointestinal disorders.
Article
Since specific treatment has not yet been decided on for Crohn’s disease, the immediate target is the induction of remission and its maintenance. We examined the effects of an elemental diet (ED) in Crohn’s disease with special reference to the maintenance of remission. Eighty-four patients received total enterai nutrition with the ED (35 to 40 kcal/kg ideal body weight/day) and/or conventional drug treatment for induction of remission. Sixty-one patients in remission were then followed-up with prolonged ED therapy (home elemental enterai hyperalimentation, HEEH) and/or drugs. During the follow-up periods the course of patients receiving HEEH was better than those of patients without HEEH, namely the cumulative continuous remission rates after one, 2 and 4 years were, 94%, 63% and 63% in the group receiving HEEH, 75%, 66% and 66% in the group receiving HEEH and drugs, 63%, 42% and 0% in the group receiving drugs, and 50%, 33% and 0% in the group receiving no maintenance therapy, respectively. In particular, when more than 30 kcal/kg ideal body weight/day of the ED was given, the maintenance of remission was successful in 95% of the patients. These results indicated that ED therapy was effective not only for the induction of remission but also for the maintenance of remission in Crohn’s disease.
Article
Crohn's disease (CD) is a chronic inflammatory bowel disease with relapse and remission. CD patients are admitted to hospital when bowel inflammation flares up severely, which lowers their quality of life. Enteral nutrition (EN) with an elemental diet plays an important role in the treatment for CD patients in Japan, because of its few adverse effects, and it is thought to be effective in maintaining remission. We investigated the effectiveness of EN with an elemental diet with regard to the avoidance of hospitalization. A total of 268 patients with CD who visited hospital from 2003-2008 were enrolled. The relationship between the caloric content of an elemental diet and hospitalization as an end-point was examined retrospectively using Cox regression analysis. Cumulative non-hospitalization rates were calculated by the Kaplan-Meier method. Of the 268 patients, 155 received an elemental diet providing 900 kcal/day or more. Among 237 patients with ileal involvement, 135 patients receiving an elemental diet providing 900 kcal/day or more showed a statistically significant improvement in cumulative non-hospitalization rate. Among 31 patients without ileal involvement, in contrast, the cumulative non-hospitalization rate did not differ among those receiving an elemental diet of less or more than 900 kcal/day. The use of an elemental diet of 900 kcal/day may be effective in avoiding hospitalization in CD patients with ileal lesions. This diet may be useful in improving the long-term convalescence of these patients.
Article
Seventeen children with active Crohn's disease of the small intestine were entered into a randomised control trial comparing the efficacy of an elemental diet with that of a high dose steroid regimen. Eight children received an elemental diet (Flexical) through a nasogastric tube for six weeks, followed by reintroduction of food over six weeks during which the Flexical was stopped. Seven children were given intramuscular adrenocorticotrophic hormone followed by oral prednisolone with sulphasalazine. Two children were withdrawn from the trial. The elemental diet was equally effective in inducing an improvement in Lloyd-Still disease activity index, erythrocyte sedimentation rate, C reactive protein and albumin concentrations, and body weight as the high dose steroid regimen. Linear growth, assessed from height velocity over six months, was significantly greater in the children receiving an elemental diet.