Nutritional management of inflammatory bowel disease

Nutritional modulation of the inflammatory response in inflammatory bowel disease- From the molecular to the integrative to the clinical

Nutrient deficiencies are common in patients with inflammatory bowel disease (IBD). Both total parenteral and enteral nutrition provide important supportive therapy for IBD patients, but in adults these are not useful for primary therapy. Dietary intervention with omega-3 polyunsaturated fatty acids contained in fish oil may be useful for the care of IBD patients, and recent studies have stressed the role of PPAR on NFκB activity on the potential beneficial effect of dietary lipids on intestinal function.

An oral supplement enriched with fish oil, soluble fiber, and antioxidants for corticosteroid sparing in ulcerative colitis: a randomized, controlled trial

BACKGROUND & AIMS

N-3 fatty acids from fish oil, antioxidants, and short-chain fatty acids (SCFAs) produced during the fermentation of soluble fiber may attenuate inflammation associated with ulcerative colitis (UC). We assessed the efficacy of a nutritionally balanced oral supplement enriched with fish oil, fructooligosaccharides, gum arabic, vitamin E, vitamin C, and selenium on disease activity and medication use in adults with mild to moderate UC.

METHODS

A total of 121 patients with UC and a disease activity index (DAI) from 3-9 on a 12-point scale were block randomized for extent of disease and smoking status. In addition to their usual diet, patients consumed 18 oz of the oral supplement or a carbohydrate-based placebo formula each day for 6 months. Clinical and histologic responses were assessed at 3 and 6 months or at the final visit. A change in average prednisone use between groups was tested by using a linear mixed-effects model.

RESULTS

Eighty-six patients completed the study. Baseline characteristics were not different between groups except for a higher total DAI score in the oral supplement group (7.3 +/- 1.3; n = 36) compared with the placebo group (6.2 +/- 2.0; n = 50) ( P < .05). Both groups showed significant and similar degree of improvement at 6 months in DAI (-2.5 for oral supplement and -2.8 for placebo) and histologic index (-1.9 for oral supplement vs. -2.0 for placebo). Both intent-to-treat and completed patients given oral supplement had a significantly greater rate of decrease in the dose of prednisone required to control clinical symptoms over 6 months as compared with the placebo group ( P < .001).

CONCLUSIONS

The improvement in clinical response combined with a decreased requirement for corticosteroids suggest that this enriched oral supplement can be a useful adjuvant therapy in patients with UC.

Protein-losing enteropathies

GI protein loss can result from a heterogeneous group of diseases, including lymphangiectasia, IBD, neoplasia, ulceration, intussusception, and histoplasmosis. PLE should be suspected in any hypoalbuminemic patient with no evidence of exudative protein loss, proteinuria, or HI. A minimum laboratory database for the suspected PLE patient should include a complete blood cell count, a biochemical and electrolyte profile, urinalysis (+/- urine protein:cretinine ratio), and pre- and postprandial bile acid determinations. Fecal alpha 1-PI concentrations may be used to confirm the presence of GI protein loss in cases with concurrent renal or hepatic disease. Because PLE is a syndrome and not a specific disease, the most effective therapy must be directed at the underlying cause. Multiple high-quality endoscopic biopsies are sufficient to diagnose most patients with PLE, although full-thickness biopsies are required in some cases. Patients with PLE are often clinically "fragile," and careful symptomatic therapy must be integrated with dietary and medical management strategies in most cases.

Metabolic characteristics of healthy adult males as affected by ingestion of a liquid nutritional formula containing fish oil, oligosaccharides, gum arabic and antioxidant vitamins

n-3 Fatty acids from fish oil and short-chain fatty acids produced from fermentation of oligosaccharides may attenuate a portion of gut injury and inflammation associated with ulcerative colitis. The purpose of this study was to assess the effects of an enteral nutritional formula containing supplemental oligosaccharides, gum arabic and fish oil on serum metabolite profiles, haematology, plasma and red blood cell membrane phospholipid fatty acid profiles, urinary constituent, and safety in healthy human adult males. 30 subjects were randomly assigned to one of two treatments, a control formula (n = 10) and an ulcerative colitis nutritional formula (UCNF; n = 20). Formulas contained comparable levels of protein, fat and non-structural carbohydrates. Daily intake of the formulas provided nutrients to meet or exceed the recommended daily allowance. Intake was recorded daily while blood and urine samples were collected weekly on days 0, 7 and 14. Certain subjects consuming large quantities of the UCNF experienced some abdominal distention, gas and loose stools. Sole source intake of the UCNF was safe over 14 days as assessed by routine measurements of serum metabolite profiles, haematology and urinalysis compared with subjects fed the control formula. Substantial decreases in plasma and red blood cell phospholipid 18:2n-6 and increases in 20:5n-3 and 22:6n-3 within 1 wk of feeding the UCNF were noted.

[What is the role of nutrition in ulcerative colitis? A contribution to the current status of diet therapy in treatment of inflammatory bowel diseases]

Nutritional therapy for ulcerative colitis (UC) is controversial. Studies are usually designed to investigate total parenteral (TPN) or total enteral nutrition (TEN), and before these can be compared it is necessary to differentiate between the different therapeutic aims. The aims of artificial nutritional support in patients with UC are the readjustment of the nutritional status, possible remission of disease activity, and decrease in the incidence of surgical intervention or postoperative complication. Owing to the heterogeneity of the results published so far, it is still difficult to compare studies. Nevertheless, they indicate that the extent and severity of the colitis and the patient selection are of paramount importance in the implementation of nutritional therapy. Positive effects of TPN reported from non-controlled studies were not confirmed by controlled trials. Moreover, TPN was no more effective than an oral diet. Regarding remission rates or operative interventions needed, TPN had more side effects than and no defined advantages over TEN. TEN seems to be useful for certain patients. In some patients with UC, it seems to be accompanied by fewer postoperative complications. However, a definitive conclusion on the effects of TEN or TPN is not yet possible. In this context, certain fatty acids may have an important role in the treatment of UC. In prospective, randomized and controlled studies omega-3 fatty acids were found to be therapeutically useful. A reduction of the steroid doses needed is particularly important. Another therapeutic approach in distal UC is seen in the rectal administration of short chain fatty acids.