Diet and nutritional therapies in inflammatory bowel disease: update with a practical approach

A American Gastroenterological Association (AGA) published a clinical practice update on the role of diet and nutritional therapies in patients with inflammatory bowel disease (IBD).

The new recommendation, authored by Dr. Jana G. Al Hashash, a physician at Mayo Clinic in Jacksonville, United States, and collaborators, recommends 12 “best practices” that address dietary options, enteral and parenteral nutrition, patient monitoring and the need for multidisciplinary care.

“There is increasing recognition of the role of diet in the treatment of patients with IBD, both as an etiopathogenic risk factor and, more recently, a disease-modifying modality,” they noted in the journal Gastroenterology update panel members.

Historically, they noted, IBD patients have been recommended to avoid different foods, such as fiber, but this approach can result in unintended consequences.

“These strategies often led IBD patients to avoid what we traditionally consider healthy foods, even after achieving clinical remission,” Dr. Jana and her colleagues described.

With a growing body of data available for dietary interventions in both Crohn’s disease and ulcerative colitis, they published this clinical practice update to provide some clarity on the subject.

Starting point

First, the panelists recommended that, unless there is a contraindication, all IBD patients follow a Mediterranean diet, reducing the consumption of salt, sugar and ultra-processed foods.

Patients with symptomatic intestinal strictures may have difficulty digesting raw fruits and vegetables due to their fibrous nature, they added; therefore, they must first soften these foods through conventional cooking, steaming, or “careful chewing” before consuming them.

“No diet consistently decreased the seizure rate in adults with IBD,” the authors noted. “A diet low in red and processed meat can reduce attacks of ulcerative colitis, but there is no evidence that it reduces relapses of Crohn’s disease.”

In addition to these dietary suggestions for adults, the update recommends breastfeeding for newborns and a Mediterranean diet for children, as both can reduce the risk of developing IBD.

Enteral nutrition

The update suggested that exclusive enteral nutrition is a reasonable option to induce clinical remission and endoscopic response in Crohn’s disease, or as an option to reduce steroid use, although it may be more effective in children than in adults.

Malnourished patients may also benefit from exclusive enteral nutrition before elective surgery for Crohn’s disease, Dr. Jana and colleagues added, as this strategy can “optimize nutritional status and reduce postoperative complications.”

An exclusion diet in Crohn’s disease, which involves partial enteral nutrition, may be considered in mild or moderate cases, according to the update.

“Data on the use of enteral nutrition in the treatment of ulcerative colitis are limited,” the panelists noted, although early data suggests it is safe, well tolerated and may improve prealbumin levels.

Parenteral nutrition

Short-term parenteral nutrition for patients with phlegmonous inflammation and/or intra-abdominal abscess may serve as a transition to surgical intervention, according to the update.

Patients with prolonged paralytic ileus, short bowel syndrome, or high-output gastrointestinal fistula may also be candidates for parenteral nutrition, as well as those who have not responded adequately to both oral and enteral nutrition.

Finally, the update encouraged the transition from long-term parenteral nutrition to oral intake and individualized control of hydration “whenever possible”.

Multidisciplinary monitoring and care

Dr. Jana and colleagues concluded by recommending that all patients with complicated IBD be monitored by a gastroenterologist and a nutritionist and remain alert for signs of malnutrition.

The use of serum protein is no longer recommended as a surrogate marker of malnutrition, which requires the use of different criteria for identification. Routine testing for iron and vitamin D is necessary, as is testing for vitamin B12 in patients with extensive ileal disease or a history of ileal surgery.

This clinical practice update was commissioned and approved by the AGA. Update panelists reported having conflicts of interest with Merck, Celgene and Janssen, among others.

This content was translated from MDedge.com — Medscape Professional Network.