Mistakes in ... 2021 - 7

ueg education
Mistakes in... 2020
Mistakes in nutrition in IBD and how to avoid them
Joseph Meredith, Konstantinos Gerasimidis and Richard K. Russell
The relationship between nutrition and inflammatory bowel disease (IBD) has been an area of
substantial interest and research for many decades now. Evidence-based nutritional strategies are
being utilised as a key part of the therapeutic armamentarium in Crohn's disease for both induction
and maintenance, as primary and adjuvant treatment methods. Exclusive enteral nutrition, for
instance, is well established in the treatment of paediatric IBD and adult centres are increasingly
incorporating it into treatment models as an effective, drug-free alternative.The role for partial enteral
nutrition and Crohn's disease specific diets are also being more clearly elucidated. Used appropriately,
and through engagement with dietetic support services, nutritional therapies can not only achieve the
IBD treatment 'targets' but serve to optimise other vital aspects of care, such as growth, bone health,
body composition and overall patient well-being. Here we discuss some of the mistakes that are
frequently made in the area of nutritional management of IBD. The discussion is evidence based, with
key references incorporated for further analysis beyond the scope of this article, and combines several
decades of leading clinical and research experience in the area of nutrition and IBD from the authors.
Mistake 1 Believing nutritional therapies
only work in paediatric patients
Exclusive enteral nutrition (EEN) has been widely
utilised as an inherently risk-free and highly
effective means of inducing remission in paediatric
patients who have active luminal Crohn's disease.
European consensus guidelines recommending it
as a first-line therapy in this population reflects the
weight of evidence in its favour.1
Clinical response rates to EEN approximating
80% are well supported by the paediatric literature,
and for children and adolescents with Crohn's
disease nutritional therapies represent a crucial
steroid-sparing strategy.2
Despite similar efficacy
being reported in various large, well-conducted
adult studies, the uptake of EEN as part of the
therapeutic strategy for adult IBD is limited
outside Japan, where EEN (or close to full EEN)
is increasingly recommended as a first-line
treatment.3
paediatrics, increased compliance rates to >85%
in one adult cohort.8
been developed to both encourage and support
EEN use in adult patients.9
Several studies support the need for exclusivity
Optimal care pathways have
We believe EEN should
be offered as a standard treatment option for
adults with active Crohn's disease both to induce
remission or reduce the burden of active disease,
particularly as a preoperative strategy for
thelatter. It is favoured especially as first-line
therapy where avoidance of steroids and
immunosuppressive medications is desired and
where malnutrition is part of the clinical picture.
This reluctance has largely been driven
by a Cochrane meta-analysis that did not replicate
the above results; however, when the analysis was
restricted to high-quality studies only, there was
no difference between corticosteroids and EEN.4
Importantly, several randomised controlled trials
(RCTs) show that mucosal healing, one of the key
'targets' when managing IBD, is more likely to be
achieved by EEN than corticosteroids.5-7
Poor adherence to EEN by adults generally
has also reduced its utility as a key part of the
therapeutic strategy. Encouragingly, involving an
experienced dietitian and providing appropriate
dietetic support, as is often standard practice in
© 2020 Meredith, Russell and Gerasimidis.
Cite this article as: Meredith J, Russell RK and Gerasimidis K.
Mistakes in nutrition in IBD and how to avoid them. UEG Education
2020; 20: 25-30.
Joseph Meredith is a paediatric gastroenterologist and
Richard K. Russell is a consultant paediatric gastroenterologist
Bottom line: EEN should be strongly considered
as an alternative to systemic corticosteroids for
induction therapy in select adults with Crohn's
disease, particularly given the increasing
accessibility and palatability of polymeric feeds, the
multitude of potential benefits beyond disease
control and recognising the key role of dietetic
support in maximising adherence. This message
should be widely communicated especially
during the COVID-19 era when alternatives to
steroid use are especially relevant.
Mistake 2 Not making exclusive enteral
nutrition exclusive during induction
Partial enteral nutrition (PEN) is an attractive
alternative to EEN given the restrictive nature of
EEN and the subsequent impact on adherence
in the absence of appropriate dietetic support.
However, PEN is currently not recommended for
induction therapy in Crohn's disease.1
and professor of paediatric gastroenterology and nutrition in the
Department of Paediatric Gastroenterology, The Royal Hospital
for Sick Children, Edinburgh, UK. Konstantinos Gerasimidis is a
professor of clinical nutrition at the School of Medicine, Dentistry
and Nursing, College of Medical, Veterinary and Life Sciences,
University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK.
of enteral nutrition during the induction phase.
One prospective study involving 90 children
demonstrated that although PEN improved clinical
symptoms, EEN was superior in achieving mucosal
healing and quality of life (QoL) parameters.10
An
earlier RCT showed threefold higher PCDAI-based
remission rates after 6 weeks in children receiving
EEN compared with those receiving 50% PEN
combined with free diet.11
Recently 50% PEN in combination with
a Crohn's disease exclusion diet (CDED) -
a whole food diet that excludes postulated
pro-inflammatory dietary components in a phased
manner - has been shown to induce remission
in mild-moderate luminal disease in children and
young adults.12
Corticosteroid-free remission was
achieved in 75% of patients after 12 weeks, and
the PEN plus CDED combination had superior
tolerance rates to EEN but no difference in efficacy.
This indicates that exclusion of elements of the
'free diet' that are part of a PEN strategy alone
might be important in achieving substantive
remission rates at induction. While small
deviations from EEN may be OK for pragmatic
reasons, at present it is best to emphasise
exclusivity until 'allowed' deviations that don't
impact on efficacy are better understood.13
Specifically developed diets including
CD-Treat and CDED are gaining an increasing
evidence base as safe, effective and sustainable
dietary therapies for induction, maintenance and
rescue therapies for Crohn's disease in adults
and children in research studies.14
CD-Treat, like
Illustrations: J.Shadwell
Introduction image: © Shutterstock
Correspondence to: josephjmeredith@gmail.com
Conflicts of interest: The authors have no conflicts of interest
to declare.
Published online: December 3, 2020.
25
Mistakes in ... 2021

Table of Contents for the Digital Edition of Mistakes in ... 2021
