Appropriate nutritional support in acute and complicated Crohn's disease

The Effect of Mastic Chios Supplementation in Inflammatory Bowel Disease: A Systematic Literature Review

Mastic Chios is a natural treasure of Greece that offers many potential benefits in various disorders due its antioxidant and anti-inflammatory properties. This systematic review aimed to investigate the effect of Mastic Chios supplementation in inflammatory bowel disease (IBD). A systematic search was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines across PubMed/Medline and EBSCO databases until February 2023. Clinical studies that examined individuals of any age being diagnosed with IBD as well as preclinical studies using animals with experimental colitis were considered eligible for inclusion. Studies included were assessed for methodological quality. Eight articles were eligible for inclusion, with seven conducted in Greece and one study in Iran. Most of the studies were randomized controlled trials (RCTs) and one was a pilot study. The intervention period varied between 3 and 7 days for animal studies and 4 weeks to 6 months for human studies. Mastic Chios supplementation varied between 2.2 and 2.8 g/day for clinical studies. The majority of studies concluded that Mastic Chios has significant antioxidant and inflammatory effects in IBD. This systematic review suggests that Mastic Chios may have a positive effect on the regulation and management of IBD. However, more high-quality clinical trials are needed to provide reliable and concrete conclusions about the effectiveness of Mastic Chios in this population. Such studies will further support the use of Mastic Chios as a reliable therapeutic option for IBD.

Evaluation of nutritional adequacy in adult patients with Crohn's disease: a cross-sectional study

Purpose

Inadequate oral intake may play an important role in the onset of malnutrition in patients with Crohn’s disease (CD). The aims of this cross-sectional study were: (1) to compare dietary intake in clinically active and quiescent CD patients, and (2) to assess patients’ nutritional adequacy relative to the dietary reference values (DRVs) for the Italian population using LARN (Livelli di Assunzione di Riferimento di Nutrienti ed energia per la popolazione italiana).

Methods

Patients aged between 18 and 65 years with a diagnosis of CD were recruited. All participants underwent anthropometry and were instructed to fill in a 3-day food record. Disease activity was clinically defined using the Crohn’s disease activity index (CDAI).

Results

Overall, 117 patients, 71 males and 46 females, with a mean age of 39.6 ± 13.8 years and a mean body weight of 65.4 ± 11.8 kg, were ultimately included. Our findings showed that the amount of nutrients was similar between patients with active and quiescent disease. The mean intake of macronutrients was adequate, except for fiber, while dietary micronutrients were insufficient. Median intakes of sodium, phosphorus, and fluorine met LARN recommendations in both sexes, and the DRVs were accomplished by many patients (53/117; 104/117 and 98/117, respectively). Interestingly, dietary amounts of iron and zinc were barely acceptable in males but not in females. However, a few of the patients (< 15) met the LARN for potassium, calcium, and magnesium, regardless of sex and CDAI. With respect to vitamins, no relevant difference was found between the active and quiescent groups, and none of them met recommended values in both sexes.

Conclusions

This study showed that the assessment of dietary intake can be crucial for optimizing dietary intervention with focused nutrition counseling, to improve nutritional status in CD patients.

Popular exclusionary diets for inflammatory bowel disease: the search for a dietary culprit

The evolving understanding of the role of the microbiome and environmental factors in the pathogenesis of inflammatory bowel disease makes diet an interesting and potentially powerful tool in the treatment of disease. However, at this time, evidence is limited but anecdotal reports of success abound. There is a bewildering array of new diets being tried by patients in an attempt to control diseases. This review attempts to summarize the most common diets for the treating physician.

Effects of intragastric administration of predigested nutrients on food intake, body weight and taste acceptability: Potential relevance of the cephalic/neural phase of digestion

In this study we analyzed the effect of the intragastric administration of partially digested and natural nutrients on subsequent food intake, body weight and flavor acceptability in rats. The results showed that enterally administered natural nutrients reduced the subsequent ingestion of food to a greater degree compared with the same nutrients in partially digested form. This greater reduction does not appear to be due to a higher nutritional effect of the former, because the body weight of both groups of animals was similar. Animals intragastrically administered with partially digested nutrients developed an acceptance response to a previously paired flavored stimulus, in contrast to animals receiving natural nutrients under the same conditions. These results are interpreted in terms of the cephalic phase of digestion and may be relevant to the treatment of clinical symptoms associated with enteral feeding.

Double percutaneous endoscopic gastrojejunostomy tubes for decompression and refeeding together with enteral nutrients: three case reports and a review of the literature

Percutaneous endoscopic gastrostomy had become a general technique for placement of indwelling feeding and decompressive tubes. There have been few reports that double percutaneous endoscopic gastrojejunostomy (PEGJ) tubes for decompression and refeeding together with enteral nutrients. We herein present 3 cases, characterized by chronic malnutrition and requiring long-term digestive decompression and enteral nutritional support, which were placed in double PEGJ tubes under endoscopic or fluoroscopic guidance. The procedures were successfully completed for all the patients. Two patients resumed oral intake and PEGJ tubes were removed. The second patient was provided home enteral nutrition while waiting for surgery. Three unusual cases were successfully treated by double PEGJ tubes for digestive decompression and refeeding together with enteral nutrients.

Importance of nutrition in inflammatory bowel disease

Inflammatory bowel disease (IBD) results from the interaction between an individual's immune response and precipitant environmental factors, which generate an anomalous chronic inflammatory response in those who are genetically predisposed. Various feeding practices have been implicated in the origin of IBD based on epidemiological observations in developed countries, but we do not have solid evidence for the etiological role played by specific food types. IBD is associated with frequent nutritional deficiencies, the pattern and severity of which depends on the extent, duration and activity of the inflammation. Nutritional support allows these deficiencies in calories, macro- and micro-nutrients to be rectified. Enteral nutrition is also a primary therapy for IBD, especially for Crohn's disease, as it allows the inflammatory activity to be controlled, kept in remission, and prevents or delays the need for surgery. Nutritional support is especially important in childhood IBD as an alternative to pharmacological treatment. This report discusses the complex relationship between diet and IBD.

Importance of nutrition in inflammatory bowel disease

Inflammatory bowel disease (IBD) results from the interaction between an individual’s immune response and precipitant environmental factors, which generate an anomalous chronic inflammatory response in those who are genetically predisposed. Various feeding practices have been implicated in the origin of IBD based on epidemiological observations in developed countries, but we do not have solid evidence for the etiological role played by specific food types. IBD is associated with frequent nutritional deficiencies, the pattern and severity of which depends on the extent, duration and activity of the inflammation. Nutritional support allows these deficiencies in calories, macro- and micro-nutrients to be rectified. Enteral nutrition is also a primary therapy for IBD, especially for Crohn’s disease, as it allows the inflammatory activity to be controlled, kept in remission, and prevents or delays the need for surgery. Nutritional support is especially important in childhood IBD as an alternative to pharmacological treatment. This report discusses the complex relationship between diet and IBD.

Adequacy of nutritional intake in a Canadian population of patients with Crohn's disease

Crohn's disease is frequently associated with nutritional deficiencies, often a result of disease activity and poor oral intake. This study investigated the adequacy of dietary intake, based on the Canadian Dietary Reference Intake, in ambulatory patients with Crohn's disease and a normal body mass index (BMI; calculated as kg/m(2)). This was a cross-sectional study of 74 patients with mean age of 35.7+/-1.4 years and BMI of 23.05+/-0.45. All patients completed a 7-day food record and a diary for the Crohn's Disease Activity Index. Mean Crohn's Disease Activity Index was 138.99+/-11.38. Energy and protein intakes were within the recommended levels of intake, but total carbohydrates, fat, and saturated fat intake exceeded the recommended levels of <55%, <35%, and <10% in 39.2%, 27%, and 59.5% of the patients, respectively. Micronutrient intakes were suboptimal most notably for folate, vitamins C, E, and calcium. There were no substantial differences between patients with active and inactive disease in terms of failure to meet the Dietary Reference Intake. In conclusion, in this population sample, a large number of ambulatory patients with Crohn's disease have suboptimal dietary patterns despite a normal BMI and inactive disease. Dietary counseling and supplementation may be warranted in this patient population.

Chios mastic treatment of patients with active Crohn’s disease

AIM: To evaluate the effectiveness of mastic administration on the clinical course and plasma inflammatory mediators of patients with active Crohn’s disease (CD).

METHODS: This pilot study was conducted in patients with established mild to moderately active CD, attending the outpatient clinics of the hospital, and in healthy controls. Ten patients and 8 controls were recruited for a 4-wk treatment with mastic caps (6 caps/d, 0.37 g/cap). All patients successfully completed the protocol. CD Activity Index (CDAI), Nutritional Risk Index (NRI), C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), monocyte chemotactic protein-1 (MCP-1), and total antioxidant potential (TAP) were evaluated in the plasma at baseline and at the end of the treatment period. Results were expressed as mean values ± SE and P < 0.05 was considered to indicate statistical significance.

RESULTS: Patients exhibited significant reduction of CDAI (222.9 ± 18.7 vs 136.3 ± 12.3, P = 0.05) as compared to pretreament values. Plasma IL-6 was significantly decreased (21.2 ± 9.3 pg/mL vs 7.2 ± 2.8 pg/ mL, P = 0.027), and so did CRP (40.3 ± 13.1 mg/mL vs 19.7 ± 5.5, P = 0.028). TAP was significantly increased (0.15 ± 0.09 vs 0.57 ± 0.15 mmol/L uric acid, P = 0.036). No patient or control exhibited any kind of side effects.

CONCLUSION: The results suggest that mastic significantly decreased the activity index and the plasma levels of IL-6 and CRP in patients with mildly to moderately active CD. Further double-blind, placebo-controlled studies in a larger number of patients are required to clarify the role of this natural product in the treatment of patients with CD.

Role of perioperative parenteral nutrition in severely malnourished patients with Crohn’s disease

AIM: To evaluate the effect of perioperative parenteral nutrition on serum immunoglobulin, weight change, and post-operative outcome in severely malnourished patients with Crohn’s disease.

METHODS: Thirty-two severely malnourished patients with Crohn’s disease who had undergone surgery in our hospital were reviewed. Sixteen patients who received perioperative parenteral nutrition were enrolled in the study group, and the other 16 patients who did not receive parenteral nutrition were enrolled in the control group. Serum immunoglobulin, body mass index (BMI), liver function, weight change, and postoperative complications were evaluated.

RESULTS: Serum IgM levels elevated 1 wk before surgery in both groups, and decreased to normal value (from 139 ± 41 to 105 ± 29 mg/dL, P = 0.04) 4 wk after operation in the study group, while no significant changes was noted in the control group (from 133 ± 16 to 129 ± 13 mg/dL, P = 0.34). There were no significant changes in concentrations of IgG and IgA. The BMI of the study group increased from 13.9 ± 0.6 to 15.3 ± 0.7 kg/m² (P = 0.02) with no significant change in the control group (14.1 ± 0.7 and 14.5 ± 0.5, respectively, P = 0.81). The percentage of resuming work was higher in the study group than in the control group.

CONCLUSION: Perioperative parenteral nutrition possibly ameliorates the humoral immunity, reverses malnutrition, and facilitates rehabilitation.

Efficacy of a Transforming Growth Factor β2 Containing Nutritional Support Formula in a Murine Model of Inflammatory Bowel Disease

OBJECTIVE

Dietary, environmental and genetic events may influence host susceptibility to inflammatory bowel diseases (IBD). Transforming growth factor beta 2 (TGF-beta 2), a multifunctional polypeptide (cytokine) present in human and bovine milk, plays a critical role in the development of tolerance, the prevention of autoimmunity, and in anti-inflammatory responses. TGF-beta 2 is a potent inhibitor of intestinal epithelial cell (IEC) growth and stimulates IEC differentiation. The objective of this study was to determine whether a diet containing TGF-beta 2 modulates intestinal injury and immune responses in an Interleukin-10 knockout (IL-10-/-) mouse model of IBD.

METHODS

Five-week-old IL-10-/- mice (in BALB/c background) reared in our transgenic facility were fed either an enteral diet (Diet-A) containing TGF-beta 2 or a control enteral diet (Diet-B) not rich in TGF-beta 2. Mice were weighed weekly, monitored for illness and euthanized after eight weeks on the diet.

RESULTS

Final weights were 28 +/- 1.2 g (58.2% gain) for Diet-A mice and 23 +/- 1.6 g (32.9% gain) for Diet-B mice (p = 0.0194). The hematocrits were 48.3% for Diet-A compared to 42% for Diet-B mice (p = 0.0021). Mice on Diet-A had significantly lower serum TNF-alpha concentrations. Forty-four percent of mice on Diet-B developed severe diarrhea and rectal prolapse compared with none on Diet-A. Evaluation of intestinal pathology (score 0-4) revealed that animals fed Diet-A had a score of 2.1 +/- 0.4 compared to 3.2 +/- 0.36 in the Diet-B group (p = 0.040). The acute phase protein, serum amyloid A (SAA), was 3.8 times higher in the Diet-B group (p = 0.0038).

CONCLUSIONS

IL-10-/- mice fed a TGF-beta 2 containing diet gained more weight, did not develop diarrhea or prolapse, had lower pathological scores, and lower SAAs. These data further support the use of TGF-beta 2 containing enteral diets as one mode of therapy for Crohn's disease.

Inflammatory bowel diseases: principles of nutritional therapy

Inflammatory Bowel Diseases - ulcerative colitis and Crohn's disease- are chronic gastrointestinal inflammatory diseases of unknown etiology. Decreased oral intake, malabsorption, accelerated nutrient losses, increased requirements, and drug-nutrient interactions cause nutritional and functional deficiencies that require proper correction by nutritional therapy. The goals of the different forms of nutritional therapy are to correct nutritional disturbances and to modulate inflammatory response, thus influencing disease activity. Total parenteral nutrition has been used to correct and to prevent nutritional disturbances and to promote bowel rest during active disease, mainly in cases of digestive fistulae with high output. Its use should be reserved for patients who cannot tolerate enteral nutrition. Enteral nutrition is effective in inducing clinical remission in adults and promoting growth in children. Due to its low complication rate and lower costs, enteral nutrition should be preferred over total parenteral nutrition whenever possible. Both present equal effectiveness in primary therapy for remission of active Crohn's disease. Nutritional intervention may improve outcome in certain individuals; however, because of the costs and complications of such therapy, careful selection is warranted, especially in patients presumed to need total parenteral nutrition. Recent research has focused on the use of nutrients as primary treatment agents. Immunonutrition is an important therapeutic alternative in the management of inflammatory bowel diseases, modulating the inflammation and changing the eicosanoid synthesis profile. However, beneficial reported effects have yet to be translated into the clinical practice. The real efficacy of these and other nutrients (glutamine, short-chain fatty acids, antioxidants) still need further evaluation through prospective and randomized trials.

Review article: nutrition and adult inflammatory bowel disease

Major advances in the understanding of the aetio-pathogenesis and genetics of inflammatory bowel disease have been accompanied by an escalation in the sophistication of immunomodulatory inflammatory bowel disease therapeutics. However, the basic 'triple' therapy (5-aminosalicylates, corticosteroids, azathioprine) and nutrition have maintained their central role in the management of patients with inflammatory bowel disease over recent decades. This review provides an overview of the supportive and therapeutic perspectives of nutrition in adult inflammatory bowel disease. The objective of supportive nutrition is to correct malnutrition in terms of calorie intake or specific macro- or micronutrients. Of particular clinical relevance is deficiency in calcium, vitamin D, folate, vitamin B12 and zinc. There is justifiably a growing sense of unease amongst clinicians and patients with regard to the long-term use of corticosteroids in inflammatory bowel disease. This, rather than arguments about efficacy, should be the catalyst for revisiting the use of enteral nutrition as primary treatment in Crohn's disease. Treatment failure is usually related to a failure to comply with enteral nutrition. Potential factors that militate against successful completion of enteral nutrition are feed palatability, inability to stay on a solid-free diet for weeks, social inconvenience and transient feed-related adverse reactions. Actions that can be taken to improve treatment outcome include the provision of good support from dietitians and clinicians for the duration of treatment and the subsequent 'weaning' period. There is evidence to support a gradual return to a normal diet through exclusion-re-introduction or other dietary regimen following the completion of enteral nutrition to increase remission rates. We also review the evidence for emerging therapies, such as glutamine, growth factors and short-chain fatty acids. The future may see the evolution of enteral nutrition into an important therapeutic strategy, and the design of a 'Crohn's disease-specific formulation' that is individually tailored, acceptable to patients, cost-effective, free from adverse side-effects and combines enteral nutrition with novel pre- and pro-biotics and other factors.

Nutrition in Crohn's disease

Nutrition plays an important role in Crohn's disease. This review provides further insights into the relationship between nutrition and Crohn's disease and focuses on three different aspects: dietary aetiological factors, nutritional status and nutritional therapy in Crohn's disease.

Enteral nutrition and corticosteroids in the treatment of acute Crohn's disease in children

BACKGROUND

The optimal treatment of acute Crohn's disease in children remains controversial. In adults, steroid therapy has been shown to be superior to exclusive enteral nutrition. However, enteral nutrition is effective at inducing a remission in many children with acute Crohn's disease. Steroid usage in children has been associated with adverse side effects, particularly with delayed growth and pubertal development.

METHODS

Randomized clinical trials comparing exclusive enteral nutrition with corticosteroids were identified. Two independent reviewers extracted data from selected studies. Studies were assessed for heterogeneity and relative risks for remission induction with enteral nutrition were obtained. Sensitivity analyses were performed in partially randomized studies. Estimates were made of the number of studies needed to overturn the current result. Other outcome measures were qualitatively assessed.

RESULTS

In five randomized clinical trials comprising 147 patients, enteral nutrition was as effective as corticosteroids at inducing a remission (RR = 0.95 [95% confidence interval 0.67, 1.34]). Addition of two further nonrandomized trials did not significantly alter the result. A minimum of 10 further studies, equal in size and outcome to the largest reported pediatric trial to date (n = 68, RR = 0.84), would be required to demonstrate a significant benefit of steroid therapy over enteral nutrition.

CONCLUSIONS

There is no difference in efficacy between enteral nutrition and corticosteroid therapy in the treatment of acute Crohn's disease in children. Improved growth and development, without the side effects of steroid therapy, make enteral nutrition a better choice for first-line therapy in children with active Crohn's disease.

Medical options for treating Crohn's disease in adults: focus on antitumor necrosis factor-alpha chimeric monoclonal antibody

Crohn's disease is a chronic inflammatory disorder that can present with symptoms throughout the gastrointestinal system. Though the etiology of Crohn's disease is unknown, genetic and environmental factors seem to play a role. An imbalance of proinflammatory versus antiinflammatory cytokines is responsible for many of the symptoms. Tumor necrosis factor alpha, a potent proinflammatory cytokine, plays a particularly important role. Several treatment modalities for Crohn's disease exist, recently including antitumor necrosis factor chimeric monoclonal antibody (cA2). Treatment for Crohn's disease, including data on the safety and efficacy of cA2, will be reviewed.